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Nag DS, Swain A, Sahu S, Swain BP, Sam M. Pitfalls in internal jugular vein cannulation. World J Clin Cases 2024; 12:1714-1717. [PMID: 38660082 PMCID: PMC11036472 DOI: 10.12998/wjcc.v12.i10.1714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 02/07/2024] [Accepted: 03/14/2024] [Indexed: 04/02/2024] Open
Abstract
Central venous catheter insertion in the internal jugular vein (IJV) is frequently performed in acute care settings, facilitated by its easy availability and increased use of ultrasound in healthcare settings. Despite the increased safety profile and insertion convenience, it has complications. Herein, we aim to inform readers about the existing literature on the plethora of complications with potentially disastrous consequences for patients undergoing IJV cannulation.
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Affiliation(s)
- Deb Sanjay Nag
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, Jharkhand, India
| | - Amlan Swain
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, Jharkhand, India
| | - Seelora Sahu
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, Jharkhand, India
| | - Bhanu Pratap Swain
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, Jharkhand, India
| | - Merina Sam
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, Jharkhand, India
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Hwang GH, Eom W. Thoracic duct cannulation during left internal jugular vein cannulation: A case report. World J Clin Cases 2023; 11:8200-8204. [PMID: 38130787 PMCID: PMC10731171 DOI: 10.12998/wjcc.v11.i34.8200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/31/2023] [Accepted: 11/28/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Central venous catheter insertion is an invasive procedure that can cause complications such as infection, embolization due to air or blood clots, pneumothorax, hemothorax, and, rarely, chylothorax due to damage to the thoracic duct. Herein, we report a case of suspected thoracic duct cannulation that occurred during left central venous catheter insertion. Fortunately, the patient was discharged without any adverse events related to thoracic duct cannulation. CASE SUMMARY A 46-year-old female patient presented at our department to undergo cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. During anesthesia, we decided to insert a central venous catheter through the left internal jugular vein because the patient already had a chemoport through the right central vein. During the procedure, blood reflux was observed when the needle tip was not within the ultrasound field of view. We did not try to find the tip; however, a guide wire and a central venous catheter were inserted without any resistance. Subsequently, when inducing blood reflux from the distal port of the central venous catheter, only clear fluid, suspected to be lymphatic fluid, was regurgitated. Further, chest X-ray revealed an appearance similar to that of the path of the thoracic duct. Given that intravenous fluid administration was not started and no abnormal fluid collection was noted on preoperative chest X-ray, we suspected thoracic duct cannulation. CONCLUSION It is important to use ultrasound to confirm the exact position of the needle tip and guide wire path.
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Affiliation(s)
- Geal Hong Hwang
- Department of Anesthesiology and Pain Medicine, National Cancer Center, Goyang-si 10408, Gyeonggi-do, South Korea
| | - Woosik Eom
- Department of Anesthesiology and Pain Medicine, National Cancer Center, Goyang-si 10408, Gyeonggi-do, South Korea
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Syed F, Khurshid Q, Wireko F, Poddar V. A Unique Case of Chylothorax Occurring Post-Chest Tube Insertion. Cureus 2023; 15:e41999. [PMID: 37593285 PMCID: PMC10428189 DOI: 10.7759/cureus.41999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/17/2023] [Indexed: 08/19/2023] Open
Abstract
Chylothorax is a relatively rare condition characterized by the accumulation of chyle, a milky lymphatic fluid, within the pleural space. It occurs because of disruption or obstruction of the thoracic duct or its tributaries, leading to chyle leakage into the pleural cavity. We present an interesting case of chylothorax that occurred as a complication post-chest tube insertion. A 66-year-old patient presented with hypotension and shortness of breath. Initial chest X-ray in the emergency room showed a right-sided hydropneumothorax requiring chest tube placement. Later on, the patient was transferred to the medical intensive care unit for respiratory failure. Chest tube drainage was initially serosanguineous but later changed to milky-white drainage. Pleural fluid analysis showed a triglyceride level of 208, confirming chylothorax. Conservative treatment was initiated with a low-fat diet and octreotide. The plan was to schedule the patient for thoracic duct embolization in view of continuous chylous drainage, but due to family preference, the procedure was deferred. This case report provides an overview of chylothorax, including etiologies and diagnostic options, and shows the importance of taking a multidisciplinary approach to finalize management strategies.
