Manejo terapéutico de hematoma mediastinal después de un acceso venoso central / Therapeutic management of mediastinal hematoma after a venous access

RESUMEN

Introducción: el hematoma mediastinal es una causa rara de complicación en el abordaje de la vía venosa central (VVC). Estudio de Gupta 2011 reportó uno y revisó varios casos clínicos analizando la conducta terapéutica. Caso clínico mujer de 51 años con ventilación mecánica invasiva en terapia intensiva por encefalitis viral, que después de la colocación de VVC subclavia presentó inestabilidad hemodinámica, dificultad para ventilar con resistencias elevadas y compliance disminuida, hace paro cardiaco que revierte con maniobras, se precisa diagnóstico de hematoma mediastinal y se indica manejo conservador con el que evoluciona satisfactoriamente. Discusión: el hematoma de mediastino siempre debe sospecharse y es evidente en radiografías de tórax en los casos graves, con ensanchamiento mediastinal. La ventilación mecánica establece una presión positiva intratorácica permitiendo contener el hematoma, el manejo conservador se reporta beneficioso. Conociendo que las complicaciones de colocación de VVC son mínimas pero con elevado riesgo de inestabilidad, prolongación de hospitalización y aumento de la mortalidad, se recomienda evitar abordajes innecesarios, en especial subclavios.

ABSTRACT

Background: Mediastinal hematoma is an uncommon complication from the central venous access. The Gupta's trial 2011 reported one case and a review of other similar cases, 3 cases were treated with coil embolisation by vascular lesion, another 3 cases who needs thoracotomy for hemothorax complication and just 2 cases was established a conservative management in which only one survived. Clinical case 51-year-old female in invasive mechanical ventilation admitted to intensive care unit (ICU) due to viral encephalitis, present hemodynamic instability and difficulty to ventilate by high resistance and low compliance after of a subclavian venous access, then complicated with cardiac arrest that reverted in 5 min with resuscitation maneuvers, we made a conservative management with continuous infusion of norepinephrine and invasive mechanical ventilation with protective technique (PEEP 10, TV6cc/kg), the requirements of norepinephrine decrease progressively, then the patient was disconnected from mechanical ventilation and was discharged from the intensive care satisfactorily. Discussion: Mediastinal hematoma should always be suspected and is evident with chest X-rays just when it is a severe case and it is suspicioned with wide mediastinum. Conservative management to this case into intensive care unit could be beneficial. Mechanical ventilation establishes a positive intra-thoracic pressure allowing the hematoma to be contained. Knowing that the complications of central venous access are minimal but these complications have high risk of instability, prolonged hospitalization and increased mortality. It is recommended avoid unnecessary central venous access, mainly subclavian access