Pulmonologist Punctures Large Blood Vessel During Lung Biopsy

This case involves a fifty-nine-year-old male patient who presented to the hospital with complaints of chest pain, shortness of breath, and a persistent cough. The patient had been a chronic smoker but had quit due to respiratory trouble. A suspicious spot on the chest imaging along with the presenting symptoms prompted physicians to order a lung biopsy. A CT-guided biopsy was performed using a posterior approach and there were no immediate complications in the PACU. Three core samples were taken and the pathologist provided a pathology report that diagnosed a poorly differentiated squamous cell carcinoma. Shortly after the procedure, the patient developed shortness of breath and a severely increased heart rate. He was transferred to ICU and immediately upon arrival, he went into cardiopulmonary arrest. ACLS maneuvers were initiated while a chest tube was placed that returned 3000cc of dark red blood. Three units of emergency blood were administered during the code, but the patient died soon thereafter.

Question(s) For Expert Witness

1. What are the accepted complications of this procedure and should the bleeding have been noticed before the patient was sent back to the recovery area?

Expert Witness Response E-005947

Complications are rare with transthoracic needle biopsy, as long as pneumothorax is considered to be an accepted part of the procedure. It is important to obtain consent for chest-tube placement while consent for the TNB is obtained, and explain that the chest tube can be omitted most of the time. Pneumothorax only occurs in 20-33% of patients undergoing TNB; this rate is interesting given that a needle is purposefully passed into the lung. A hemothorax or bleeding is not an accepted complication as all major vessels should be clearly avoided especially when conducting the procedure via CT guidance. Some serious bleeding, however, may occur in about 1% of all thoracocentesis procedures. If bleeding does occur, it should be addressed immediately, as this is considered to be a medical emergency.