An appropriate dietary management strategy is a relevant part of treatment of newborns with very low birth weight, extremely low birth weight (< 1000 g), incredibly low birth weight (<750 g) and foetal neonates (<500 g). The immature gastrointestinal and nervous systems, no sucking reflex and lack of coordination of this process with a swallowing reflex are indications for intragastric nutrition through a tube. In cases of scheduled parenteral feeding, e.g. in gastrointestinal failure, which in neonates may result from functional immaturity of the gastrointestinal tract, developmental defects, colitis, including necrotizing enterocolitis (NEC), the insertion of a central venous catheter is necessary [1].

Peripheral venous catheters in newborns and infants are placed in the veins of upper and lower limbs as well as veins of the head skin. However, full supply of nutritional substances, electrolytes and microelements through such catheters is not possible as osmolality of solutions must be limited, maximally to 600-800 mOsm. Cannulation of the external jugular vein is a special kind of peripheral access used for supply of fluids of slightly higher osmolality [3].

Central venous cannulation in children and adults is an invasive procedure during which the catheter is inserted into the vena cava with the tip in the inferior vena cava below the opening of renal veins or in the superior vena cava near the right ventricular ostium.  Catheters are placed through the internal jugular, subclavicular or femoral veins [4]. For long-term therapy, e.g. nutritional, chemotherapy, tunnelled central venous catheters are used. The proximal end is inserted (under X-ray guidance) into the superior vena cava; the distal end passed through the subcutaneous tunnel and placed on the anterior surface of the thorax. 

Percutaneous central venous lines are commonly used in neonates as the underdeveloped venous valves facilitate their insertion [1, 4]. Two techniques are widely known: the Seldinger`s technique and the technique involving the insertion of a long, flexible catheter through the needle lumen into one of the peripheral veins (ulnar, tibial, axillary) and passing it to the vena cava (epicutaneo-cava-catheter – ECC). These are the methods of choice in newborns weighing less than 1800 g and requiring long-term parenteral feeding [4].

Nutritional therapy, similarly to other stages of the therapeutic process, is associated with the risk of complications. The aim of the present report was to describe iatrogenic lung and pleura damage complicating the nutritional therapy.

CASE REPORT

A male 700 g b.w. infant was born by Caesarean section at 28 weeks of gestation due to premature detachment of the placenta with an Apgar score 1 at 1 min, and 5 at 5 min. On day 1, the newborn was diagnosed with acute respiratory distress syndrome; the surfactant was administered and mechanical lung ventilation initiated. The physical examination and results of additional tests (CRP 170.4 mg L-1 – day 2 and 2297.9 mg L-1– day 4) showed intrauterine infection; the patient received immunoglobulins and antibiotic therapy was implemented. On day 2, the patient developed hypotension requiring the use of catecholamines. Since the moment of birth, he was fed parenterally. On day 3, lack of peristalsis and abdominal distension were observed; the symptoms subsided after metronidazole and the H2-receptor blocker.

On day 9, oral feeding with maternal milk was initiated, gradually increasing the volume of a single portion to 9 mL.

On day 12, the ECC was introduced through the right ulnar vein to the superior vena cava; the cannula was removed on the next day when the radiological picture demonstrated the leak of the infusion fluid to the right pleural cavity with complete shadowing of the right lung.

On day 15, the child’s condition deteriorated. Abdominal distension increased, the green fluid was visible in the nasogastric tube, and the indices of inflammation were found to be higher (WBC 55 G L-1, CRP 2270 mg L-1). The X-ray picture revealed the presence of free air in the abdominal cavity. Perforation of the gastrointestinal tract in the course of NEC was suspected and the patient was transported to the Teaching Hospital in Bydgoszcz.

On admission, the child’s condition was defined as severe. The symptoms of respiratory and circulatory failure were observed  (SAP/DAP - 43/17 mm Hg; HR – 149 min-1).

The skin was yellowish and abdominal integuments were blue-greenish. The vesicular murmur over the right lung was weakened, the abdomen distended, peristalsis inaudible. The laboratory results showed: WBC 19 G L-1, CRP 1260 mg L-1, fibrinogen 5.65 g L-1;  capillary blood gasometry disclosed mixed acidosis (pH 7.26; pCO2 78 mm Hg /10.4 kPa/; BE –12), no increased number of pathogens was detected in blood culture. The chest X-ray revealed total atelectasis of the right lung and traces of fluid in the right pleural cavity; the ultrasound scan of the abdomen demonstrated intestinal loops partially filled with gas, partially airless, without peristalsis. In the free peritoneal cavity, the fluid was detected around the gallbladder, between the right kidney and liver and in the splenic region.

