PMC8651211_01
(A) Volumetric-rendering reconstructed image of the chest CT shows the path of the epidural catheter (arrows labeled #1) crossing the midline between the T6-7 spinous processes before entering the pleural space via the left 6th-7th intercostal space. (B) Maximal intensity projection (MIP) coronal CT image shows the course of the catheter (arrows labeled #2) enters the left 6th-7th intercostal space. (C) MIP axial CT image shows the course of the catheter (arrow labeled #3), crossing the midline and entering the pleural space. Note the tip of the catheter immediately medial the chest tube (arrowhead labeled #4). (D) MIP sagittal CT image demonstrates the catheter (arrow labeled #5) anchored at the site of entering the pleural space.
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TEC had crossed midline and entered the posterior left pleural space (Figure 1). The catheter was immediately removed, and the decision was made not to reattempt TEP because of continued hemodynamical instability, which lowers the likelihood of significant benefit from TEA now that the patient was 10 days post-thoracotomy.
Series of chest x-ray digital image enhancements reveal intrapleural epidural misplacement in our patient. These chest films were obtained on day after epidural placement, 3 days prior to the CT in Figure 1. (A) Initial chest radiograph. (B) The same image with grayscale inversion. (C) After adjusting image window and level (digital contrast enhancement), the path of the epidural catheter is better seen (arrows labeled #1). (D) A magnified crop of the radiograph highlights the path of the epidural catheter crossing midline with tip in the left lung field (arrow labeled #2) abutting against the left chest tube (arrows labeled #3).
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ICU stay was retrospectively reviewed (Figure 2A). Initially, the pathway of TEC was not easily identifiable; however, it could be easily appreciated after digital image enhancement with grayscale inversion (Figure 2B), contrast enhancement by adjusting window and level (Figure 2C), and magnification (Figure 2D) applied to the daily bCXR.
Series of chest x-ray digital image enhancements to reveal the appropriate TEP in another bilateral orthotopic lung transplant patient. (A) The initial chest radiograph taken within a day after the epidural placement. (B) The same image with grayscale inversion. (C) After adjusting image window and level (digital contrast enhancement), the path of the epidural catheter is better seen (arrows labeled #1). (D) A magnified crop of the radiograph highlights the path of the epidural catheter with tip eventually overlying the midline vertebral body (arrow labeled #2).
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TEP. The resulting radiograph clearly demonstrates the path of TEC (Figure 3).