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Central venous catheterization is not without hazard. Inadvertent placement in the pleural space can occur without the development of a pneumothorax and pressure measurements may appear misleadingly normal. This case report illustrates an effective method of diagnosing and draining an iatrogenic hydrothorax which resulted in this way.
OBJECTIVE: To investigate the prognostic factors for primitive fetal hydrothorax (PFHT) and propose a clinical strategy based on systematic literature review. METHODS: We reviewed 64 articles describing 204 cases of PFHT. For each case we focused on 11 criteria. We investigated prognostic factors in the 89 cases where no in utero treatment was undertaken. We also studied the impact of different in utero treatments on the evolution of PFHT. RESULTS: We have found 4 factors correlated with the course of PFHT: the presence of hydrops, gestational age at time of birth, the unilateral or bilateral nature of the effusion, and the occurrence of spontaneous resolution. With multivariate analysis, only hydrops remained determinant as a prognostic factor. CONCLUSIONS: Studies such as ours, reviewing case reports or series, are subject to the biases of literature underreporting of therapeutic failures or nonintervention. However (with the best available data) we propose a clinical approach to PFHT discovered in utero.
BACKGROUND/AIMS: Hydrothorax is a complication of continuous ambulatory peritoneal dialysis (CAPD) occurring due to pleuroperitoneal fistulae. Several treatments exist with no consensus as to best management. We report on the largest series of video-assisted thoracoscopic surgery (VATS) treated pleuroperitoneal fistulae yet available. METHODS: Between 1995 and 2000, we treated 6 CAPD patients for acute right hydrothoraces using VATS. Data pertaining to size and sterility of hydrothoraces, presence of diaphragmatic defects, surgical procedures performed, morbidity and return to CAPD were obtained. RESULTS: Hydrothoraces were drained in all patients and there were no significant growths on subsequent culture. Fistulae were directly identified and closed in three patients. In the remaining patients, endoclips were placed across the base of small diaphragmatic blebs (the presumed site of communication). Parietal pleurectomy was performed uneventfully in all patients. There was no morbidity, all patients returned to haemodialysis and there have been no recurrences. CONCLUSIONS: Pleuroperitoneal fistulae produce symptomatic hydrothoraces in CAPD patients. A variety of approaches to the problem have been described. This is the largest series of VATS available and shows the usefulness of this approach in both closing the defect and producing an effective pleurectomy to prevent recurrence.
OBJECTIVE: This study examines the role of serial ultrasound in predicting fetal outcomes based on progress, resolution or stability of pleural effusions in primary fetal hydrothorax (PFHT). METHODS: Records from consecutive cases of fetal pleural effusions referred to the fetal echocardiography unit over a 12-year period were reviewed. Study patients underwent thorough investigation to rule out secondary causes of pleural effusions. The clinical course was monitored with serial ultrasound studies every 2 weeks until delivery. Pleurocentesis and pleuroamniotic shunts were performed in select cases of PFHT. Fetal survival was the primary outcome variable. RESULTS: Eighteen of 44 patients referred for perinatal evaluation of fetal pleural effusions met the study criteria for PFHT. Diagnosis was made at 28 +/- 7 weeks and fetuses delivered at 35 +/- 3 weeks' gestational age. Overall survival was 78%. Effusion progression, greater effusion ratios, earlier gestational age at delivery, and lower Apgar scores at birth were associated with poor outcome. Conservative management was appropriate for most cases. CONCLUSIONS: Serial ultrasound studies to evaluate the clinical course of the pleural effusions are essential in the management of PFHT. Expectant management of stable and resolving effusions was appropriate in all cases.
We report on a case of unilateral primary fetal hydrothorax leading to nonimmunological fetal hydrops (NIHF). The NIHF was treated successfully by inserting two consecutive intrauterine catheters at 23 weeks gestation. The first catheter was dislocated through the uterine wall to the maternal peritoneal cavity. At 36 weeks gestation, the mother had a spontaneous onset of labor after premature rupture of membranes and a normal vaginal delivery of a healthy infant with good perinatal outcome. Shunting of PFHT has rarely been described up to now. This case report supports observations of previous authors that early shunting of pleural effusions may prevent progression of NIHF as well as postnatal pulmonary hypoplasia. Unexpected perinatal complications of fetus, mother or both should not be neglected.
