Tamponade and massive pleural effusions secondary to peripherally inserted central catheter in neonates-A complication to be aware of

Abstract

Background: Peripherally inserted central catheters (PICC) are frequently used in neonatal intensive care units (NICU) to assist premature and critically ill neonates. Massive pleural effusions, pericardial effusions, and cardiac tamponade secondary to PICC are extremely uncommon but have potentially fatal consequences.

Objective: This study investigates the incidence of tamponade, large pleural, and pericardial effusions secondary to peripherally inserted central catheters in a neonatal intensive care unit at a tertiary care center over a 10-year period. It explores possible etiologies behind such complications and suggests preventative measures.

Study design: Retrospective analysis of neonates who were admitted to the NICU at the AUBMC between January 2010 and January 2020, and who required insertion of PICC. Neonates who developed tamponade, large pleural, or pericardial effusions secondary to PICC insertion were investigated.

Results: Four neonates developed significant life-threatening effusions. Urgent pericardiocentesis and chest tube placement were required in two and one patients, respectively. No fatalities were encountered.

Conclusion: The abrupt onset of hemodynamic instability without an obvious cause in any neonate with PICC in situ should raise suspicion of pleural or pericardial effusions. Timely diagnosis through bedside ultrasound, and prompt aggressive intervention are critical.

Keywords: central catheter; neonates; pericardial effusions; pleural effusions; tamponade.

FIGURE 1

(A) Supine chest radiograph following PICC insertion in Case I. Chest X-ray performed in supine position, revealed the PICC inserted through the right basilic vein reaching the left subclavian vein. According to this image, the PICC was retracted 2.5 cm. The black arrow identifies the PICC. NG, nasogastric tube; ET, endotracheal tube. (B) Supine chest radiograph following the sudden deterioration in clinical status. Chest X-ray was carried out when the patient had sudden cardiopulmonary decompression. It revealed total whitening of the left lung, as shown on the left side of the image, representing total collapse with left sided pleural effusion. The PICC is represented by the black arrow. ET, endotracheal tube. (C) Chest imaging 2 days following chest tube insertion. Chest X-ray showed complete resolution of the pleural effusion, and normal aeration of the left lung. NG, nasogastric tube; ET, endotracheal tube.

FIGURE 2

Echocardiogram showing cardiac tamponade of Case III.

FIGURE 3

Peripherally inserted central catheters migration leading to vascular perforation. One of the potential etiologies behind pericardial and pleural effusions is chronic friction resulting in vascular wall compromise and ultimate perforation. As the line migrates, the catheter tip might meet the continuously moving vessel wall. Subclavian vein, superior vena cava and the right atrium are potential sites of injury. The thin vascular walls, and the rapid heart rate contribute to increased frequency and impact of friction. The angle formed by the line and vascular wall is important. When the angle is relatively perpendicular, direct vessel trauma and erosion occur, leading to thrombus formation and further catheter adherence to the vascular structure. Eventually, erosion is potentiated, which might lead to preformation and fluid accumulation in the pericardium (35).

FIGURE 4

Displacement of PICC inserted through the cephalic vein during arm movement. As illustrated in the figure, when the upper extremity is moving from abduction to adduction position, the PICC inserted via the cephalic vein moves in a cephalic fashion, away from the heart.

FIGURE 5

Displacement of PICC inserted through the Basilic vein during arm movement. When the arm is moved from abduction position to adduction, there is tendency for the PICC to move inward toward the heart. This should be considered during the final PICC placement.