Life-Threatening Mediastinal Hematoma Caused by Extravascular Infusion Through a Triple-Lumen Central Venous Catheter

Mediastinal hematoma following thrombolysis for acute pulmonary thromboembolism

Massive pulmonary thromboembolism (PE) is a cardiorespiratory emergency and can be fatal if left untreated. The recommended treatment for PE in the presence of right ventricular dysfunction and hemodynamic instability is thrombolysis. However, the latter is a double-edged sword as life-threatening bleeding manifestations can occur post-thrombolysis. Timely identification and management of these complications can prevent a catastrophic outcome. We report a case of mediastinal hematoma with new onset hemodynamic compromise following thrombolysis for acute massive pulmonary embolism. Clinico-radiological features and Point of Care Ultrasound (POCUS) findings helped in the identification of the bleeding site in our case. Despite early diagnosis and timely intervention, the patient succumbed to secondary complications.

Life-Threatening Mediastinal Hematoma Formation After Removal of the Hemodialysis Catheter in a Boxer: A Case Report

A 4-year-old female Boxer was referred for renal replacement therapy 2 days after observed grape ingestion. An 11-French dual-lumen dialysis catheter was placed into the right jugular vein and continuous renal replacement therapy was initiated for 66 h. Afterwards the patient received enoxaparin subcutaneously as a thromboprophylaxis. Four hours after removal of the dialysis catheter the patient developed severe dyspnea with hypercapnia and signs of hemorrhagic shock. Bedside ultrasound and X-rays of the thorax revealed a soft tissue opacity dorsally of the trachea, located in the mediastinum. The findings were consistent with mediastinal bleeding and hematoma formation. Blood gas examination indicated hypoventilation. The dog was managed conservatively with multiple blood transfusions and mechanical ventilation. The patient survived to discharge, and the hematoma was fully absorbed in the radiographs after 17 days. Patients with impaired kidney function should receive individualized enoxaparin dosage adjusted to anti-Xa levels and should be strictly monitored for complications. Mediastinal hemorrhage and hematoma formation should be considered as a potential complication in patients receiving a jugular vein catheter.

Dorsal mediastinal haemorrhage in dogs: four cases (2010-2018)

OBJECTIVE

This retrospective case series describes the clinical presentation and CT findings of dogs with presumed mediastinal haemorrhage with no apparent identifiable underlying cause.

MATERIALS AND METHODS

Medical records were searched for dogs with presumed or suspected mediastinal haemorrhage of non-thymic origin. For all dogs, data on signalment, history, physical examination, treatment and outcome were collected by reviewing the medical records. Follow-up information was collected by telephone interviews with the owners and/or their primary-care veterinarians.

RESULTS

Four dogs were included. All survived to discharge with apparent resolution of the mediastinal haemorrhage (based on repeat imaging and/or clinical signs) with supportive treatment alone. Follow-up information was available from 2 months to 5 years following discharge, and none of the patients showed a recurrence of clinical signs during this period.

CLINICAL SIGNIFICANCE

This case series highlights that presumed haemorrhage into the mediastinum can occur in dogs without an obviously identifiable cause and, whilst rare, should be considered as a cause of dorsal mediastinal masses and may be successfully managed with supportive care alone.

A Life-Threatening Mediastinal Hematoma After Central Venous Port System Implantation

BACKGROUND

We report a case of surgical central venous port system implantation using Seldinger's technique with a life-threatening mediastinal hematoma due to the perforation of the superior vena cava.

CASE REPORT

A 68-year-old woman was admitted to our institution for port implantation. Open access to the cephalic vein and 2 punctures of the right subclavian vein were unsuccessful. Finally, the port catheter could be placed into the superior vena cava using Seldinger's technique. As blood aspiration via the port catheter was not possible, fluoroscopy was performed, revealing mediastinal contrast extravasation without contrasting the venous system. A new port system could be placed in the correct position without difficulties. After extubation, the patient presented with severe respiratory distress and required consecutive cardiopulmonary resuscitation and reintubation. The CT scan showed a significant hematoma in the lower neck and posterior mediastinum with tracheal compression. We assumed a perforation of the superior vena cava with the tip of the guidewire using Seldinger's technique. Long-term intensive treatment with prolonged ventilation and tracheotomy was necessary. The port system had to be subsequently explanted due to infection.

CONCLUSIONS

Mediastinal hematoma is a rare but life-threatening complication associated with central venous catheterization using Seldinger's technique. Perforation occurs most often during central venous catheterization in critical care. Mediastinal hematoma is an example of a mechanical complication occurring after central venous catheterization, which has been described only a few times in the literature to date. This case highlights the importance of awareness of possible, rare, life-threatening complications during port implantation, mostly performed in multimorbid patients by surgeons in training.

