In-Reply-To: <[log in to unmask]>
I do recall working with a chap who managed to perforate the balloon on a
double-lumen tube putting a subclavian line in - twice! In the same
patient!At thoracotomy, an extensive hole was found that required repair
in the subclavian vein. There was a good paper some years ago from the
Cardiff group in Anaesthesia about complications of central vein puncture,
and arterial puncture was certainly a major complication with appreciable
morbidity. I am surprised that you managed to get the catheter into the
/left/ artery - for the purposes of this discussion I shall presume your
interpretation of the CXR was accurate.
Initial management therefore depends on your back-up; if there is nobody
able to do the thoracotomy and repair you probably should not remove it
blind. Ensure the clotting is ok(!). The best bet would be to inject dye
under II to see if there is a leak. Then, if not, remove the catheter and
replace it with a fine imaging line to see if there is a leak round that
(there probably will be for a while - pressing on any structure will be
pointless) which may need a stent introduced at the brachial artery. If
there is no persistent leak you will probably get away with it, but the
patient will still need observation for pleural effusions, stridor,
hypotension etc.
The worst case scenario is a persistent arterial leak that does not
tamponade and you are forced into exploratory upper thoracotomy - which is
real tiger country in the presence of soft squishy arterial haematoma.
Best wishes,
Rowley Cottingham
[log in to unmask]
In God we trust. All others get a spine board.
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
|