Acontinuous infusion of local anesthetic agents administered via a paravertebral intrapleural pain catheter is commonly employed in the postoperative management of patients following lung resection.1 Despite reports that morbidity associated with such catheter placement is low, unusual and adverse events have occurred.2,3 We describe two cases of intrathoracic hemorrhage that occurred after placement of an intrapleural pain catheter in two patients who underwent pulmonary lobectomy.
TWO PATIENTS
Case 1 A 76-year-old male had biopsy-proven stage IA (cT1N0) nonsmall cell lung carcinoma (NSCLC) in the right middle lobe. A thoracoscopic right middle lobectomy with mediastinal lymph node dissection was uneventful.
Following the operation, subpleural deployment of a paravertebral catheter was carried out using the standard technique described by Detterbeck.4 The insertion process was unremarkable, and a postoperative infusion of 0.25% bupivacaine through an elastomeric pump was initiated immediately after the patient's sterile drapes were removed.
Late on the second postoperative day, the patient experienced episodes of hypoxia and underwent CT in accordance with a pulmonary embolism (PE) protocol. This study confirmed the presence of a PE in the secondary pulmonary arterial branches bilaterally. There was no evidence of intrathoracic bleeding. He subsequently was anticoagulated with a heparin drip; strict guidelines were followed to maintain his partial thromboplastin time (PTT) within a previously established therapeutic range.
On the fourth postoperative day, his morning chest radiograph findings were normal and his PTT continued to be therapeutic. Despite appearing well when seen during hospital rounds, he became hypotensive and tachycardic later in the day. Evaluation revealed signs and symptoms consistent with acute hemorrhagic shock. A repeat chest radiograph demonstrated an opacified right chest. His hematocrit had dropped from 37% to 28%. He was brought to the OR for emergency surgery. On repeat thoracoscopy, the parietal pleura appeared to be dissected from the endothoracic fascia for most of the posterior chest wall. A residual hematoma could be seen along the dependent regions of the dissected pleura (Figure 1). Closer inspection revealed that the site of bleeding was most likely the area along the chest wall where the extrapleural catheter had been placed. Ultimately, the remaining hematoma was cleared, and Surgicel and Coseal were applied to promote hemostasis. Postoperatively, an inferior vena cava (IVC) filter was placed. The remainder of the patient's postoperative course was unremarkable. He was eventually discharged home 5 days after his second operation.
Case 2 An 84-year-old male had a biopsy-confirmed right lower lobe stage IB (cT2N0) NSCLC abutting the inferior pulmonary veins and densely adherent to the pericardium. He underwent muscle-sparing thoracotomy, intrapericardial right lower lobectomy with an en bloc resection of the pericardium as well as a rim of the left atrium, and mediastinal lymph node dissection. Following this operation, a paravertebral catheter was deployed subpleurally using the standard technique described by Detterbeck.4 The insertion process went smoothly, and an infusion of 0.25% bupivacaine through an elastomeric pump was begun immediately after the sterile drapes were removed.
In the recovery room, the patient's postoperative chest radiograph was unremarkable (Figure 2A). Shortly following his transfer to the floor, however, he became hypotensive. Output from his chest tube was at a rate of 100 cc/hour and sanguineous. A stat radiograph revealed complete opacification of the right chest (Figure 2B), and he underwent urgent reexploration for presumed hemorrhage. At entry into the right chest, a large extrapleural hematoma, containing approximately 1 liter of blood, was encountered. The source of the hemorrhage was a disrupted intercostal vascular bundle. This was oversewn with plegdeted nonabsorbable sutures, and a new subpleural catheter was placed. Following confirmation of hemostasis, the chest was closed, and the patient was brought to the cardiothoracic ICU and eventually transferred to the regular floor. He was discharged home 5 days after his operations.