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Central venous catheterization carries the second highest risk of iatrogenic pneumothorax. Subclavian catheterization carries a higher risk than internal jugular catheterization. Pneumothorax is one of the most common CVC insertion complications, reportedly representing up to 30% of all mechanical adverse events of CVC insertion.We report a case of central venous catheterization in a 35-year-old female patient, developed hydropneumothorax during subclavian vein catheterization.
Case Presentation A 35-year-old Asian female patient with severe lupus nephritis disease and hypertension, admitted to our ED with chieft complaint acute shortness of breath, undergoing hemodialysis through a right subclavian venous catheter.
Then, 8 hours after the catheter is inserted, during dyalisis, the patient developed shortness of breath, right-sided pleuritic chest pain, sudden onset, and gradually progressive in nature. Physical examination revealed absent air entry over the right lung field. A post-procedure chest X-ray showed right sided hydropneumothorax. An emergency intercostal drainage tube was placed in the 5th intercostal space in the right side in the safe triangle. Post chest tube insertion, the patient’s symptoms resolved, and the patient was clinically better, oxygen saturation normalized. A post chest tube insertion, X-ray was taken, and showed tube in position with pneumothorax being resolved and lung expanded. The chest tube was placed for 5 days after which it was clamped for an observation period of 8 h and the patient had no complaints of dyspnea or chest pain during the observation period. The patient was discharged on day 7 with significant improvement.
Subclavian vein insertion has been reported to have a higher incidence of pneumothorax than IJV insertion.While it is standard practice to obtain a chest X-ray after catheterization to confirm placement and to exclude complication, initial films may fail to show a hydropneumothorax, a delayed pneumothorax may occur from 8 h to 4 days after insertion. A routine practice of taking a post-procedure X-ray immediately after cannulation and monitoring the patient for any symptoms of dyspnea or chest pain should be made mandatory.Furthermore, there are evidence of delayed development of hydropneumothorax post central line insertion, hence, repeat chest X-ray in symptomatic cases should be done even after an initial negative chest X-ray. Pulmonary involvement in SLE is common, pleuritis can occurred in 45 % of patients. In SLE, pleural effusion usually bilateral and small to moderate in size, massive effusion leading to mediastinal shift have also been reported.
This case highlights the potential for complications during central venous catheter insertion via subclavia vein in in severe lupus nephritis patient.
