Hydromediastinum and hydrothorax as delayed complications of peripherally inserted central catheter used for total parenteral nutrition: A case report

Abstract

Introduction Central venous catheters (CVCs) and peripherally inserted central catheters (PICCs) may cause delayed complications, such as venous erosion, hydrothorax, or hydromediastinum. Vascular erosion is most frequently associated with left-sided CVC insertions. We report a case of hydropneumomediastinum and hydropneumothorax as a delayed complication of right-sided PICC used for total parenteral nutrition. Presentation of case A 77-year-old man with muscle-invasive urothelial bladder cancer underwent pelvic lymphadenectomy and radical cystectomy with uretero-ileostomy reconstruction (Bricker). The patient developed postoperative ileus, and thus, a right PICC was inserted for total parenteral nutrition. On postoperative day 8, he developed bilateral hydromediastinum, and bilateral thoracentesis was performed. After the procedure, he presented with respiratory and hemodynamic deterioration and was transferred to the intensive care unit for 12 days. The patient was eventually discharged and followed-up at the outpatient department. Discussion Ruptured SVC has been predominantly described in left-sided CVCs at the right angle of the junction of the left brachiocephalic vein and SVC. However, our patient is the second documented case of bilateral hydropneumothorax and hydropneumomediastinum as a delayed complication of a PICC used to administer total parenteral nutrition. Catheters may migrate from their initial position due to breathing, bloodstream flow dynamics, postural rotation, and neck movements. Chemical irritation of the vessel wall may be caused by hyperosmolar hyperalimentation fluid. Conclusion A right-sided vascular approach is preferred to avoid friction complications, and the tip should be placed at the lower third of the vena cava to prevent vascular erosion.

Friction injury of the central vein caused by catheter for hemodialysis: an in vitro study

“…Essentially, not only CVCs are used for dialysis; peripherally inserted central catheters (PICCs) also have similar problems. They migrate with respiration, bloodstream flow dynamics, postural rotation and neck movements, injuring the blood vessel wall by rubbing 33 ; thus, this experimental outcome may extend to PICCs.…”

Chylothorax and mediastinal haematoma by central venous catheter post-duodenal ulcer and pyloroplasty surgery: a case report

“…The incidence of catheter-related complications is higher in left-sided IJV catheterization due to anatomical differences. 5 These include catheter malposition and thoracic duct injury. The ideal CVC tip position is in the lower third of the superior vena cava or near the cavoatrial junction.…”