Neonatal hydrothorax following migration of a central venous catheter
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《美国医学杂志》
Department of Neonatology, Christian Medical College, Vellore, Tamil Nadu, India
Abstract
The use of a central venous catheter may occasionally be associated with complications like sepsis, effusions and thrombosis. Migration of the central catheter is an unusual complication that often goes unrecognized. This case report is of a neonate who developed hydrothorax resulting from a migrating central line and highlights the need for a high level of clinical suspicion in diagnosing catheter related problems.
Keywords: Central venous catheter; Neonatal hydrothorax
The placement of a central venous catheter (CVC) has become an integral component of neonatal intensive care, especially in the management of extremely preterm and surgical newborn babies. Percutaneously inserted central catheters (PICC) aid in the administration of total parenteral nutrition (TPN) and medications. However, the use of PICCs is occasionally associated with complications like sepsis, thrombosis and effusions.
The possibility of a CVC migrating from its position leading to complications, though often reported, is still not well recognized by clinicians. Migration of a catheter leading to complications such as pericardial effusion[1],[2] and ascites[3] has been reported in neonates. There have been few case reports of pleural effusion in neonates due to CVC migration.[4],[5]
We report here a case where successful PICC placement was followed a few days later by the development of a hydrothorax due to migration of the catheter tip.
Case report
A case of a primigravida mother whose pregnancy was complicated by gestational hypertension was booked. Pregnancy was terminated in the 31st week of gestation for severe pre-eclampsia. She delivered a girl baby weighing 1070 gm. The baby received respiratory support with continuous positive airway pressure (CPAP) for 36 hours after birth for respiratory insufficiency. She also received antibiotics during this period. Nasogastric feeds were commenced on the third postnatal day but were stopped the next day because of increased gastric residues. A PICC was inserted through the right brachial vein and parenteral nutrition commenced. The position of the tip of PICC was confirmed to be at the junction of the superior vena cava (SVC) and right atrium by chest X-ray. On the sixth postnatal day, the baby was noticed to have abdominal distension, poor perfusion and lethargy. Suspecting secondary sepsis, antibiotics were changed to meropenem and vancomycin and she was given ventilatory support. Twenty-four hours later she was noticed to have decreased chest movement on the left side. A chest X-ray revealed a large pleural effusion following which an intercostal drainage tube (ICD) was inserted. An analysis of the pleural fluid revealed a protein concentration of 0.3 gm/dl, sugar content of 879 mg/dl and the bacterial culture of the aspirate was negative. Corresponding blood sugar was 239 mg% that normalised following one dose of insulin given intravenously.
In the first 48 hours following ICD insertion, there was about 60 ml of fluid draining per day. At this time it was suspected that the PICC could have migrated into the pulmonary circulation. The position of the PICC was re-evaluated by contrast radiograph. The tip of the catheter was found to be in the left pulmonary artery and dye could be seen in the left lung fields. The catheter was immediately removed. Following this, the pleural effusion decreased and it was possible to remove the ICD 24 hours later. The baby was extubated at the same time.
Discussion
Insertion of a PICC has been associated with both immediate and long term complications. The immediate complications include catheter malposition, pneumonia and hemothorax usually secondary to the insertion procedure. Late complications are occlusion, thrombosis, sepsis and catheter tip migration.[1]
There have been many case reports of PICC tip migration leading to pericardial effusion and cardiac tamponade.[1],[2],[3],[6] There have been occasional reports of migration leading to hydrothorax in neonates.
Various explanations have been given for the extravascular exudation of fluid. Some authors have hypothesized that hyperosmolar parenteral infusate could cause endothelial damage and subsequent increase in vascular permeability leading to an effusion.[5],[6] One study found an increased incidence of Staphylococcus epidermidis ctions in such cases.[3] The authors proposed that phlebitis as a result of the infection could have weakened the vessel wall and led to the perforation. In one case report, there was migration of the tip into the pulmonary venous system with subsequent pleural effusion probably secondary to increased hydrostatic pressure.[5]
Migration of the catheter tip may occur because of movement of the head and extremities. It is also generally accepted that flushing of the CVC by nursing staff could aid in line migration.[5],[7]
The ideal position of the catheter tip is at the SVC-right atrial junction or in the inferior vena cava at the level of the diaphragm.[8],[9] In our unit, the position of the line is usually confirmed by plain chest radiograph before parenteral nutrition is commenced. Additionally, it is recommended to recheck the tip with serial X-rays, especially in the event of an unexpected cardio-respiratory event.[6] In many instances, as in the present case, the infusion pump does not usually signal an occlusion in cases of tip migration leading to effusions.[6],[7]
In a baby receiving parenteral nutrition through a CVC, a high pleural fluid sugar level should alert the clinician of the possibility of perforation and extravascular exudation.
