The outcome of the problem was that a vascular surgeon was contacted who
strongly advised against blindly removing the triple line. Instead the line
was removed through supra and sub-clavicular incisions. The hole in the
artery being repaired with 5/0 prolene x2.
This is fair enough but one wonders if a vascular surgeon has a biased view
as they only usually see complications. Or, is the potential for harm
(although probably rare - but death, AV fistula's and severe bleeding are
all described) sufficiently high to warrant such intervention.
I still do not know the answer, but now that we have asked, and the
precedent has been set it seems that we may have to continue with this
invasive management in the future.
Simon Carley
Anaesthetics / Intensive Care
Stepping Hill Hospital
Stockport
England
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----------
> From: Simon Carley <[log in to unmask]>
> To: acadae messages <[log in to unmask]>
> Subject: a pulling dilemma
> Date: 05 January 1999 12:43
>
> I recently (but not too recently) had a patient with chest trauma who
left
> us in a bit of a clinicla dilemma.
>
> Hx.
> Pedestrian
> Blunt chest trauma to right side chest resulting in #2,3,4,5, ribs, flail
> segment, large pulmonary contusion and tension pneumothorax.
>
> The mechanism was a direct blow from a passing vehicle, there was no
other
> trauma. The left side of the chest appeared fine (on 3 x-rays and
> clinically)
>
> Tension was drained and the patient was observed, however after about 15
> hours he became tired and was intubated and ventilated on ITU. 10 minutes
> later airway pressures up, SBP down, pulse up, sao2 down (34%!!!!!!).
Both
> sides of the chest were then decompressed, tension on the left relieved
> leading to resolution of symptoms. Interestingly, because he was
ventilated
> on SIMV with a large contusion (plus collapse) on the left breath sounds
> were heard well on the right despite there being a large tension
(potential
> trap for the unwary - if in doubt and things are going badly wrong
consider
> decompressing both sides).
>
> Anyway, I placed a right subclavian triple lumen central line. This was
> easily done (performed >200 in past) with nothing different from usual,
> (bright red blood but ventilated on 80% at this point), non-pulsatile
flow
> on cannulation of the vessel.
>
> However, Check XRay shows triple lumen line in left subclavian artery -
> bugger!
>
> So the questions:
> 1. Do you just pull the line out, press and hope? (or do something
> different?)
> 2. Some people claim to transduce the intoducer needle routinely to avoid
a
> arterial puncture - is this over the top?
>
> I can let you know what happened later.
>
> Simon Carley
> Anaesthetics / Intensive Care
> Stepping Hill Hospital
> Stockport
> England
> [log in to unmask]
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