A case of left pneumothorax after trans-subclavian central venous catheterization

This is a case report of the patient who suffered pneumothorax after central venous (CV) catheterization through subclavian vein. A 68-yr-old man had tumor resection, neck dissection, and immediate reconstructive surgery using a rectus abdominis free flap for cancer of the left mandibular gingiva. Postoperatively, he had severe pneumonia (Fig. 1) accompanied with increased WBC and CRP and seriously decreased Pao₂ when oral feeding was started (Table 1, 2). Oral and nasal feeding were stopped to prevent aspiration, and feeding by intravenous hyperalimentation (IVH) was selected. For this purpose, CV catheterization was attempted through the left subclavian vein. The test puncture at this time aspirated air, and the catheterization was unsuccessful. The CV catheter was finally inserted through the left internal jugular vein. After this procedure, left pneumothorax was noticed in chest X- ray. After 3 days of observation, the air in the thorax was still not spontaneously absorbed (Fig. 2), so thoracic drainage with continuous negative pressure was performed using 10 Fr. trocker catheter (Fig. 3). After 4 days of negative drainage, the pneumothorax in the chest X-ray disappeared, and the state of respiration became stable. The intrathoracic drain was removed. He was discharged after 2 months without any further complications. The causes inducing pneumothrax in this case are 1) the anatomically higher position of the apex of left lung, 2) the difficulties in subclavian venous puncture caused by postoperative dehydration and by the head down position not being ordered for dyspnea.