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Affiliation(s)
- Faisal Syed
- Internal Medicine, Howard University Hospital, Washington DC, USA
| | - Qasim Khurshid
- Internal Medicine, Howard University Hospital, Washington DC, USA
| | - Felix Wireko
- Internal Medicine, Howard University Hospital, Washington DC, USA
| | - Vishal Poddar
- Pulmonary and Critical Care, Howard University Hospital, Washington DC, USA
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Ünal M, Ünal E, Imholz ALT. Chylothorax due to thrombosis of the jugular and subclavian veins in a patient with gastric cancer: a case report. J Med Case Rep 2023; 17:75. [PMID: 36869391 PMCID: PMC9985247 DOI: 10.1186/s13256-023-03775-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 01/13/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Chylothorax is a rare condition due to leakage of chyle in the thoracic cavity. When large amounts of chyle leak into the thoracic cavity, it can lead to severe respiratory, immune, and metabolic complications. Chylothorax has many potential underlying etiologies, and the most common causes are traumatic chylothorax and lymphoma. Venous thrombosis of the upper extremities is a rare cause of a chylothorax. CASE PRESENTATION A 62-year-old Dutch man with a medical history of gastric cancer, treated with neoadjuvant chemotherapy and surgery 13 months prior, presented with dyspnea and a swollen left arm. Computed tomography thorax showed bilateral pleural effusion that was more prominent on the left side. The computed tomography scan further revealed thrombosis of the left jugular and subclavian veins and osseal masses suggesting cancer metastasis. Thoracentesis was performed to confirm the suspicion of gastric cancer metastasis. The obtained fluid was milky with a high level of triglycerides, but contained no malignant cells; hence, the diagnosis of the pleural effusion was chylothorax. Treatment with anticoagulation and a medium-chain-triglycerides diet was started. Furthermore, bone metastasis was confirmed with a bone biopsy. CONCLUSION Our case report demonstrates chylothorax as a rare cause of dyspnea in a patient with pleural effusion and a history of cancer. Therefore, this diagnosis should be considered in all patients with a history of cancer with new-onset pleural effusion and thrombosis of the upper extremities or clavicular/mediastinal lymphadenopathy.
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Affiliation(s)
- M Ünal
- Department of Internal Medicine, University Medical Center Groningen UMCG, P.O. Box 30.001, 9713 GZ, Groningen, The Netherlands.
| | - E Ünal
- Department of Internal Medicine, Hospital Group Twente, Almelo, The Netherlands
| | - A L T Imholz
- Department of Internal Medicine, Deventer Hospital, Deventer, The Netherlands
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Indonesian female with bilateral chylothorax and mediastinal non-Hodgkin lymphoma: A case report. Int J Surg Case Rep 2022; 102:107827. [PMID: 36473268 PMCID: PMC9723926 DOI: 10.1016/j.ijscr.2022.107827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Bilateral chylothorax is leakage and accumulation of lymph fluid in the pleural space on both sides of the lung and in non-traumatic cases, caused mainly by lymphoma. CASE PRESENTATION An Indonesian female, 34 years old, complained of short breath, cough, and swelling in several areas (neck, breast, and hands). Chest X-ray and thorax CT scan showed the anterior mediastinal mass and bilateral pleural effusion. Pleural fluid from both hemithorax was yellow and turbid but odorless. Aerobic culture and cytology of pleural fluid were negative. Triglyceride (TG) of both pleural fluids was >110 mg/dL with the ratio of cholesterol/triglyceride of pleural fluid <1 supporting chylothorax. The core biopsy analysis was negative. Non-Hodgkin lymphoma was established by open thoracotomy biopsy and immunochemistry examination. Chylothorax prognosis was an improvement which was reduced after chest tube insertion. On the outpatient, the patient plans chemotherapy with R CHOP regimen (Rituximab + Cyclophosphamide, prednisone, doxorubicin, and vincristine). DISCUSSION Malignancy is the primary cause of non-traumatic chylothorax and thoracotomy is used to repair the thoracic duct. CONCLUSION Bilateral chylothorax and non-Hodgkin lymphoma were confirmed based on pleural fluid analysis, thoracotomy open biopsy, and immunochemistry examination.
