Haemothorax after removal of subclavian venous catheter: An unusual complication

In the view of the short duration of the procedure, general anaesthesia was planned. Following intravenous fentanyl (60 μg) and propofol (100 mg), a Pro-seal laryngeal mask airway was inserted. Anaesthesia was maintained with O2, N2O, isoflurane. The patient was placed in lithotomy position and 4% formalin was instilled intravesically. Formalin was kept in situ for 20 min, after which the bladder was evacuated. There was an immediate hypertensive response following formalin instillation, the blood pressure rose from a baseline value of 110/80 mmHg to 190-180/120-100 mmHg with a pulse rate of 86 beats/min. The hypertensive response persisted despite repeating fentanyl (90 μg). After the procedure, on awakening, the patient complained of severe, unbearable pain in the suprapubic region despite repeated doses of IV fentanyl and morphine. His blood pressure continued to remain high. To alleviate his pain an epidural catheter was inserted in the L2-3 space and 10 ml of 0.125% bupivacaine administered. After 20 min the pain subsided and his vitals returned to normal.

haemorrhagic cystitis was made. The patient twice underwent cystoscopy with clot evacuation for the same under subarachnoid block. However, the hematuria persisted, necessitating repeated transfusions of packed Red Blood Cells. As a last-ditch effort to stop the diffuse bleeding, an old technique of intravesical instillation and irrigation with formalin was planned. [1] The patient was a diabetic on insulin. He had no other comorbid disease. His preoperative haemoglobin was 7.4 g% and coagulation profile was within normal limits.
In the view of the short duration of the procedure, general anaesthesia was planned. Following intravenous fentanyl (60 µg) and propofol (100 mg), a Pro-seal laryngeal mask airway was inserted. Anaesthesia was maintained with O 2 , N 2 O, isoflurane. The patient was placed in lithotomy position and 4% formalin was instilled intravesically. Formalin was kept in situ for 20 min, after which the bladder was evacuated. There was an immediate hypertensive response following formalin instillation, the blood pressure rose from a baseline value of 110/80 mmHg to 190-180/120-100 mmHg with a pulse rate of 86 beats/min. The hypertensive response persisted despite repeating fentanyl (90 µg). After the procedure, on awakening, the patient complained of severe, unbearable pain in the suprapubic region despite repeated doses of IV fentanyl and morphine. His blood pressure continued to remain high. To alleviate his pain an epidural catheter was inserted in the L2-3 space and 10 ml of 0.125% bupivacaine administered. After 20 min the pain subsided and his vitals returned to normal.
Formalin has a dessicating effect when applied to living tissue; it hydrolyzes proteins and coagulates superficial tissue. This effect controls the haemorrhage from telangiectatic capillaries in the mucosal and submucosal layers. [1] Sloughing of the urothelium, local oedema and inflammation cause severe pain. Regeneration can take up to three weeks. Suprapubic pain, dysuria, a reduction in bladder capacity, urgency and incontinence are known complications. [1] The severity of the pain requires that, where possible, the procedure should be carried out under regional anaesthesia. Not many anaesthesiologists may be aware of the severe pain engendered by the intravesical instillation of formalin and we wanted to share our experience. We came across only one other report where suprapubic pain following formalin instillation was managed with intravesical lidocaine. [2] However, the duration of pain relief with such a technique would be limited. An epidural catheter offers the advantage of repeated dosing which can be beneficial, as our patient needed epidural morphine for two days. Sir, We like to report a case of haemothorax which occurred after removal of subclavian venous catheter. A 35 year old male patient, a case of left Cerebello pontine angle tumour was posted for craniectomy and excision. On the day of surgery after induction of general anaesthesia, subclavian venous catheterization was done on the right side through standard infraclavicular approach. Central venous pressure monitoring was done intraoperatively and intraoperative haemodynamics and vital parameters remained normal. After surgery patient was shifted to the intensive care unit for postoperative ventilatory support. Chest X-ray taken in the postoperative period with the catheter in situ was normal [ Figure 1].
In the ICU, patient was weaned from ventilator support and extubated on the first postoperative day. Patient  On the third postoperative day subclavian catheter was removed and dressing applied. Within 2 h after removal of catheter, patient started complaining of respiratory difficulty with pain on right side of chest. Patient was maintaining an SpO 2 of 91-93% and clinical examination revealed reduced air entry on the right side of the chest. Chest X-ray taken showed effusion on right chest with collapse of right lung [ Figure 2]. Intercostal drain insertion was done in the right side of the chest and about 1 litre of blood got collected in the ICD bag. Flow of blood through ICD gradually got reduced and stopped after a few hours [ Figure 3]. Patient became comfortable with stable vitals after ICD insertion. ICD was retained for three days and then removed. Repeat chest X-rays showed no further collections and the patient was discharged.
Various complications like pneumothorax and haemothorax have been reported to occur during insertion of subclavian venous catheter. [1,2] But, haemothorax occurring after subclavian catheter removal is an unusual complication. Massive haemothorax after subclavian catheter removal in a patient who had undergone renal transplant was reported previously by Collini in 2002. [3] The probable mechanism behind this complication could be injury to the pleura during insertion and a communication could have occured between the vein and right pleural cavity after catheter removal. This complication has been reported to emphasize that careful monitoring is necessary after subclavian venous catheter removal.

Srinivasan Swaminathan, Rajnish K Jain
Department of Anaesthesiology and Critical Care, Bhopal Memorial Hospital and Research Centre, Bhopal, India