The recent use of soft catheters made of silastic polymeric silicone or polyurethane has decreased the incidence of perforation of great veins or right-sided heart chambers but has not eliminated it as had been hoped. Two premature infants who presented with cardiac tamponade more than 24 hr after the insertion of a 23-gauge silastic catheter for total parenteral nutrition (TPN) administration are described. In one infant, bilateral hydrothorax preceded the occurrence of cardiac tamponade. Osmotic injury to great vessels and/or myocardium seems to be the common mechanism but which these complications of intraluminal catheters are produced. Review of the pediatric literature revealed a proportion of low birth weight infants among the reported cases. Despite a prohibitively high mortality rate, early recognition can prevent a fatal outcome.
A 59-year-old woman underwent chest tube placement, repeated pleurodesis, and pleuroperitoneal shunt implantation for unsuccessful treatment of a large refractory hepatic hydrothorax. Two days after placement of a transjugular intrahepatic portosystemic shunt for treatment of variceal hemorrhage, her pleural effusion resolved. At 10 months' follow-up, only minimal fluid remains.
To understand the mechanism of hepatic hydrothorax clearly, thoracoscopy was performed with a flexible bronchoscope. It revealed an intrathoracic influx of ascitic fluid via a bleb and two defects located in the tendinous portion of the right hemidiaphragm and confirmed the existence of transdiaphragmatic peritoneal-pleural communications.
STUDY OBJECTIVE: To determine indications, limitations, morbidity and mortality of surgical thoracoscopy for management of hepatic hydrothorax, a rare, but often recurrent, complication in cirrhotic patients. PATIENTS AND METHODS: From May 1985 through May 1999, 10 men and 8 women, with a mean age of 57.6 years (range, 26 to 76 years), underwent 21 therapeutic thoracoscopies to achieve pleurodesis by application of talc. RESULTS: The procedure was effective in 10 of 21 procedures. There were four recurrences (19. 1%) that were retreated, with only one being successful. In this specific group, we detected high morbidity (57.1%) and mortality (38.9%) during the follow-up period of 3 months. Diaphragmatic defects were localized and closed five times (23.8%). Hospital stay was approximately 15 days (range, 5 to 41 days). CONCLUSION: The procedure appears to be indicated for these fragile patients, especially when medical therapy fails. Immediate efficacy was 47.6%, increasing to 60% with videothoracoscopy and suture of the diaphragmatic defect. However, morbidity and mortality were high.
Replacement of central venous catheters over a guidewire is now practiced throughout the United States. Although potential mechanical complications of this technique have been mentioned in the literature, few such complications have been documented. We report a patient who suffered a fatal contralateral hydrothorax following replacement of a central venous catheter using the guidewire technique.
A patient with renal failure who received acute peritoneal dialysis rapidly developed a tension hydrothorax which required immediate drainage of the pleural space. Rapid identification and therapeutic intervention for this rare complication of peritoneal dialysis is necessary because of its life-threatening potential.
The subject of this study was 38 cases of non-immune hydrops fetalis and 11 cases of fetal hydrothorax and/ or ascites (FH/A), a syndrome characterized by the accumulation of pleural effusion and/or ascitic fluid, without generalized skin edema, due to various etiologies, admitted to the obstetrics ward of Hokkaido University Hospital during the period between 1987 and 1994. Fetal treatment consisted of (1) intravascular transfusion or intra-abdominal transfusion for anemia, (2) frequent centesis or shunt insertion for pleural effusion and ascites, (3) reduction of cystic hygroma by puncturing and OK432 injection, and (4) intravascular or maternal injection with an anti-arrhythmic drugs to treat tachycardia. The outcome of NIHF and FH/A was assessed to be able to make a prognosis in NIHF and to compare the efficacy of fetal therapy in cases with (15 cases: 9 NIHF, 6 FH/A) and without (34 cases: 29 NIHF, 5 HF/A) intrauterine treatment. The average survival rates were 23.1% in NIHF and 54.5% in FH/A. None of fetuses with a chromosomal abnormality or cystic hygroma survived. The average GW at the time of detection of NIHF by ultrasonography was week 24.9 +/- 1.1 (mean +/- S.E., n = 38). The average GW at the time of detection of FH/A by ultrasonography was week 26.6 +/- 1.8 (n = 11). NIHF was detected significantly earlier in the IUFD and early neonatal death group (GW 22.4 +/- 1.4) than in the survivor group (GW 27.6 +/- 1.2) (p < 0.05). FH/A was also detected earlier in the IUFD/early neonatal death group than in the survivor group (GW 21.8 +/- 2.4 vs. 31.1 +/- 1.1, n = 11, p < 0.05). The survival rate in the intrauterine treatment group was higher than in the nontreatment group (treatment group: 10/15; non-treatment group: 5/34, p < 0.001). After the trial of intrauterine treatment in the 15 cases mentioned above, some efficacy was observed in 7 cases (reduction of cysts, effusion or edema, disappearance of arrhythmia).