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Kim Y, Kim HB, Pak CJ, Suh HP, Hong JP. Using Lymphovenous Anastomosis and Lymph Node to Vein Anastomosis for Treatment of Posttraumatic Chylothorax with Increased Thoracic Duct Pressure in 3-Year-Old Child. Arch Plast Surg 2022; 49:549-553. [PMID: 35919557 PMCID: PMC9340176 DOI: 10.1055/s-0042-1751026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Chylothorax is a rare disease and massive lymph fluid loss can cause life-threatening condition such as severe malnutrition, weight loss, and impaired immune system. If untreated, mortality rate of chylothorax can be up to 50%. This is a case report of a 3-year-old child with iatrogenic chylothorax. Despite conservative treatment and procedures, like perm catheter insertion, the patient failed to improve the respiratory symptoms over 3 months of period. As an alternative to surgical option, such as pleurodesis and thoracic duct ligation which has high complication rate, the patient underwent lymphovenous anastomosis (LVA) and lymph node to vein anastomosis (LNVA). Follow-up at fourth month showed clear lungs without breathing difficulty despite perm catheter removal. This is the first report to show the effectiveness of LVA and LNVA against iatrogenic chylothorax.
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Affiliation(s)
- Yeongsong Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Hyung B Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Changsik J Pak
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Hyunsuk P Suh
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Joon P Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
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Waikar HD, Kamalaneson P, Mohamad Zamri MS, Jayakrishnan AG. Chylothorax after off-pump coronary artery bypass graft surgery: Management strategy. Ann Card Anaesth 2019; 21:300-303. [PMID: 30052221 PMCID: PMC6078034 DOI: 10.4103/aca.aca_212_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Chylothorax is a rare complication after cardiac surgery but is associated with morbidity and mortality. The most common cause of chylothorax is damage to or avulsion of thoracic duct by electrocautery during left internal thoracic artery harvesting for coronary artery bypass graft (CABG) surgery. We describe a case of chylothorax after off-pump CABG, which was successfully treated with thoracostomy tube drainage, withholding of oral intake, total parenteral nutrition and subcutaneous octreotide, a somatostatin analog, and chemical pleurodesis.
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Affiliation(s)
| | - Peter Kamalaneson
- Department of Cardiothoracic Surgery, Nawaloka Hospitals (Pvt) Ltd., Colombo, Sri Lanka
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Thind GS, Zoltowska DM, Agrawal Y. Rare case of massive bilateral chylothorax. BMJ Case Rep 2017; 2017:bcr-2017-221031. [PMID: 28883011 DOI: 10.1136/bcr-2017-221031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present a case of a 48-year-old woman who was referred from an outside hospital. There, she had initially underwent hysterectomy and left salpingo-oophorectomy for tubo-ovarian abscess. She later developed a colovaginal fistula and perforation of sigmoid colon and underwent Hartmann's procedure along with drainage of a left subphrenic abscess. Subsequently, she had to be intubated for acute respiratory failure and was transferred to our hospital. At our hospital, she was found to have massive bilateral pleural effusions. Bilateral small-bore chest tubes were inserted that drained milky fluid. Pleural fluid analysis was consistent with bilateral chylothorax. Thereafter, patient's respiratory status improved and she was extubated. The mechanism of chylothorax was thought be either secondary to the multiple abdominal procedures or alternatively as a complication of the right subclavian catheter that was placed at the outside hospital. Her chest tubes were removed eventually, and she had a slow but definite recovery.
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Affiliation(s)
- Guramrinder Singh Thind
- Department of Internal Medicine, Western Michigan University School of Medicine, Kalamazoo, Michigan, USA
| | - Dominika M Zoltowska
- Department of Internal Medicine, Western Michigan University School of Medicine, Kalamazoo, Michigan, USA
| | - Yashwant Agrawal
- Department of Internal Medicine, Western Michigan University School of Medicine, Kalamazoo, Michigan, USA
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Go JY, Han DJ, Kim J, Yoon SP. A supraclavicular cephalic vein drained into the subclavian vein. Surg Radiol Anat 2017; 39:1413-1415. [PMID: 28547035 DOI: 10.1007/s00276-017-1878-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 05/19/2017] [Indexed: 10/19/2022]
Abstract
Although the cephalic vein follows a fairly consistent course, numerous variants have been reported. We found a rare anatomical presentation of the cephalic vein in a 75-year-old Korean male cadaver. The left cephalic vein was identified in the deltopectoral groove, ascended over the clavicle, and terminated into the left subclavian vein just before its union with the left internal jugular vein. The detailed knowledge on the variations of the cephalic vein is important for clinicians as well as anatomists since the approach through the axillary base is favored in many invasive clinical procedures.
