A 19-year-old patient who had undergone caesarean section two years previously due to suspected chorioamnionitis. She then began with fever and night sweats without affecting her general condition, and a large mediastinal mass was found on chest X-ray. Following mediastinoscopy and biopsy, a diagnosis of Hodgkin's lymphoma nodular sclerosis type, stage III-IV due to infradiaphragmatic adenopathic involvement and hepatosplenomegaly was made. Chemotherapy was started according to the ABVD scheme to complete nine cycles, followed by radiotherapy on the mediastinum. One year later, disease was again detected in the mediastinum and lung parenchyma together with hepatosplenomegaly.
For the last month he has been suffering moderate pain treated with paracetamol, 3,000 mg/day-1 and metamizol 1,500 mg/day-1.
It was decided to start a new line of chemotherapy with ESCHAP.
Systematically, at the beginning of the chemotherapy cycles and during the following 5-7 days, the patient suffered intense mediastinal and dorsal interscapular pain that did not subside with oral morphine or fentanyl TD, relieved only with parenteral morphine, 10 mg s.c., which provided her with analgesia of irregular duration, between 4 and 12 hours. This occurred during the previous cycle of chemotherapy and after a first cycle of the ESCHAP scheme.
In view of the poor peripheral routes, vascular portal placement was proposed, which was approached via the right subclavian route. We took advantage of this circumstance to plan PCA with an external pump during and after the chemotherapy cycles, through the vascular portal.
Monitoring consisted of continuous EKG in DII lead, pulse oximetry and blood pressure measurement by oscillometry every five minutes. The procedure was performed under local anaesthesia and sedation with 2 mg intravenous midazolam, using the Seldinger technique. The right subclavian vein was approached below the junction between the distal third and the midclavicular third with satisfactory progression of the guidewire and subsequent blood aspiration. Antero-posterior (A-P) radiological control was carried out to verify correct placement.
Chemotherapy was then started. Twenty-four hours after starting chemotherapy, the patient reported chest pain and intense dyspnoea, with tachycardia, tachypnoea and abolition of vesicular murmur in the right hemithorax on examination. Chest X-ray showed massive right pleural effusion, with a catheter tip outside the right atrium in the pleural cavity.
In view of the suspected extravasation of a chemotherapy substance in the pleura, a diagnostic puncture was performed, obtaining serous pleural fluid with the same biochemical characteristics as the chemotherapy used. The patient's radiological series was reviewed and the tip of the venous catheter was observed to migrate until it was located at pleural level, possibly between the two blades, resulting in secondary drainage of the infused liquid into the pleural space.
It was decided to place an endopleural drainage after evacuating thoracentesis by thoracic surgery, extracting 2,000 cc of serous content. Clinical improvement was immediate. Seventy-two hours later, the pleural drain was removed and a new central venous access was placed via the left subclavian approach, without incident, through which chemotherapy treatment was resumed.