Hepatic hydrothorax in the absence of ascites is a rare complication of liver cirrhosis. A 56-year-old woman was referred to our hospital because of a massive pleural effusion on the right side, requiring continuous drainage. Although the patient was known to have chronic hepatitis C, she had no signs of hepatic failure including ascites. A laparoscopic examination revealed a nodular liver and a small volume of ascites in the peritoneal cavity. Indocyanine green sprayed into the intraperitoneal cavity was excreted from the pleural drain just after the spraying, indicating an intraperitoneal origin of the pleural fluid. Discontinuation of pleural drainage and an introduction of standard treatment for ascites due to liver cirrhosis (including restriction of salt intake and diuretic administration) resulted in a marked decrease of pleural effusion.
Hepatic hydrothorax occurred in a 38-year-old woman of severe hepatic failure complicated with pulmonary tuberculosis. The transdiaphragmatic passage of ascitic fluid to the pleural cavity was visually shown with a scintigram using technetium-99m macroaggregated albumin and also shown with a tracer analysis using indocyanine green. The ascites was suggested to be transported to the pleural cavity via the defect in the right diaphragm.
Massive acute hydrothorax (MAH) is a severe and unusual noninfectious complication of peritoneal dialysis (PD). It can lead to acute respiratory failure and may diminish the effectiveness of the dialytic therapy. Many therapeutic strategies for this complication are employed, ranging from conservative methods like reduction of the volume of the dialysate and the transitory interruption of the PD, to more aggressive therapies as the closure of diaphragmatic defects by videothoracoscopy with or without pleurodesis. Herein, we report a two years old girl that developed acute renal failure due to an hemolytic uremic syndrome. She underwent PD and developed MAH. PD was temporarily ceased and continuous veno-venous hemofiltration was started. After 8 days, PD was resumed uneventfully. The temporary interruption of the PD was an effective measure to avoid the recurrence of the MAH.
Marked stimulation of the chorionic gonadotropins underlies the frequent finding in the mole of larger ovaries with multiple luteal cysts, identifiable using ultrasound imaging, resembling ovarian hyperstimulation syndrome. The authors report a case of hyadatid pregnancy which presented serious non-neoplastic complications. Laboratory tests showed high values of beta-hCG and GOT/GPT, electrolytic alterations, hypoproteinemia, hypoalbuminemia, associated with conditions of severe dyspnea and tachycardia following hydrothorax diagnosed by X-ray. USG showed hypertrophic placenta containing anechoid lacunar areas and swollen ovaries with multiple luteal cysts. Positive results were achieved by using intensive therapy leading to the restitutio ad integrum of damaged functions. Endocrine hyperactivity of the molar trophoblast, with high levels of beta-hCG was responsible for ovarian hyperstimulation. Important findings for the early diagnosis of hyadatid pregnancy are: beta-hCG assay and ultrasound scan; moreover, an adequate follow-up lasting about 6 months is necessary to evaluate the serial trend of beta-hCG and the disappearance of ovarian luteal cysts.
Current practice standards indicate the need for tube thoracostomy in the management of clinically significant recurrent pleural effusions. The following case presentation and review of the literature illustrate a contraindication to chest tube insertion with pleural effusions associated with portal hypertension (hepatic hydrothorax) and suggest alternative therapies.
Acute, insulated hydrothorax can be observed after ovulation induction without other signs of hyperstimulation. Usually, it is unilateral, localized on the right side and associated with ongoing pregnancy. We regularly noted a good outcome although the pathogenesis of this affection is still enigmatic. It may recur in the case of a new ovarian stimulation.