Transpleural central venous catheter discovered during thoracotomy
A 37-year-old male with cystic bronchiectasis in the left lower lobe was scheduled for left lower lobectomy. His preoperative checkup was unremarkable. Computerized tomography scan of the chest revealed cystic bronchiectasis in the left lower lobe with consolidation. Imaging cannot show “infection” and mild bronchiectasis in the right middle lobe. Following placement of routine monitors, thoracic epidural catheter was inserted in the T6-T7 interspace. Patient refused CVC insertion under local anesthesia. After induction of general anesthesia, the patient was intubated with right sided 41 FG double lumen tube. Left infraclavicular access for CVC was selected as the patient had to undergo left thoracotomy. Venipuncture was performed 1 cm lateral to the curvature of the middle third of the clavicle with the needle pointing horizontally directed at the sternal notch until free aspiration of blood was obtained. Positive pressure ventilation was withheld during the CVC insertion until free flow of blood was obtained. 16G catheter through needle CVC was introduced in the first attempt. The blood aspirated during the insertion was uninterrupted and no air or fluid was noticed. CVC was confirmed with easy aspiration of blood and appropriate waveform. The catheter was fixed at the mark of 12 cm from the tip of the catheter. Bedside chest xray to confirm CVC position was not immediately available and thus, the CVC was only used for monitoring the waveform. No fluids were infused through the CVC. During the surgical exploration, it was noticed that CVC was traversing the superior aspect of the pleural cavity []. Position of the CVC tip was reconfirmed and was found to be satisfactory as per the waveform and aspiration of blood.\nSuspecting the puncture site as a potential site for bleeding, it was decided to remove the catheter before thoracic cavity was closed. While it was being removed under vision, bleeding was noticed from both puncture sites at the pleural surface. Manual pressure was insufficient to stop the bleeding. Therefore, two sutures one at each puncture site were placed. Post-operative course was uneventful.