Journal of The Association of Physicians of India ■ Vol.

64 ■ September 2016 91

Delayed Haemothorax Resulting from Indwelling Right Internal

Jugular Central Venous Catheter: A Rare Complication
KV Vinod1, S Nishanth2, MV Vidya3

echocardiography were unremarkable

Abstract and cardiac troponins were negative. For
monitoring of central venous pressure
Haemothorax is an uncommon and serious complication, occurring most often
and anticipating the requirement
during or immediately after percutaneous internal jugular and subclavian
for hemofiltration, percutaneous
vein catheterizations. Delayed haemothorax is a rare complication, especially
right sided internal jugular double
following right-sided catheterization. We report a case of acute yellow phosphorus lumen CVC [12 Fr caliber, 16 cm
poisoning with acute liver failure (resulting from rat killer paste ingestion) in l e n g t h ] wa s p l a c e d u n d e r a s e p t i c
a 28-year-old male who developed right-sided haemothorax eight days after conditions in single attempt [by blind
placement of right internal jugular central venous catheter. The proposed anterior approach], after prophylactic
pathogenesis involves vascular wall erosion by the indwelling catheter tip. administration of fresh frozen plasma.
Awareness of this complication perhaps avoids unnecessary investigations for Post-procedure chest X-ray [CXR]
other causes of haemothorax such as pulmonary embolism. had ruled out complications (Figure
1a). Hypotension and urine-output
improved after fluid administration
and vasopressor support. Over the
Introduction sec, partial thromboplastin time: 42 sec,
next seven days, there was gradual
hemoglobin: 14.6 g/dl, total leucocyte

H
aemothorax is an uncommon and
serious complication, occurring
most often during or immediately
after percutaneous internal jugular
and subclavian central venous
catheter [CVC] placement. 1 Delayed
haemothorax, occurring several
days after CVC placement, is a rare
complication and most often reported
following left-sided catheterizations. 2
We r e p o r t a r a r e c a s e o f d e l a ye d
right-sided haemothorax, resulting
from indwelling right internal
jugular CVC, occurring eight days
after CVC placement, in a patient of
acute yellow phosphorus poisoning
with toxic hepatitis and acute liver
failure. Pathogenesis, management and
measures to reduce this complication
are discussed.
improvement of encephalopathy, liver
count: 12.6×10 9/ l, platelets: 44×10 9/ l,
function, coagulation parameters and
normal renal function, serum creatine
thrombocytopenia.
phosphokinase and electrolytes. A
diagnosis of acute toxic hepatitis, with On day-13, patient complained
acute liver failure was made and he of breathlessness and discomfort
was transferred to intensive care unit. on right side of the chest. He was
He was started on N-acetyl cysteine, tachypnoeic and chest radiograph
vitamin-K, lactulose, rifaximin and revealed moderate right-sided
nasogastric tube feeds. p l e u r a l e f f u s i o n . Pl e u r o c e n t e s i s
r e ve a l e d h a e m o r r h a g i c f l u i d w i t h
On day-5, he developed
a hematocrit of 28.3 %, confirming
hypotension, with decreased urine
haemothorax. Electrocardiogram and
output. Electrocardiogram and