Emergent Median Sternotomy for Mediastinal Hematoma: A Rare Complication following Internal Jugular Vein Catheterization for Chemoport Insertion-A Case Report and Review of Relevant Literature

Mediastinal hematoma is a rare complication following insertion of a central venous catheter with only few cases reported in the English literature. We report a case of a 71-year-old female who was admitted for elective chemoport placement. USG guided right internal jugular access was attempted using the Seldinger technique. Resistance was met while threading the guidewire. USG showed a chronic clot burden in the RIJ. A microvascular access was established under fluoroscopic guidance. Rest of the procedure was completed without any further issues. Following extubation, the patient complained of right-sided chest pain radiating to the back. Chest X-ray revealed a contained white out in the right upper lung field. She became hemodynamically unstable. Repeated X-ray showed progression of the hematoma. Median Sternotomy showed posterior mediastinal hematoma tracking into right pleural cavity. Active bleeding from the puncture site at RIJ-SCL junction was repaired. Patient had an uneventful recovery. Injury to the central venous system is the result of either penetrating trauma or iatrogenic causes as in our case. A possible explanation of our complication may be attributed to the forced manipulation of the dilator or guidewire against resistance. Clavicle and sternum offer bony protection to the underlying vital venous structures and injuries often need sternotomy with or without neck extension. Division of the clavicle and disarticulation of the sternoclavicular joint may be required for optimum exposure. Meticulous surgical technique, knowledge of the possible complications, and close monitoring in the postprocedural period are of utmost importance. Chest X-ray showed to be routinely done to detect any complication early.

Spontaneous Atraumatic Mediastinal Hemorrhage: Challenging Management of a Life-Threatening Condition and Literature Review

Spontaneous atraumatic mediastinal hematomas are rare. We present a case of a previously fit and well middle-aged lady who presented with acute breathlessness and an increasing neck swelling and spontaneous neck bruising. On plain chest radiograph, widening of the mediastinum was noted. The bruising was later confirmed to be secondary to mediastinal hematoma. This life-threatening diagnostic conundrum was managed conservatively with a multidisciplinary team approach involving upper gastrointestinal and thoracic surgeons, gastroenterologists, radiologists, intensivists, and hematologists along with a variety of diagnostic modalities. A review of literature is also presented to help surgeons manage such challenging and complicated cases.

The use of central venous catheters for intravenous contrast injection for CT examinations

The use of intravenous (i.v.) contrast media in CT examinations is often of great value in improving diagnostic accuracy. The preferable route of administration is via a peripheral i.v. cannula, with powered injectors allowing reliable delivery of rapid flow rates. However, many patients with a pre-existing central venous access device may have difficult peripheral access and there is a temptation to use the central device for delivery of contrast media. This review summarises the available evidence for the safe and effective use of these devices to assist the radiologist in balancing the relative risks and benefits of their use for contrast medium injection.

Mediastinal hematoma caused by central venous catheterization: a rare cause of obscure blood loss

Gastrointestinal hemorrhage, internal bleeding beyond the gastrointestinal tract and hemolysis are common causes of blood loss in intensive care unit patients. However, mediastinal hematoma is a rare cause of blood loss and is not usually detected. Here, we report a patient who developed a mediastinal hematoma resulting from central venous catheterization who presented with obscure blood loss refractory to blood transfusion. A mediastinal hematoma should be considered in the presence of obscure blood loss in patients with catheter placement.

[Central venous lines in children: new trends]

Central venous catheterisation under two-dimensional ultrasound (US) guidance has been proved to be quicker and safer than the classical landmark method in both adults and children. In the literature US guidance with sterile dressing of the probe is the 'gold-standard'. Another way to use US is simple preoperative US location followed either by blind puncture, either by US guided puncture when difficulties are expected: small infants (<15 kg), small diameter or collapses of the vein, multiple unsuccessful attempts during blind technique. Ideal location of the tip of central venous catheters is no more controversial but can depend on age and weight. In 2002 a French agency (Afssaps) study showed that the risk of perforation and tamponade was especially high in small weight prematures with 27 gauge polyurethane catheters when tip was located in the cardiac cavities. In children and adults venous thrombosis and catheter malfunction are closely related to short catheters whose tip is above T3-T4. Excepted polyurethane catheters in small weight prematures, the best location of long-term central venous catheters tip is the superior vena cava-right auricle junction. At this time routine antithrombotic prophylaxis is not recommended for children with long-term central venous catheters.

Fatal haemothorax following large-bore percutaneous cannulation before liver transplantation

Percutaneous bypass catheters are routinely used for veno-venous bypass (VVBP) during orthotopic liver transplantation (OLT). The recognized risks include bleeding, injury of vascular and nerve structures and lymphatic leakage. We describe a case where there were difficulties during catheterization and the patient suffered a cardiac arrest on commencing VVBP. Post-mortem examination revealed the bypass catheter tip in the pleural space and a large right haemothorax. Possible mechanisms of vascular perforation and preventative measures are discussed.