Presentation
Signs and symptoms suggestive of congestive cardiac failure with a known history of chronic hypertension and diabetes.
Patient Data
The portable chest x-ray demonstrates apparent cardiomegaly, pulmonary venous congestion, cephalisation of the pulmonary veins and pulmonary interstitial edema consistent with congestive cardiac failure. There are no pleural effusions.
A newly inserted right subclavian access central venous catheter is identified. The distal tip projects overlying the superior vena cava. There are persistent features of congestive cardiac failure and cardiomegaly. There are overlying ECG leads. There are no pleural effusions.
The follow-up chest x-ray confirms a new, large, right, pleural effusion.
A CT of the chest is requested following the identification of the large right pleural effusion in a setting of ongoing treatment for congestive cardiac failure.
The right central venous catheter is identified to be extravascular and intrapleural, projecting posteromedially and overlying a thoracic vertebral body.
There is a large right pleural effusion and compressive atelectasis (lung windows have not been uploaded).
The injected contrast for the CT accumulates within the pleural space confirming the extravascular central venous catheter placement.
Image courtesy: Dr PGNM Quvane
The patient is intubated with the ETT low-lying within the proximal right main bronchus and recommended retraction.
There is a right mid-zonal intercostal drain with near total drainage of the pleural effusion and a small pseudotumor due to the minor fissural pleural fluid.
There is significant improvement in the interstitial pulmonary edema and venous congestion.
Case Discussion
An example of an infusothorax due to the malposition and extravascular placement of the right central venous catheter. The catheter tip is intrapleural and the administered fluid accumulated within the pleural space as demonstrated by the day 4 chest x-ray. There is the inadvertent extravasation of contrast into the pleural space due to the use of the malpositioned central venous catheter for contrast injection for the requested CT chest study.
There is no subclavian arterial or venous rupture and the pleural fluid is nearly totally drained once the intercostal drain was inserted as demonstrated by the day 5 chest x-ray.
The patient subsequently fully recovered without any further incident.
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