Thus, the present case report reinforces the need for a high level of clinical suspicion of a catheter related problem in a newborn with cardio-respiratory insufficiency. The need for serial X-rays, especially contrast-aided radiographs, is also clearly demonstrated in this case.
References
1. Van Engelenburg KCA, Festen C. Cardiac Tamponade: A rare but life-threatening complication of central venous catheters in children. J Pediatr Surg 1998; 33: 1822-1824.
2. Nowlen TT, Rosenthal Gl, Johnson Gl et al. Pericardial effusion and tamponade in infants with central catheters. Pediatrics 2002; 110: 137-142.
3. Bansal V, Strauss A, Gyepes M, Kanchanapoom V. Central line perforation associated with Staphylococcus epidermidis infection. J Pediatr Surg 1993; 28(7): 894-897.
4. Cupitt JM. An unusual complication of a central venous catheter in a neonate. Pediatric Anaesthesia 2000; 10:665-668
5. Madhavi P, Jameson R, Robinson MJ. Unilateral pleural effusion complicating central venous catheterization. Arch Dis Child Fetal Neonatal Ed 2000; 82: F248-F249
6. Goutail-Flaud MF, Sfez M, Berg A et al. Central venous catheter-related complications in newborns and infants: A 587-Case Survey. J Pediatr Surg 1991; 26(6): 645-650.
7. Krasna IH, Krause T. Life-threatening fluid extravasation of central venous catheters. J Pediatr Surg 1991; 26 (11): 1346-1348.
8. Dunbar RD, Mitchell R, Lavine M. Aberrant locations of central venous catheters. The Lancet 1981; 28: 711-715.
9. Rorke JM, Ramasethu J. Percutaneous Central venous catheterization. In MacDonald MG, Ramasethu J, eds. Atlas of Procedures in Neonatology. 3rd edn. Philadelphia; Lippincott Williams & Wilkins, 2002; 214-224.(Sridhar S, Thomas Niranja)
Abstract
The use of a central venous catheter may occasionally be associated with complications like sepsis, effusions and thrombosis. Migration of the central catheter is an unusual complication that often goes unrecognized. This case report is of a neonate who developed hydrothorax resulting from a migrating central line and highlights the need for a high level of clinical suspicion in diagnosing catheter related problems.
Keywords: Central venous catheter; Neonatal hydrothorax
The placement of a central venous catheter (CVC) has become an integral component of neonatal intensive care, especially in the management of extremely preterm and surgical newborn babies. Percutaneously inserted central catheters (PICC) aid in the administration of total parenteral nutrition (TPN) and medications. However, the use of PICCs is occasionally associated with complications like sepsis, thrombosis and effusions.
The possibility of a CVC migrating from its position leading to complications, though often reported, is still not well recognized by clinicians. Migration of a catheter leading to complications such as pericardial effusion[1],[2] and ascites[3] has been reported in neonates. There have been few case reports of pleural effusion in neonates due to CVC migration.[4],[5]
We report here a case where successful PICC placement was followed a few days later by the development of a hydrothorax due to migration of the catheter tip.
Case report
A case of a primigravida mother whose pregnancy was complicated by gestational hypertension was booked. Pregnancy was terminated in the 31st week of gestation for severe pre-eclampsia. She delivered a girl baby weighing 1070 gm. The baby received respiratory support with continuous positive airway pressure (CPAP) for 36 hours after birth for respiratory insufficiency. She also received antibiotics during this period. Nasogastric feeds were commenced on the third postnatal day but were stopped the next day because of increased gastric residues. A PICC was inserted through the right brachial vein and parenteral nutrition commenced. The position of the tip of PICC was confirmed to be at the junction of the superior vena cava (SVC) and right atrium by chest X-ray. On the sixth postnatal day, the baby was noticed to have abdominal distension, poor perfusion and lethargy. Suspecting secondary sepsis, antibiotics were changed to meropenem and vancomycin and she was given ventilatory support. Twenty-four hours later she was noticed to have decreased chest movement on the left side. A chest X-ray revealed a large pleural effusion following which an intercostal drainage tube (ICD) was inserted. An analysis of the pleural fluid revealed a protein concentration of 0.3 gm/dl, sugar content of 879 mg/dl and the bacterial culture of the aspirate was negative. Corresponding blood sugar was 239 mg% that normalised following one dose of insulin given intravenously.
