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

Abstract

In handling critically ill patients, central venous catheterization is a fundamental procedure. Incidence of pleural effusion and mediastinal haematoma following central venous placement is rare, with a rate between 0.17% and 1%. We report a frail elderly man who was started on parenteral nutrition administered by left internal jugular vein catheter post-emergency laparotomy surgery for a perforated duodenal ulcer. He developed bilateral chylothorax immediately on the first day of parenteral nutrition supplement. Contrast-enhanced computed tomography of the thorax as part of chylothorax workouts incidentally revealed anterior mediastinal haematoma in communication with the catheter tip, implying likely an iatrogenic injury. Rapid onset of chylothorax may indicate a thoracic duct injury and concurrent parenteral nutrition content leakage from the extravasated catheter. The anatomical connection between the pleural and mediastinal cavities has not been clearly illustrated in the literature. Bilateral chest drains were inserted and the catheter was removed at bedside without complications. Despite using ultrasound guidance, clinical methods and post-procedure chest X-ray, the catheter malposition was not detected before initiation of parenteral nutrition. The learning point is for the clinician to remain vigilant for potential catheter-related complications.