Mechanical lung ventilation (BIPAP) was instituted (f – 65 min-1, FIO2 – 0.6). The antibacterial drugs (imipenem, teicoplanin, fluconazole, metronidazole) and agents with positive inotropic effects (dobutamine 10 µg kg-1 min-1, dopamine 2.5 µg kg-1 min-1) were continued. Leukoreduced red blood cells were transfused. The child was parenterally fed through the access placed via the right internal jugular vein, whose proper placement was confirmed radiologically. After the several-hour observation, suspecting the perforation of the GI tract, laparotomy was decided; no abdominal pathology was detected. On postoperative day 2, the symptoms of respiratory failure intensified and were accompanied by hypotension and oliguria. The volume of fluid in the right pleural cavity increased and the drain was inserted; the evacuated fluid showed features of an exudate (pH 7.0; glucose <0.27 mmol L-1; activity of diastase 500 U L-1; LDH 6729 U L-1; Na+ 131.5 mmol L-1; triglycerides 1140 mg L-1, proteins 270 mg L-1, relative density 1015 kg m3). Microscopic morphological evaluation was not possible due to numerous fatty particles covering the visual field. The microbiological test of the fluid showed the presence of Enterococcus faecium. Despite vigorous therapy, the patient`s condition worsened. He died on the 35th day of life (16 days after surgery) due to increasing multi-organ failure and sepsis.

DISCUSSION

Acute respiratory failure is one of the most common reasons of ITU hospitalization of newborns. Its major causes include lung immaturity, isolated pneumonia or pneumonia accompanying generalized infections.

In the case described, respiratory failure developed in the course of a rare and severe complication, i.e. leak of parenteral formula to the pleural cavity. Complications accompanying central venous cannulation in paediatric patients are common. Cases of extravasation of the infusion fluid to the pleural cavity and (more commonly) to the pericardial sac have been reported.  In our case, the catheter was removed from the injured vessel on the day following its placement; despite this, symptoms of respiratory failure did not subside. Most likely, the hyperosmolar solution used for parenteral feeding caused the absorption of the serous fluid to the pleural cavity. The solution was also an excellent medium for bacterial multiplication, which led to sepsis.

Many cases of cardiac tamponade complicating central venous cannulation have been described. Zajączkowska-Sadlok and colleagues [5] reported three cases of cardiac tamponade in newborns fed parenterally through the catheters inserted to the superior vena cava. The authors stress a long interval between the catheter insertion and the development of this complication – even 15 days.  According to the authors, cardiac tamponade resulted from the mechanical injury to the right atrial wall and osmotic damage caused by highly osmolar solutions administered through the central venous access. Mechanical injuries usually happen during vein cannulation, albeit they can also be caused by improper fixation of the catheter to the skin resulting in its migration to the cardiac cavities; hence, during heart contractions the catheter injures the endothelium. Micro-injuries are likely to induce erosions, and highly osmolar solutions favour their penetration to the pericardial sac [5, 6]. In five cases of cardiac tamponade described by other authors, the fluid permeating through the wall of the right atrium was initially observed; the wall perforation disclosed later [6]. Moreover, it is emphasized that injuries can be caused during high-pressure administration of drugs and contrast agents through the venous line [7]. The mortality rates in cardiac tamponade cases are high [8, 9, 10].

Central venous cannulation in paediatric patients is a difficult procedure due to small diameters of veins and thin catheters adjusted to such diameters. Walas and colleagues [6] detected obstructed catheters in 24% of cases and their mechanical damage in 19%. Mechanical catheter damage is common and occurs in 0.9 – 26.4% of patients [11, 12, 13, 14]. The most vulnerable place of catheters is their proximal part for connecting them with the infusions sets [6]. 

In our case, the highly osmolar fluid for parental feeding extravasated to the pleural cavity, most likely due to the big vein injury during the insertion of ECC. Despite early removal of the catheter, the patient`s condition deteriorated, which was additionally favoured by low birth weight and gestational age. Such a correlation has been confirmed by other reports [6, 14].

The leak of parenteral formula to the pleural cavity in a low birth weight newborn was also reported by Powrózek and co-workers [16]. In their case, stormy symptoms accompanying the complication required the institution of resuscitation procedures, which were eventually successful. Another report described the case of extravasation of parenteral formula to the pleural cavity and to the peritoneal cavity in a 8-week premature infant [17]. Furthermore, respiratory failure and peritonitis were reported in a 7-kg child due to femoral vein cannulation [18]. In this report, multifactor aetiology of the complication is stressed: repeated central venous cannulation in the past, liveliness of the child, a rigid polyethylene catheter used and supply of hyperosmolar solutions.

