Background: Intercostal drain (ICD) insertion is a common procedure for managing pleural collections, but complications such as vascular injury can lead to catastrophic bleeding. This case highlights an iatrogenic pulmonary artery injury following ICD insertion and its successful surgical management. Case Report:A 70-year-old male with a history of pulmonary tuberculosis, coronary artery disease, and diabetes presented with breathing difficulty. Three days prior, a pigtail catheter was inserted for pneumothorax with pleural effusion at a local hospital, which was later replaced with an ICD due to improper drainage. Following ICD insertion, 600 mL of blood drained suddenly, leading to hemodynamic instability. The patient was transferred to our hospital in shock with tachycardia (HR 120/min) and hypotension (BP 80/46 mmHg). Emergency chest X-ray showed the ICD positioned near the right hilum. A CT thorax with pulmonary angiogram revealed the ICD misplacement within the right pulmonary artery, causing occlusion of lobar and segmental branches.Emergency thoracotomy was planned after multidisciplinary discussions. Anesthesia concerns included hemodynamic instability, advanced age, pulmonary tuberculosis, and coronary artery disease. The patient was managed under general anesthesia with a double-lumen tube for one-lung ventilation. Surgical exploration confirmed ICD penetration into the right pulmonary artery. Purse-string sutures were placed, and the ICD was carefully removed. Hemostasis was achieved without requiring cardiopulmonary bypass. Postoperatively, the patient was extubated after 8 hours, stabilized, and discharged following an uneventful recovery. Discussion: Pulmonary artery injury from ICD placement is rare but potentially fatal. Preoperative imaging, meticulous anesthetic management, and surgical expertise contributed to the successful outcome. Unlike previously reported cases requiring cardiopulmonary bypass, this patient was managed without it. This case underscores the importance of proper ICD placement techniques and the role of multidisciplinary collaboration in managing such emergencies.
Intercostal drain (ICD)is a flexible plastic tube that is inserted through the chest wall into the pleural space to remove air, fluid or pus. Tuberculosis is usually a parenchymal disease often associated with pleural collections, which warrants drainage to relieve mechanical restriction. ICD insertion can result in vascular injury with an incidence of 2%. involvement of great vessels could lead to catastrophic bleeding (1).
70-year-old man with complaints of breathing difficulty for 1 week .3 days prior to admission pig tail catheter was inserted in his local area hospital for pneumothorax with pleural effusion. Just before admission his pigtail catheter was changed, and intercostal drain was inserted in view of improper drainage. After the insertion of the intercostal drain attending physician was noted suddenly filling of intercostal drain (ICD) with 600ml of blood The ICD was immediately clamped and referred to our hospital within one hour due to haemodynamic instability. Patient was shifted to our hospital with a heart rate of 120 per min and systolic blood pressure of 80 over 46 diastolic blood pressure with respiratory rate of 24 per min with oxygen saturation of 95-96%. Patient had a history of pulmonary tuberculosis on antituberculosis treatment (ATT). Patient had a history of coronary artery disease 2 months prior to admission. Patient had a history of diabetes for 1 year. For coronary artery disease patient was kept on medical management with aspirin 150 mg and rosuvastatin 20 mg once a day. A coronary angiography conducted six months prior showed the recanalization of the left anterior descending artery. After admission to the emergency room chest x ray was taken and the patient was simultaneously stabilized with IV fluids and vasopressors infusion (noradrenaline 0.2 mcg/kg/min). Blood investigations like blood grouping and typing and cross matching were done along with complete blood count and coagulation profile like prothrombin time and partial thromboplastin time and international normalized ratio. Chest x ray showed Intercostal drain at right hilar region. Patient was shifted to CT thorax with pulmonary angiogram for further evaluation (2).
Figure 1: Chest xray showing ICD in right hilar region at the time of admission
Patient was shifted to Computed Tomogram (CT) scan of thorax after hemodynamic stabilization. CT thorax showed misplaced ICD in right pulmonary artery with complete occlusion of lobar, segmental and subsegmental branches of right middle lobe. Bilateral lung fields had multiple consolidation patches. Mediastinal lymphadenopathy with fibrosis of right upper lobe and right lower lobe superior segments.
Figure 2 CT thorax showing ICD in right pulmonary artery. Arrow indicates ICD in right pulmonary artery
Figure 3- CT thorax showing ICD in right pulmonary artery. Arrow indicates ICD in right pulmonary artery.