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Affiliation(s)
- Jun-Yong Go
- Medical Course, Medical School, Jeju National University, Jeju-si, Jeju-do, 63243, Republic of Korea
| | - Dong-Jae Han
- Medical Course, Medical School, Jeju National University, Jeju-si, Jeju-do, 63243, Republic of Korea
| | - Jinu Kim
- Department of Anatomy, School of Medicine, Jeju National University, 102 Jejudaehak-ro, Jeju-si, Jeju-do, 63243, Republic of Korea
| | - Sang-Pil Yoon
- Department of Anatomy, School of Medicine, Jeju National University, 102 Jejudaehak-ro, Jeju-si, Jeju-do, 63243, Republic of Korea. .,Institute of Medical Science, Jeju National University, Jeju-si, Jeju-do, 63243, Republic of Korea.
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Abram J, Klocker J, Innerhofer-Pompernigg N, Mittermayr M, Freund MC, Gravenstein N, Wenzel V. [Injuries to blood vessels near the heart caused by central venous catheters]. Anaesthesist 2016; 65:866-871. [PMID: 27709274 DOI: 10.1007/s00101-016-0226-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Injuries to blood vessels near the heart can quickly become life-threatening and include arterial injuries during central venous puncture, which can lead to hemorrhagic shock. We report 6 patients in whom injury to the subclavian artery and vein led to life-threatening complications. Central venous catheters are associated with a multitude of risks, such as venous thrombosis, air embolism, systemic or local infections, paresthesia, hemothorax, pneumothorax, and cervical hematoma, which are not always immediately discernible. The subclavian catheter is at a somewhat lower risk of catheter-associated sepsis and symptomatic venous thrombosis than approaches via the internal jugular and femoral veins. Indeed, access via the subclavian vein carries a substantial risk of pneumo- and hemothorax. Damage to the subclavian vein or artery can also occur during deliberate and inadvertent punctures and result in life-threatening complications. Therefore, careful consideration of the access route is required in relation to the patient and the clinical situation, to keep the incidence of complications as low as possible. For catheterization of the subclavian vein, puncture of the axillary vein in the infraclavicular fossa is a good alternative, because ultrasound imaging of the target vessel is easier than in the subclavian vein and the puncture can be performed much further from the lung.
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Affiliation(s)
- J Abram
- Univ.-Kinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, 6020, Innsbruck, Österreich
| | - J Klocker
- Univ.-Klinik für Gefäßchirurgie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - N Innerhofer-Pompernigg
- Univ.-Kinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, 6020, Innsbruck, Österreich
| | - M Mittermayr
- Univ.-Kinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, 6020, Innsbruck, Österreich
| | - M C Freund
- Univ.-Klinik für Radiologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - N Gravenstein
- Univ.-Klinik für Anästhesie und Intensivmedizin, University of Florida, Gainesville, USA
| | - V Wenzel
- Bodensee Medizin Campus, Klinik für Anästhesie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Röntgenstraße 2, 88048, Friedrichshafen, Deutschland.
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Ray A. Pathogenesis of bilateral chylothorax after injury of thoracic duct during central venous catheterization. Lung India 2015; 32:673-5. [PMID: 26664195 PMCID: PMC4663892 DOI: 10.4103/0970-2113.168115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Animesh Ray
- Department of Pulmonary Critical Care and Sleep Medicine, Fortis Flt. Lt. Rajan Dhall Hospital, Vasantkunj, New Delhi, India E-mail:
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12
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Saxena P, Shankar S, Kumar V, Naithani N. Bilateral chylothorax as a complication of internal jugular vein cannulation. Lung India 2015; 32:675-6. [PMID: 26664196 PMCID: PMC4663893 DOI: 10.4103/0970-2113.168118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Puneet Saxena
- Department of Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India E-mail:
| | - Subramanian Shankar
- Department of Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India E-mail:
| | - Vivek Kumar
- Department of Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India E-mail:
| | - Nardeep Naithani
- Department of Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India E-mail:
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