A patient underwent emergent subclavian central line placement 3 days ago. She subsequently developed difficulty breathing and a nonproductive cough. Chest x-ray demonstrates a large pleural effusion. Thoracentesis produces a milky white fluid with high fat and lymphocyte count and 4 g/dL of protein. The structure inadvertently injured during the procedure was the:
Lung parenchyma.
+Thoracic duct.
+Subclavian artery.
+Esophagus.
+Thymus gland.
The thoracic duct is the largest lymphatic vessel in the body. It terminates in the left subclavian vein just distal to the junction with the left internal jugular vein. In this case, the thoracentesis demonstrates a chylothorax, an accumulation of lymphatic fluid in the thorax that has slowly accumulated in the pleural cavity. Disruption of the thoracic duct can result from central line misadventure, chest trauma, or intraoperative injury. Management includes repeated thoracentesis or tube thoracostomy and parenteral alimentation.