CASE 15811 Published on 01.08.2018

Iatrogenic haemothorax following thoracentesis

Section

Chest imaging

Case Type

Clinical Cases

Authors

Tonolini Massimo, MD.

Patient

57 years, female

Categories
Area of Interest Lung ; Technique CT
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.
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].
Differential Diagnosis List
Iatrogenic actively bleeding haemothorax following thoracentesis
Chest wall haematoma
Pneumothorax
Re-expansion pulmonary oedema
Final Diagnosis
Iatrogenic actively bleeding haemothorax following thoracentesis
Case information
URL: https://www.eurorad.org/case/15811
DOI: 10.1594/EURORAD/CASE.15811
ISSN: 1563-4086