Had an interesting patient last night… something I had not run into before. I'm wondering if any of you have seen this.
25 year old female presents with chest pain, syncope and vomiting blood. Vitals and physical are essentially normal. She reports a history of Barrets esophagus and nissen fundoplication. She has very poor peripheral veins due to numerous recent iv sticks. Eventually I place a right EJ. Goes in smoothly, good blood return. I'm able to draw all the labs for the nurse off of this. It is hooked up to saline and is flowing. The patient later describes some discomfort in that area. I recheck the iv, still has good blood return and no evidence of infiltration. Chest X-ray is normal except for a subtle abnormality… density along right mediastinum. No pneumothorax. Time goes by, labs are normal. Guiac negative, NG lavage negative. Pt's pain is getting worse. Skipping many of the details, eventually order a CT angio of the chest to evaluate for PE. I then get a call from the CT tech that all of the contrast had extravasated into the patients neck. The CT was continued with out contrast. It shows that there is mass effect from the contrast causing some mild shift of trachea and mediastinum but not major. It also shows that there is a large right pleural effusion.
The X-ray had not shown this an hour or so before. When I saw the pleural effusion… i nearly lost all sphincter tone… initially thinking that I somehow caused an arterial puncture and that this was a hemothorax. The patient remained hemodynamically stable. The density of the fluid was likely transudative per radiologist. The patients H/H remained stable.
It now seems obvious that he abnormality in the mediastinum was likely from fluid extravasating from the line early on… although it seemed to be working fine and there was no physical evidence of infiltration. The large pleural effusion was likely the 1 liter normal saline bolus I had ordered for my patient.
I discussed the case with vascular, mostly regarding the shifting of the mediastinum due to contrast extravasation. They didn't seem to think it would be a problem at all and didn't seem to impressed. He said he had seen similar things before. They recommended serial h/h and repeat X-ray in the morning but expect that since she is otherwise healthy the pleural fluid will reabsorb without a problem.
Now the worst part is that after I was scratching my head from working this lady up for an upper gi bleed and finding no evidence of one, I received an "anonymous" phone call from a concerned friend/family member telling me that she has been to 4 other hospitals recently with her complaints of vomiting blood and chest pain. She was eventually discharged from all of them with a diagnosis of psychiatric illness.
At this point I had to call the hospitalist with my tail between my legs so that they could admit this patient, not for her chief complaint, but for her iatrogenic pleural effusion and extravasated contrast.
Have any of you ever seen an EJ infiltrate like this??? Local infiltration I can understand but she didn't demonstrate that. All of the fluid seemed to go into the pleural space. This was a pretty easy superficial stick so I can't imagine the catheter was in the pleural space directly. It must have dissected through the tissues and collected there.
Strange...
25 year old female presents with chest pain, syncope and vomiting blood. Vitals and physical are essentially normal. She reports a history of Barrets esophagus and nissen fundoplication. She has very poor peripheral veins due to numerous recent iv sticks. Eventually I place a right EJ. Goes in smoothly, good blood return. I'm able to draw all the labs for the nurse off of this. It is hooked up to saline and is flowing. The patient later describes some discomfort in that area. I recheck the iv, still has good blood return and no evidence of infiltration. Chest X-ray is normal except for a subtle abnormality… density along right mediastinum. No pneumothorax. Time goes by, labs are normal. Guiac negative, NG lavage negative. Pt's pain is getting worse. Skipping many of the details, eventually order a CT angio of the chest to evaluate for PE. I then get a call from the CT tech that all of the contrast had extravasated into the patients neck. The CT was continued with out contrast. It shows that there is mass effect from the contrast causing some mild shift of trachea and mediastinum but not major. It also shows that there is a large right pleural effusion.
The X-ray had not shown this an hour or so before. When I saw the pleural effusion… i nearly lost all sphincter tone… initially thinking that I somehow caused an arterial puncture and that this was a hemothorax. The patient remained hemodynamically stable. The density of the fluid was likely transudative per radiologist. The patients H/H remained stable.
It now seems obvious that he abnormality in the mediastinum was likely from fluid extravasating from the line early on… although it seemed to be working fine and there was no physical evidence of infiltration. The large pleural effusion was likely the 1 liter normal saline bolus I had ordered for my patient.
I discussed the case with vascular, mostly regarding the shifting of the mediastinum due to contrast extravasation. They didn't seem to think it would be a problem at all and didn't seem to impressed. He said he had seen similar things before. They recommended serial h/h and repeat X-ray in the morning but expect that since she is otherwise healthy the pleural fluid will reabsorb without a problem.
Now the worst part is that after I was scratching my head from working this lady up for an upper gi bleed and finding no evidence of one, I received an "anonymous" phone call from a concerned friend/family member telling me that she has been to 4 other hospitals recently with her complaints of vomiting blood and chest pain. She was eventually discharged from all of them with a diagnosis of psychiatric illness.
At this point I had to call the hospitalist with my tail between my legs so that they could admit this patient, not for her chief complaint, but for her iatrogenic pleural effusion and extravasated contrast.
Have any of you ever seen an EJ infiltrate like this??? Local infiltration I can understand but she didn't demonstrate that. All of the fluid seemed to go into the pleural space. This was a pretty easy superficial stick so I can't imagine the catheter was in the pleural space directly. It must have dissected through the tissues and collected there.
Strange...