2-Dimensional echocardiogram prior to procedure showed normal chamber dimensions with mild pulmonary artery hypertension with hypokinesia of entire anterior wall, apical inferior wall, with left ventricular ejection fraction of 45%. Multi-disciplinary team discussion done with cardiac surgeon, anesthesiologist and intensivist and emergency room physician. Patient clinical situation was explained to attenders and advised for emergency surgery. High risk consent was obtained from patient and patient attendants. Post operatively consent for publication of this case report was obtained from patient.
Anesthesia concerns in this case are emergency surgery, old age, diabetes, Hemodynamic instability (vasopressors), known case of coronary artery disease, pulmonary tuberculosis with fibrotic changes and borderline oxygen saturation. Perioperative pain management and one lung ventilation are also other anesthesia concerns.
Anesthesia goals include controlling heart rate, blood transfusion and maintenance of hemodynamics with adequate mean artery pressure, adequate analgesia and airway pressure monitoring during induction, and after intubation.
Apart from routine theatre preparation like anesthesia machine, anesthesia monitor, adequate face mask, airways, laryngoscopy and suction additionally double lumen tubes for one lung ventilation and Cardiopulmonary bypass was kept ready for any accidental displacement of ICD during shifting to operating table.
The plan of Anesthesia was General anesthesia with endotracheal intubation with double lumen tube and controlled mechanical one lung ventilation. Patient was transferred inside the operating room with vasopressor support and monitors like electrocardiogram, noninvasive blood pressure, oxygen saturations were connected. 18 G intravenous cannula was inserted in right upper limb and 20 G jelco was used to cannulate the left radial artery.Anesthesia was induced with intravenous (IV) fentanyl 100 mcg, ketamine 60mg and IV vecuronium 8mg and patient was intubated with 37 French left sided broncho Cath. After confirmation of DLT position with fiberoptic bronchoscope 7 French triple lumen was inserted in right internal jugular vein and base line arterial blood gas analysis was sent. Base line ABG shows pH of 7.23 with Pco2 of 48.5, Po2 173 with 50% fio2 base excess of -9.1, Hemoglobin of 7.48 mg/dl, lactates 10.49mmol/l. Patient was kept on left lateral position and thoracotomy was done. After thoracotomy tracheal tube was clamped and right lung was isolated and one lung ventilation was initiated. One unit of Packed red blood cells were transfused, and patient was kept on intravenous nor epinephrine infusion of 0.2 mcg/kg/min to maintain hemodynamic changes. Suctioning of right thoracic region was done to remove the blood clots.After lung isolation ICD traversing the right middle lobe towards the hilum and into branch of right pulmonary artery was identified. At the entrance of ICD into right pulmonary artery branch, purse string sutures were taken, and ICD was removed under vision followed by tightening of sutures were done. Post procedure right intercostal drain was kept, and closure of right thoracotomy was done. At the end of procedure left double lumen tube was changed to single lumen endotracheal tube of 8.0 mm ID and patient was shifted to intensive care unit for elective mechanical ventilation monitoring of hemodynamics. Immediate postoperative period chest x ray was taken (Figure 4)
Figure 4 Chest x-ray in immediate postoperative period
The patient was hemodynamically stabilized and weaned from ventilator and extubated after 8 hours. Post extubation vitals were within normal limits. Right ICD drain was removed on 2nd post operative day and after 3 days of ICU stay, patient was transferred to postoperative ward and discharged from hospital.
This patient has a documented history of pulmonary tuberculosis with parenchymal involvement, accompanied by hemothorax in the right thoracic region, underlying lung collapse, and total occlusion of lobar and subsegmental bronchi in the right middle lobe due to an indwelling catheter, adversely affecting preoperative oxygenation. Preoperative blood loss leading to anemia in a patient with a known history of coronary artery disease. The role of anesthesiologists in this particular case was to preserve hemodynamic stability while balancing the parameters influencing myocardial oxygen demand and supply, in addition to delivering sufficient analgesia and maintaining stable hemodynamics. Yuncu et al. similarly reported pulmonary artery injury during chest tube insertion; however, the study indicated no clinical manifestations of injury, categorising it as an incidental discovery (3). The cardiopulmonary bypass equipment was prepared for any unforeseen complications during the procedure. Gabriel etal in their cae report showed that repair of pulmonary artery was done under Cardiopulmonary bypass, but in this case we managed the patient without cardiopulmonary bypass (4) . A multi-disciplinary team discussion, accompanied by appropriate preoperative decision-making
(CT thorax with pulmonary angiography) and thorough intraoperative monitoring, as well as dedicated postoperative care, results in the effective management of this case.
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