Spontaneous hemothorax in a hemodialysis patient
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Dialysis Brief report
Spontaneous hemothorax in a hemodialysis patient È zdemir BirguÈl Varan, Hamdi Karakayali, Ali Kutsal, and Nurhan O Department of Pediatrics, Faculty of Medicine, BasËkent University, TR-06490 BahcËelievler, Ankara, Turkey Received January 21, 1997; received in revised form June 27, 1997; accepted July 2, 1997
Abstract. An 8-year-old girl who had undergone chronic hemodialysis for 1 year presented with respiratory distress 24 h after a hemodialysis session. She had a massive pleural effusion of the left chest that was shown to be hemothorax by thoracentesis. After chest tube insertion, drainage was maintained for 2 days. Pleural effusion recurred after withdrawal of the chest tube. The antecubital arteriovenous fistula on the left arm was found to have an excessive flow with a thrill which was felt all over her left shoulder and left hemithorax. The pleural effusion resolved spontaneously a week after ligation of the fistula. Excessive flow in the arteriovenous fistula was thought to be the cause of the hemothorax and should be included in the differential diagnosis of hemothorax in hemodialysis patients. Key words:mHemothorax ± Arteriovenous fistula ± Hemodialysis
Introduction Hemothorax is a complication of subclavian catheter insertion in hemodialysis patients [1, 2]. Systemic heparinization during hemodialysis prolongs the spontaneous closure of puncture sites in vessels and may result in extensive bleeding. Spontaneous hemothorax occurs rarely. We present a chronic hemodialysis patient with spontaneous hemothorax.
19 and 18 kg, respectively. Her hemoglobin concentration was 8 g/dl and hematocrit 25% 3 days prior to admission. On admission her general condition was poor. Her weight and height were 18 kg and 105 cm, respectively. Vital signs were: temperature 37 °C, pulse 170/min, respiratory rate 60/min, and blood pressure 150/90 mmHg. She was orthopneic, dyspneic, and had central and peripheral cyanosis. Chest auscultation revealed bilateral fine rales with decreased bilateral breath sounds. The thrill of her arteriovenous fistula could be palpated on the left arm, the left shoulder, and the left hemithorax. She had no hepatomegaly or peripheral edema. A chest Xray revealed bilateral stasis compatible with pulmonary edema, pleural effusion on the left side, and cardiomegaly. Ultrafiltration was carried out for 2 h but resulted in only minimal comfort. Her weight was 17 kg after the ultrafiltration. Echocardiography revealed no pericardial effusion. A diagnostic thoracentesis was performed and yielded a hemorrhagic fluid, 500 ml of which was drained. Laboratory investigation revealed a hemoglobin concentration of 4.5 g/dl, hematocrit of 13%, a white cell count of 14,500/mm3, and a platelet count of 240,000/mm3. Prothrombin and partial thromboplastin times were 13 and 30 s, respectively. Serum values for urea nitrogen and creatinine were 36 and 2.8 mg/dl, respectively; the total protein and albumin levels were 6.5 and 3.9 g/dl, respectively. The pleural fluid contained a hemorrhagic exuda
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