Teaching Case

Section

Chest imaging

Case Type

Clinical Cases

Authors

Tonolini Massimo, MD.

"Luigi Sacco" University Hospital,Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy; Email:mtonolini@sirm.org

Patient

57 years, female

Categories

Area of Interest Lung ; Imaging Technique CT ;

Procedure Drainage ; Special Focus Haemorrhage ;

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Clinical History

A 57-year-old female patient with history of radical cystectomy and external urinary diversion with ureteral stents (18 months earlier), hospitalised in the intensive care unit (ICU) because of persistent urinary sepsis, anasarca, and impaired renal function requiring haemodialysis. After thoracentesis, she suddenly developed worsening of respiratory function and haemoglobin levels dropped.

Differential Diagnosis List

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Iatrogenic actively bleeding haemothorax following thoracentesis

Chest wall haematoma

Pneumothorax

Re-expansion pulmonary oedema

Imaging Findings

Initial CT (Fig.1) showed presence of significant pericardial effusion, bilateral fluid-attenuation pleural effusions and atelectatic consolidations of both inferior lung lobes.
A few hours after left-sided thoracentesis, emergency CT (Fig.2) showed development of near-complete left lung atelectasis, appearance of some intrapleural air, marked increase of ipsilateral pleural effusion containing hyperattenuating components consistent with haemothorax, which caused contralateral dislocation of mediastinum and downwards dislocation of the hemidiaphragm. Additionally, a sizeable focus of contrast medium extravasation indicating active bleeding originating from the visceral pleura was visible within the haemothorax.
The patient underwent immediate tracheal intubation and pleural tube drainage. Repeated CT a day later (Fig.3), which showed partial re-expansion of left lung, moderately decreased haemothorax and minimal residual focal bleeding at visceral pleura. Despite clinical and laboratory stabilisation, she ultimately required thoracotomic surgery to evacuate the haemothorax and achieve haemostasis.

Discussion

Pleural effusion is a common condition which may develop secondary to a variety of causes and contributes to dyspnoea and patients’ sufferings. Nowadays, thoracentesis is routinely performed as a bedside procedure to remove fluid from the pleural space via percutaneous introduction of a needle: in the USA, among 1.5 million people with an effusion, an estimated 178.000 procedures are performed each year. Thoracentesis allows both symptomatic relief and evaluation of pleural fluid features which aid in recognizing the underlying aetiology [1].
Albeit regarded as safe and generally well tolerated, thoracentesis is not without risks, particularly pneumothorax from puncture of the visceral pleura (at least 3% of cases, depending on definition). Other complications include haemorrhage (0.1%) and re-expansion pulmonary oedema (0.01%) [1-5].
Albeit uncommon, iatrogenic bleeding may be increasingly encountered since recent evidence suggested that patients with contraindications such as prolonged International Normalized Ratio (INR), low platelet count, anticoagulation or clopidogrel may undergo thoracentesis without correcting bleeding risk or withholding medications [6-9].
Iatrogenic bleeding is potentially fatal, generally occurs shortly (within 24 hours) after thoracentesis, may develop in either pleural space or thoracic wall, and manifests with worsening respiratory distress, chest pain and hypotension. As in this patient, this complication is more common (0.6% of procedures) in the intensive care unit (ICU) and may also develop following thoracostomy for chest tube insertion or central venous catheterisation. Notably, overall short-term mortality after thoracentesis is high (>20%, >35% in ICU patients) particularly in bilateral, malignant, and multiple-aetiology effusions [5, 10].
As exemplified by the hereby presented case, the role of CT includes detection of haemothorax and of active bleeding. Borrowing from experience with polytraumatised patients, haemothorax appears as hyperattenuating (35-70 Hounsfield units) effusion with dependent layering of dense clots [11].
Most haemorrhages result from laceration during needle access of the intercostal artery [12-14], which is often tortuous and does not always lie along the inferior rib edge. Awareness of the higher “safe space” laterally than medially and use of colour Doppler US for guidance of thoracentesis significantly reduces risk of bleeding [9, 15, 16].
Management depends on haemodynamic conditions and blood volume evacuated via tube drainage. Surgical exploration (either video-assisted or thoracotomy) is warranted in massive (>1.5 l) haemothorax and ongoing blood loss [13, 17].

References

[1] Cantey EP, Walter JM, Corbridge T, et al (2016) Complications of thoracentesis: incidence, risk factors, and strategies for prevention. Curr Opin Pulm Med 22:378-385 (PMID: 27093476)

[2] Ault MJ, Rosen BT, Scher J, et al (2015) Thoracentesis outcomes: a 12-year experience. Thorax 70:127-132. (PMID: 25378543)

[3] Mercaldi CJ, Lanes SF (2013) Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest 143:532-538. (PMID: 23381318)

[4] Kozmic SE, Wayne DB, Feinglass J, et al (2016) Factors Associated with Inpatient Thoracentesis Procedure Quality at University Hospitals. Jt Comm J Qual Patient Saf 42:34-40 (PMID: 26685932)

[5] Chen CY, Hsu CL, Chang CH, et al (2010) Hemothorax in a medical intensive care unit: incidence, comorbidity and prognostic factors. J Formos Med Assoc 109:574-581. (PMID: 20708508)

[6] Patel PA, Ernst FR, Gunnarsson CL (2012) Ultrasonography guidance reduces complications and costs associated with thoracentesis procedures. J Clin Ultrasound 40:135-141. (PMID: 21994047)

[7] Patel MD, Joshi SD (2011) Abnormal preprocedural international normalized ratio and platelet counts are not associated with increased bleeding complications after ultrasound-guided thoracentesis. AJR Am J Roentgenol 197:W164-168 (PMID: 21700980)

[8] Puchalski JT, Argento AC, Murphy TE, et al (2013) The safety of thoracentesis in patients with uncorrected bleeding risk. Annals of the American Thoracic Society 10:336-341. (PMID: 23952852)

[9] Puchalski J (2014) Thoracentesis and the risks for bleeding: a new era. Curr Opin Pulm Med 20:377-384. (PMID: 24852328)

[10] DeBiasi EM, Pisani MA, Murphy TE, et al (2015) Mortality among patients with pleural effusion undergoing thoracentesis. Eur Respir J 46:495-502. (PMID: 25837039)

[11] Kaewlai R, avery LL, Asrani A, et al (2008) Multidetector CT of blunt thoracic trauma. Radiographics 28:1555-1570 (PMID: 18936021)

[12] Mansour W, Samaha G, El Bitar S, et al (2017) Intercostal Artery Laceration: Rare Complication of Thoracentesis and Role of Ultrasound in Early Detection. Case Rep Pulmonol 2017:6491083 (PMID: 28831322)

[13] Spanuchart I, Gallacher S (2016) Hemothorax after Thoracentesis. N Engl J Med 375:1878. (PMID: 27959649)

[14] Yacovone ML, Kartan R, Bautista M (2010) Intercostal artery laceration following thoracentesis. Respir Care 55:1495-1498 (PMID: 20979678)

[15] Yoneyama H, Arahata M, Temaru R, et al (2010) Evaluation of the risk of intercostal artery laceration during thoracentesis in elderly patients by using 3D-CT angiography. Intern Med 49:289-292 49:289-292 (PMID: 20154433)

[16] Kanai M, Sekiguchi H (2015) Avoiding vessel laceration in thoracentesis: a role of vascular ultrasound with color Doppler. Chest 147:e5-e7. (PMID: 25560873)

[17] Boersma WG, Stigt JA, Smit HJ (2010) Treatment of haemothorax. Respir Med 104:1583-1587 (PMID: 20817498)

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