Acute haemothorax--a hazard of subclavian vein cannulation.

Case report A 44-year-old man was admitted to the Casualty Department following a severe haematemesis. He was unconscious, apnoeic, had a barely detectable pulse and an irrecordable blood pressure. Intravenous infusions were started in the left subclavian vein and both long saphenous veins. An oral endotracheal tube was inserted and artificial ventilation commenced with 100% oxygen. He was transfused with 6 units of whole blood, 1.5 1 of dextran and 1 1 of normal saline. Four of the units of blood and the 1 1 of saline were transfused through the subclavian vein cannula. All the transfusions were assisted by Martin's pumps. Throughout the resuscitation he continued to have severe haematemesis with little improvement in his clinical state. It was decided that emergency laparotomy was necessary. On arrival in the operating theatre he had a blood pressure of 80/40 mmHg and the subclavian cannula recorded a pressure of + 2 cm H20 with good respiratory fluctuation. Laparotomy revealed pyloric stenosis with a pre-pyloric ulcer 5 cm in diameter. Control of the haemorrhage was achieved and a Polya partial gastrectomy done. During the anaesthetic it was noticed that respiratory movement was reduced on the left side of the chest. Auscultation revealed reduced air entry on that side. The endotracheal tube was withdrawn to its limit in case of right bronchial intubation. Endotracheal suction and hyperventilation was carried out with no improvement. As the patient's colour was good and as there had been no deterioration during the anaesthetic it was decided to complete the operation and assess the chest fully afterwards. During the operation a further 8 units of blood were given into the saphenous vein cannulae. The left subclavian vein cannula was used for monitoring venous pressure. Throughout it showed a good respiratory swing and recorded pressures varying from 0 to + 6 cm H20. After operation, a chest X-ray taken on the table showed a large left pleural effusion (Fig. 1). A diagnostic tap showed this to be blood. A size 20 Argyle chest drain was inserted into the second intercostal space in the mid clavicular line of the front of the left chest. Four litres of blood were removed from the chest. The chest movements improved and air entry became normal. Fifteen millilitres of 40Y Hypaque were injected down the subclavian cannula and a further chest X-ray taken (Fig. 2). This showed the cannula lying freely in the pleural cavity with overspill of the dye. The cannula was withdrawn and a compression dressing put on the neck.