aka Cardiovascular Curveball 001
An 86 year-old male presented with shortness of breath.He developed a complication after insertion of a left chest drain. Here is his CT:
Q1. What is the complication?
The chest drain is in the left ventricle.
Q2. Outline your management.
This complication was identified at the time by the presence of pulsatile bright red blood coming from the drain.
- Clamping the drain to prevent exsanguination is a good first step!
- Not taking the drain out is a good second step.
- The next step is to prepare the patient for cardiac surgery to remove the drain and repair the heart. In this patient, removing the drain and repairing the heart was achieved via a mini thoracotomy.
In addition to the issues of patient care, this is a sentinel event and appropriate reporting and follow-up needs to be undertaken. The CT below demonstrates how this complication arose…not everything that looks like a left pleural effusion on a plain chest X-ray is one!
Q3. How could this complication have been prevented?
Put your finger in the hole!
One of the most important steps in the insertion of an intercostal catheter is to insert a finger through the hole you have just made. Do this before inserting the intercostal catheter.
Using your finger you can detect any adhesions that may lead to penetration of the lung on insertion of the intercostal catheter, as well as the presence of underlying organs such as a beating heart!
In this case, the intercostal catheter is a one from a Seldinger kit. If you are going to use one of these kits, you should do an ultrasound to make sure that there really is a pleural effusion that can be safely drained.
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.