Inefficacity of thoracic drain or continual bleeding Inefficacity of thoracic drain or continual bleeding from pleural laceration at massive spontaneous from pleural laceration at massive spontaneous hematopneumothorax. Case reporthematopneumothorax. Case report

Shqiptar Demaçi*, Saudin Maliqi*, Selajdin Bajrami*, Shqiptar Demaçi*, Saudin Maliqi*, Selajdin Bajrami*,

Agreta Gashi**, Isak Maxhuni**Agreta Gashi**, Isak Maxhuni**

Dpt. of Thoracic Surgery, Clinic of Surgery, UClC of Kosova, Prishtina *Dpt. of Thoracic Surgery, Clinic of Surgery, UClC of Kosova, Prishtina *

Dpt. of Anestesiology and Reanimation **Dpt. of Anestesiology and Reanimation **

Causes of spontan.hemothoraxCauses of spontan.hemothorax– Neoplasia (primary or metastatic) Neoplasia (primary or metastatic) – Blood dyscrasias, including complications of Blood dyscrasias, including complications of

anticoagulation anticoagulation – Pulmonary embolism with infarction Pulmonary embolism with infarction – Torn pleural adhesions in association with spontaneous Torn pleural adhesions in association with spontaneous

pneumothoraxpneumothorax – Bullous emphysema Bullous emphysema – Necrotizing infectionsNecrotizing infections– TuberculosisTuberculosis– Pulmonary arteriovenous fistulae Pulmonary arteriovenous fistulae – Hereditary hemorrhagic telangiectasia Hereditary hemorrhagic telangiectasia – Nonpulmonary intrathoracic vascular pathology (eg, Nonpulmonary intrathoracic vascular pathology (eg,

thoracic aortic aneurysm, aneurysm of the internal thoracic aortic aneurysm, aneurysm of the internal mammary artery) mammary artery)

– Intralobar and extralobar sequestration Intralobar and extralobar sequestration – Abdominal pathology (eg, pancreatic pseudocyst, splenic Abdominal pathology (eg, pancreatic pseudocyst, splenic

artery aneurysm, hemoperitoneum) artery aneurysm, hemoperitoneum) – CatamenialCatamenial

Abstract:Abstract:

Spontaneous hematothorax is rare occurred complication of Spontaneous hematothorax is rare occurred complication of tearing of pleural adhesion during spontaneous tearing of pleural adhesion during spontaneous pneumothorax.pneumothorax.

At Emergency Centre (EC) at UCLC-Kosova,Prishtina patient At Emergency Centre (EC) at UCLC-Kosova,Prishtina patient Xh. K. 23 year- old is admitted as urgent case, drained in Xh. K. 23 year- old is admitted as urgent case, drained in thorax in one regional Hospital in Kosova hospitalised there thorax in one regional Hospital in Kosova hospitalised there two day before with diagnosis: Hemato-pneumothorax two day before with diagnosis: Hemato-pneumothorax spontaneus lat.sin. There were evacuated in start 900 ml spontaneus lat.sin. There were evacuated in start 900 ml fresh blood, redrained tomorrow and evacuated plus 350 ml fresh blood, redrained tomorrow and evacuated plus 350 ml blood. In admission in EC are registered parameters of blood. In admission in EC are registered parameters of arterial pressure 125/ 78 mm Hg, periferic pulse 126 /min, arterial pressure 125/ 78 mm Hg, periferic pulse 126 /min, oxygen saturation with 89%, conscious, difficult breathing, oxygen saturation with 89%, conscious, difficult breathing, pale skin, agitative. In drainage collecting subaqual bottle pale skin, agitative. In drainage collecting subaqual bottle (Pleurevac), is counted 200 ml blood and is seen drain 24 Fr (Pleurevac), is counted 200 ml blood and is seen drain 24 Fr in situ in left chest. Drain is replaced with another of 32 in situ in left chest. Drain is replaced with another of 32 French grade, and now evacuate plus 200 ml blood. French grade, and now evacuate plus 200 ml blood. Hematocrite is measured 0.28 . Hematocrite is measured 0.28 .

Blood producing dynamics are measured 100 ml /1 Blood producing dynamics are measured 100 ml /1 hour- for 4 hour. So is given indication for urgent hour- for 4 hour. So is given indication for urgent thoracotomy for hemostasis . Intraoperatory is thoracotomy for hemostasis . Intraoperatory is seen and evacuated big coagulated amount of seen and evacuated big coagulated amount of blood (circa 300 ml) and slowly active bleeding blood (circa 300 ml) and slowly active bleeding from laceration of parietal pleura which is from laceration of parietal pleura which is cauterised. cauterised.

Also is done apical resection of small blebses and Also is done apical resection of small blebses and after that parietal pleurectomy and abrasion of after that parietal pleurectomy and abrasion of other part of pleura. In ward was ordinate other part of pleura. In ward was ordinate cristalloides, analgetics, two doses of blood. cristalloides, analgetics, two doses of blood. After 4 days the drain was removed and patient After 4 days the drain was removed and patient is released in fifth day with expanded lungs with is released in fifth day with expanded lungs with hemoglobine - count 97 g / L and hematocrite hemoglobine - count 97 g / L and hematocrite 0.32. The next chest X-ray show expanded lung. 0.32. The next chest X-ray show expanded lung.

Ptx 1 our after beginning of pain and dispnoa-collpas.lung

Day after Drained left but still collapsed left lung Day after Drained left but still collapsed left lung – chest x ray done in regional hospital– chest x ray done in regional hospital

In admmitance on emergency ward-two day after In admmitance on emergency ward-two day after drainage of pleura but still collpased left lungdrainage of pleura but still collpased left lung

IntraoperationemIntraoperationem

Inefficacity of thoracic drain or continual bleeding from pleural laceration at massive spontaneous hematopneumothorax

3-d day after th- tomy.Two drains in situ –left 3-d day after th- tomy.Two drains in situ –left and expanded lungsand expanded lungs

9-th day after operation – expanded lungs9-th day after operation – expanded lungs

Conclusion:Conclusion:

Even inefficacity of drain aspiration could collect big Even inefficacity of drain aspiration could collect big amount of pleural blood, slowly bleeding from pleural amount of pleural blood, slowly bleeding from pleural adhesion adhesion in this case in this case is most beleiving cause of is most beleiving cause of massive bleeding from pleura.massive bleeding from pleura.These cases stress the need for early recognition and These cases stress the need for early recognition and management of a potentially life-threatening event. management of a potentially life-threatening event.

Key word: Hemothorax spontaneous, tube thoracostomy drainage, Key word: Hemothorax spontaneous, tube thoracostomy drainage, urgent thoracotomyurgent thoracotomy

Correspondent author: Shqiptar Demaçi MD, thoracic surgeonCorrespondent author: Shqiptar Demaçi MD, thoracic surgeonUClC of Kosova,Prishtina UClC of Kosova,Prishtina email: email: shdemaci@hotmail.comTel mob.++ 377 44 307 585Tel mob.++ 377 44 307 585 ++ 381 38 226 573++ 381 38 226 573

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