A 19-year-old patient underwent a cesarean section two years before due to suspected chorioamnionitis.
It begins with fever and night sweats without affecting the general condition, and the chest X-ray shows a large mediastinal mass.
After mediastinoscopy and biopsy, the diagnosis was nodular Hodgkin's lymphoma, stage III-IV, due to infradiaphragmatic adenopathic involvement and hepatomegaly.
Chemotherapy was established according to ABVD scheme until completing nine cycles and then radiotherapy over mediastinum.
A year later, a new mediastinal and pulmonary parenchymal disease together with hepatosplenic enlargement was detected.
One month ago she had moderate pain treated with paracetamol, 3,000 mg.day-1 and metamizole 1,500 mg.day-1.
It was decided to start a new line of chemotherapy with ESCHAP scheme.
Systemically, at the beginning of chemotherapy cycles and for the following 5-7 days, the patient complains of intense mediastinal pain and irregular dorsal interscapular pain lasting only 4 hours with parenteral morphine 12 or fentanyl TD.
This occurred during the previous chemotherapy cycle and after the first cycle of the ESCHAP scheme.
Because of the poor peripheral pathways, we propose the placement of a vascular portal that is approached through the right subclavian artery.
We took advantage of this circumstance to plan the implementation of PCA with external pump during and after chemotherapy cycles through the vascular portal.
Monitoring consisted of continuous EKG in DII derivation, pulse oximetry, and measurement of blood pressure by every five minutes.
The procedure was performed under local anesthesia and sedation with 2 mg of intravenous midazolam, using the Seldinger technique.
The right subclavian vein was approached under the junction point between the distal third and the midclavicular third, with satisfactory progression of the metallic guidewire and subsequent blood aspiration.
Anteroposterior radiological control (A-P) was performed to verify its correct placement.
Chemotherapy is then established.
Twenty-four hours after starting chemotherapy, the patient complained of chest pain together with intense dyspnea. Examination revealed tachycardia, tachypnea and abolition of vesicular murmur in the right hemithorax.
A chest X-ray showed massive right pleural effusion, catheter tip outside the right atrium in the pleural cavity.
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The suspicion of extravasation of chemotherapeutic substance is based on diagnostic puncture, obtaining serous pleural fluid with the same biochemical characteristics as the chemotherapy used.
The radiological series of the patient diagnosed with pleural effusion migration of the tip of the venous catheter until it was located at the pleural level, possibly between the two sheets, resulting in secondary drainage of the fluid infused into the pleural space
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It was decided to place an endopleural drainage after evacuation for bladder cancer surgery.
Clinical improvement was immediate.
Two hours later, pleural drainage was removed and a new central venous access was placed through the left subclavian approach, without incidents, through which chemotherapy was resumed again.