In the first 48 hours following ICD insertion, there was about 60 ml of fluid draining per day. At this time it was suspected that the PICC could have migrated into the pulmonary circulation. The position of the PICC was re-evaluated by contrast radiograph. The tip of the catheter was found to be in the left pulmonary artery and dye could be seen in the left lung fields. The catheter was immediately removed. Following this, the pleural effusion decreased and it was possible to remove the ICD 24 hours later. The baby was extubated at the same time.
Discussion
Insertion of a PICC has been associated with both immediate and long term complications. The immediate complications include catheter malposition, pneumonia and hemothorax usually secondary to the insertion procedure. Late complications are occlusion, thrombosis, sepsis and catheter tip migration.[1]
There have been many case reports of PICC tip migration leading to pericardial effusion and cardiac tamponade.[1],[2],[3],[6] There have been occasional reports of migration leading to hydrothorax in neonates.
Various explanations have been given for the extravascular exudation of fluid. Some authors have hypothesized that hyperosmolar parenteral infusate could cause endothelial damage and subsequent increase in vascular permeability leading to an effusion.[5],[6] One study found an increased incidence of Staphylococcus epidermidis ctions in such cases.[3] The authors proposed that phlebitis as a result of the infection could have weakened the vessel wall and led to the perforation. In one case report, there was migration of the tip into the pulmonary venous system with subsequent pleural effusion probably secondary to increased hydrostatic pressure.[5]
Migration of the catheter tip may occur because of movement of the head and extremities. It is also generally accepted that flushing of the CVC by nursing staff could aid in line migration.[5],[7]
The ideal position of the catheter tip is at the SVC-right atrial junction or in the inferior vena cava at the level of the diaphragm.[8],[9] In our unit, the position of the line is usually confirmed by plain chest radiograph before parenteral nutrition is commenced. Additionally, it is recommended to recheck the tip with serial X-rays, especially in the event of an unexpected cardio-respiratory event.[6] In many instances, as in the present case, the infusion pump does not usually signal an occlusion in cases of tip migration leading to effusions.[6],[7]
In a baby receiving parenteral nutrition through a CVC, a high pleural fluid sugar level should alert the clinician of the possibility of perforation and extravascular exudation.
Thus, the present case report reinforces the need for a high level of clinical suspicion of a catheter related problem in a newborn with cardio-respiratory insufficiency. The need for serial X-rays, especially contrast-aided radiographs, is also clearly demonstrated in this case.
References
1. Van Engelenburg KCA, Festen C. Cardiac Tamponade: A rare but life-threatening complication of central venous catheters in children. J Pediatr Surg 1998; 33: 1822-1824.
2. Nowlen TT, Rosenthal Gl, Johnson Gl et al. Pericardial effusion and tamponade in infants with central catheters. Pediatrics 2002; 110: 137-142.
3. Bansal V, Strauss A, Gyepes M, Kanchanapoom V. Central line perforation associated with Staphylococcus epidermidis infection. J Pediatr Surg 1993; 28(7): 894-897.
4. Cupitt JM. An unusual complication of a central venous catheter in a neonate. Pediatric Anaesthesia 2000; 10:665-668
5. Madhavi P, Jameson R, Robinson MJ. Unilateral pleural effusion complicating central venous catheterization. Arch Dis Child Fetal Neonatal Ed 2000; 82: F248-F249
6. Goutail-Flaud MF, Sfez M, Berg A et al. Central venous catheter-related complications in newborns and infants: A 587-Case Survey. J Pediatr Surg 1991; 26(6): 645-650.
7. Krasna IH, Krause T. Life-threatening fluid extravasation of central venous catheters. J Pediatr Surg 1991; 26 (11): 1346-1348.
8. Dunbar RD, Mitchell R, Lavine M. Aberrant locations of central venous catheters. The Lancet 1981; 28: 711-715.
9. Rorke JM, Ramasethu J. Percutaneous Central venous catheterization. In MacDonald MG, Ramasethu J, eds. Atlas of Procedures in Neonatology. 3rd edn. Philadelphia; Lippincott Williams & Wilkins, 2002; 214-224.(Sridhar S, Thomas Niranja)