Case Report
A 28-year-old male was admitted to
our emergency department following
suicidal ingestion of about 10 g of rat
killer paste (RATOL), containing 3%
yellow phosphorus. He had abdominal
pain and vomiting initially. On day-3
post-ingestion, he developed icterus,
Fig. 1: Chest X-ray taken on day-5 (a) after uneventful right internal jugular venous
confusion, irritability and asterixis.
catheter placement and repeat CXR done on day-13 (b), after placement of
Laboratory evaluation revealed intercostal tube to drain right sided haemothorax
deranged liver function- serum
bilirubin: 3.9 mg/dl [direct fraction: 3
mg/dl], aspartate transaminase: 240 IU/l, 1
Associate Professor, 2Junior Resident, Department of General Medicine, 3Senior Resident, Dept. of Anaesthesiology, Jawaharlal
alanine transaminase: 365 IU/l, alkaline Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantri Nagar, Puducherry, Pondicherry
phosphatase: 196 IU/l, deranged Received: 13.05.2015; Revised: 09.11.2015; Accepted: 05.12.2015
coagulation tests- prothrombin time: 46
 92 Journal of The Association of Physicians of India ■ Vol. 64 ■ September 2016
two-dimensional echocardiography
were normal. Ultrasound with color
Doppler study did not reveal internal
jugular or subclavian vein thrombosis
on the right side. The CVC was removed
i m m e d i a t e l y . Tu b e t h o r a c o s t o m y
(Figure 1b) drained 1000 ml of
hemorrhagic fluid, with prompt relief
of breathlessness and chest discomfort.
Contrast CT of the chest ruled out
pulmonary thromboembolism. Patient
r e c e i ve d t w o u n i t s o f p a c k e d r e d
blood cells. Intercostal tube drain
was removed on day-16 and he was
discharged later.
Discussion
5-19% of patients have been reported
to suffer mechanical complications such
as pneumothorax, vascular injuries,
CVC malposition, cardiac tamponade,
hydrothorax and haemothorax, during
or after CVC placement.1,3 Haemothorax
complicates approximately 1% of
CVC insertions, 4 usually develops
early- either during or immediately
after CVC placement and is mostly
due to inadvertent arterial injury or
innominate vein/ superior vena cava
perforation during internal jugular
and subclavian vein catheterizations. 1
Delayed haemothorax, occurring
several days after CVC placement, is
rare and thought to result from superior
vena cava erosion and perforation by
the indwelling CVC tip.
Depending on the site of vascular
perforation, cardiac tamponade from
hydropericardium/ haemopericardium
may develop when the perforation
occurs below the pericardial reflection
or hydrothorax/ haemothorax can
result- when the perforation occurs
a b o ve t h e p e r i c a r d i a l r e f l e c t i o n . 1
Pe r f o r a t i o n o c c u r r i n g a b o v e t h e
pericardial reflection has been reported
following 0.4 to 1 % of CVC insertions 1
and hydrothorax is more common
than haemothorax in this situation.
Left-sided catheterizations result in
more horizontal position of CVC shaft,
with perpendicular impingement,
steady pressure and friction of the
indwelling CVC tip on the vena cava
wall and hence carry higher risk of
vascular wall erosion and perforation. 1,2
Chemical damage to vessel wall from
the infused solutions or medications
may predispose to erosion and
perforation. Although right-sided
CVC placement is much safer in this
regard due to more parallel position
of the catheter shaft to vessel wall, the
index patient developed haemothorax
from indwelling right internal jugular
CVC. Subclavian and internal jugular
CVC tips can move by up to 2 cm after
insertion in adults, 5 with head, neck
and respiratory movements. CVC tip
migration, coupled with chemical vessel
wall damage might have contributed to
vascular perforation and haemothorax
in the index case. Management includes
prompt CVC removal and drainage of
the haemothorax. 2
M a n i f e s t a t i o n s o f a c u t e ye l l o w
phosphorus poisoning include hepatitis,
acute kidney injury, encephalopathy,
coagulopathy, hypotension/ shock and
other manifestations of multi-organ
dysfunction. There was no clinical or
radiologic evidence of pleural effusion
in the index patient till eight days
after CVC placement. Haemothorax
developed after improvement of liver
function, with normalization of the
coagulation parameters and platelet
c o u n t . H e n c e i t wa s u n r e l a t e d t o
coagulopathy and thrombocytopenia.
Using longer CVCs with a length of
20 cm for left sided catheterizations in
adults, as against 16 cm CVCs for right
sided catheterizations ensures more
horizontal position of the distal CVC
shaft to vessel wall, thereby reducing
risk of vessel wall perforation. 1 The
finding of a curled-up tip of a CVC that
does not normally have a curvature or
abutment of the CVC tip on venous wall
in frontal or lateral CXR films predicts
impending vascular perforation 1 and
should prompt immediate repositioning
of the CVC. However, the CXR done
in present case after CVC placement
(Figure 1a) had not shown curling-up
of the CVC tip. “Pig-tail” tipped CVCs
may reduce the risk of vascular erosion
and perforation.1 Radiographic contrast
i n j e c t i o n t o i n ve s t i g a t e s u s p e c t e d
vascular erosion by the catheter tip and
to demonstrate contrast extravasation
could not be carried out in our patient.
Conclusion
Haemothorax, a complication most
often encountered early following
internal jugular and subclavian CVC
placements, can rarely develop several
d a y s l a t e r . Pa t h o g e n e s i s i n v o l ve s
vascular wall erosion by the indwelling
CVC tip. Although reported most often
following left-sided catheterizations,
delayed haemothorax can rarely
follow right-sided CVC placements.
Awareness about this complication
ensures proper management and
avoids unnecessary investigations for
other causes of haemothorax such as
pulmonary embolism and malignancy
of the lung or pleura.
References
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venous catheters: internal jugular versus subclavian
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