SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Hemorrhagic complications of thoracentesis are rare but life-threatening. We report a fatal case of intercostal artery (ICA) laceration during percutaneous thoracentesis, presenting as intra-abdominal hematoma diagnosed on bedside sonogram (US). CASE PRESENTATION: A 49-year-old female with end-stage renal disease, coronary artery bypass grafting on dual anti-platelet therapy (DAPT) was admitted for pneumonia. Despite 7 days of inpatient antibiotic treatment she remained hypoxic. Chest radiograph (CXR) showed complete opacification of left hemithorax. Bedside left percutaneous US guided thoracentesis was done which revealed fluid consistent with empyema. Post procedure CXR showed left lung re-expansion with no pneumothorax. Approximately 3 hours after procedure patient had a pulseless electrical activity cardiac arrest. After 3 minutes of resuscitation she was awake, responsive and transferred to the medical ICU. Initial laboratory values including hemoglobin (Hb), troponin and a repeat CXR were unchanged from prior. She remained hypotensive despite aggressive fluid resuscitation and maximal vasopressor support. A chest tube was inserted which drained 50ml of sero-sanguinous fluid. Repeat Hb approximately 6 hours after thoracentesis, revealed drop from 12 to 5gm/dl, requiring massive transfusion. On re-examination, her abdomen appeared distended and firm. Bedside US revealed a 19cm hypoechoic mass in left abdomen concerning for hematoma. Emergent CT angiogram showed contrast extravasation from left 10th ICA which was successfully embolized. Hemodynamics improved. Shortly after she developed abdominal compartment syndrome and DIC and unfortunately passed away. DISCUSSION: : Thoracentesis is a common procedure and considered low risk. Hemorrhage is usually from ICA laceration, and manifests as hemothorax, rarely as abdominal wall hematoma, but intra-abdominal hematoma have not been reported. Patients at risk are those with INR > 1.5-2, platelets <50,000/µl, advanced renal disease; anti-platelets are generally considered safe, though some studies report higher chest tube outputs especially with DAPT. ICA typically runs along the subcostal groove, however studies demonstrate increased exposure and tortuosity with advanced age, previous sternotomy, and caudal intercostal spaces. Some studies have noted utility of thoracic US in identifying ICA. Recent reports suggest the use of vascular US with color Doppler to visualize the ICA and its collaterals. These are yet to be universally adopted in clinical practice. US is helpful in quick bedside evaluation for location of bleed which is critical in unstable patients. CONCLUSIONS: Clinicians should be mindful of anatomical variations of ICA even in US guided thoracentesis. They should also consider abdominal bleeding and appropriately use the bedside US in suspected cases. Reference #1: Helm EJ, Rahman NM, Talakoub O, Fox DL. Course and Variation of the Intercostal Artery by CT Scan. Chest. 2013;143(3):634-639. https://doi.org/10.1378/chest.12-1285 Reference #2: Patel IJ, Davidson JC, Nikolic B, et al. Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions. JVIR. 23(6):727-736. https://doi.org/10.1016/j.jvir.2012.02.012 Reference #3: Kanai M, Sekiguchi H. Avoiding Vessel Laceration in Thoracentesis A Role of Vascular Ultrasound With Color Doppler. Chest. 2015;147(1):e5-e7. https://doi.org/10.1378/chest.14-0814. DISCLOSURES: No relevant relationships by Jayashri Bhaskar, source=Web Response No relevant relationships by Jyotirmayee Lenka, source=Web Response No relevant relationships by Laurie Lerner, source=Web Response No relevant relationships by Yetunde Ogunsesan, source=Web Response No relevant relationships by Naman Sharma, source=Web Response No relevant relationships by Qiu Tong, source=Web Response