Emergency lung ultrasound examination for the diagnosis of massive-clotted haemothorax in two cardiac surgery patients.
A 67-year-old man underwent triple coronary artery bypass graft surgery (left internal mammary artery to left anterior descending artery, saphenous vein autograft to right coronary artery and saphenous vein autograft to the circumflex artery). After the end of surgery, the patient was referred to the intensive care unit (ICU) and although his ICU stay was apparently uncomplicated, seven days after discharge the patient developed dyspnoea and chest pain. He was readmitted to the ICU for further monitoring. Initial examination showed hypotension 80/45 mmHg, tachycardia 110 pulse/minute and hypoxaemia oximeter reading of 88% on room air. Physical examination showed diminished breath sounds over the left hemithorax. Blood gas analysis showed P[O.sub.2] 55 mmHg, C[O.sub.2] 48 mmHg and haemoglobin level of 7.5 g/dl.
A 77-year-old woman underwent triple coronary artery bypass graft and was transferred to the ICU. The patient was successfully extubated six hours after the end of surgery. On the first postoperative day the patient showed hypotension (80/50 mmHg), tachycardia (100 pulse/minute) and oximeter reading of 90%. Physical examination showed diminished breath sounds at the right hemithorax. Blood gas analysis also revealed P[O.sub.2] 58 mmHg, C[O.sub.2] 30 mmHg and haemoglobin level of 7 g/dl.
[FIGURE 1 OMITTED]
Of note in the second case, due to better access and harvesting of the left internal mammary artery and to avoid postoperative tamponade, the left pleura had been opened, while in the first case both the right and left pleura had been opened intraoperatively.
In both cases combined transthoracic echocardiography and lung ultrasound were immediately performed to distinguish the causes of dyspnoea and haemodynamic instability. Transthoracic echocardiography did not show any sign of pericardial effusion or other cardiac pathology. Lung ultrasound demonstrated an extensive echogenic mass with unclear borders, compressing the left (first case) and the right (second case) aerated lung, consistent with extensive thrombosis of the haemothorax (Figure 1A and B). The patients were immediately transferred to the operating room where the sternum was opened and the left hemithorax in the first case and the right hemithorax in the second case were full of thrombus. The thrombi were removed and the bleeding site was controlled. It was also worth noting that, in the first case, the venous graft bleeding was caused by graft tear, possibly due to repetitive friction between the graft and the wires used for sternal closure. In the second case, the right lung haematoma was due to intercostal vessel injury, possibly during right pleura preparation.
In both cases, a follow-up lung ultrasound was performed immediately after surgery showing complete re-expansion of the affected lung (Figure 1C).
Patients who sustain massive haemothorax are at risk of haemodynamic instability due to loss of intravascular volume and compromised central venous return due to increased intrathoracic pressure. Lung compression due to massive blood accumulation may also cause respiratory compromise (1-3). Therefore prompt identification and treatment of haemothorax is essential.
Lung ultrasound also has the added advantage of being able to be performed in much less time, making it a useful diagnostic tool for the early diagnosis of haemothorax (4-6). Indeed in our cases, chest radiograph was not performed and clotted haemothoraces were immediately diagnosed by lung ultrasound examination.
In conclusion, ultrasound may provide critical diagnostic information in cardiac anaesthesia patients. Our case is an example that shows the indispensable role of lung ultrasound in the identification of haemodynamic, respiratory or other instability.
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(4.) Beaulieu Y, Marik PE. Bedside ultrasonography in the ICU: part 1. Chest 2005; 128:881-895.
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|Author:||Saranteas, T.; Santaitidis, E.; Valtzoglou, V.; Kostopanagiotou, G.|
|Publication:||Anaesthesia and Intensive Care|
|Article Type:||Letter to the editor|
|Date:||May 1, 2012|
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