It should be remembered that respiratory disorders in premature newborns are not only caused by immaturity of lungs or infections but can also be related to central venous cannulation and parenteral nutrition.

To limit their number, the following rules should be adhered to:

• procedures should be performed in operating room settings under ultrasound or X-ray guidance;

• catheters should be sized according to the diameter of vessels;

• no excessive force should be applied to overcome resistances during insertion of a catheter or a guide;

• proper placement of a catheter should be radiologically confirmed;

• a free outflow of blood should be obtained before a catheter is used [18].

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REFERENCES

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2.    Świetliński J, Musialik-Świetlińska E, Bober, Szreter T, Kornacka MK, Czyżewska M, Rudzińska I, Książyk J, Migdał M: Dostępy żylne obwodowe u noworodka; kaniulacja i pielęgnacja. Post Neonatol 2007; 2: 13-17.

3.    Szponar E, Kulik-Rechberger B, Kościesza A: Powikłania żywienia pozajelitowego u noworodków. Post Neonatol 2005; 2: 119-121.

4.    Świetliński J, Bober K, Musialik-Świetlińska E, Szreter T, Kornacka MK, Lauterbach R, Zielińska M, Książyk J, Migdał M: Czas utrzymania centralnych cewników dożylnych u noworodków. Post Neonatol 2007; 2: 18-22.

5.    Zajączkowska-Sadlok A, Mikołajczak A, Korbal P: Tamponada serca – opis trzech przypadków wcześniaków, z uwzględnieniem metod rozpoznania, diagnostyki różnicowej oraz leczenia. Post Neonatol 2005; 2: 176-179.

6.    Walas W, Szczapa J, Wróblewska-Seniuk K: Hydropericardium as a complication of central vein catherization in neonates – description of four cases. Arch Perinat Med 2004; 10: 46-47.

7.    Agarwal KC, Khan MA, Falla A, Amato JJ: Cardiac perforation from central venous catheters: survival after cardiac tamponade in an infant. Pediatrics 1984; 73: 333-338.

8.    Byard RW, Bourne AJ, Moore L, Little KE: Sudden death in early infancy due to delayed cardiac tamponade complicating central venous line insertion and cardiac catheterization. Arch Pathol Lab Med 1992; 116: 654-656.

9.    Bar-Joseph G, Galvis AG: Perforation of the heart by central venous catheters in infants: guidelines to diagnosis and management. J Pediatr Surg 1983; 18: 284-287.

10.    Stanek J, Willett GD, Lage J.M: Idiopathic hydropericardium as a cause of death of a preterm neonate. Pediatr Pathol 1993; 13: 1-8.

11.    Durand M, Ramanathan R, Martinelli B, Tolentino M: Prospective evaluation of percutaneous central venous silastic catheters in newborn infants with birth weights of 510 to 3,920 grams. Pediatrics 1986; 78: 245-250.

12.    Walas W: Ocena przezskórnej kaniulacji żył centralnych u noworodków w aspekcie powikłań wczesnych i późnych. Przegl Pediatr 2000; 30: 128-135.

13.    Neubauer AP: Percutaneous central i.v. access in the neonate: experience with 535 silastic catheters. Acta Paediatr 1995; 84: 756-760.

14.    Goutail-Flaud MF, Sfez M, Berg A, Laguenie G, Couturier C, Barbotin-Larrieu F, Saint-Maurice C: Central venous catheter-related complications in newborns and infants: a 587-case survey. J Pediatr Surg 1991; 26: 645-650.

15.    Sheridan RL, Weber JM: Mechanical and infectious complications of central venous cannulation in children: lessons learned from a 10-year experience placing more than 1000 catheters. J Burn Care Res 2006; 27: 713-718.

16.    Powrózek A, Mazur A, Nowak-Plęs M, Witalis JS: Hydrothorax jako późne powikłanie kaniulacji żył centralnych w neonatologii – opis przypadku. Prz Med Uniw Rzeszów 2006; 4: 220-222.

17.    Been JV, Degraeuwe PL: Pleural effusion due to intra-abdominal extravasation of parenteral nutrition. Pediatr Pulmonol 2008; 43: 1033-1035.

18.    Nowicka M, Kurczabińska D, Stołtny L, Luboń D, Daab M, Karpeli E: Niewydolność oddechowa i zapalenie otrzewnej jako odległe powikłanie kaniulacji żyły udowej u dzieci. Opis przypadku. Anest Inten Terap 2004; 36: 282-285.

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Address:

*Marlena Jakubczyk
Katedra i Klinika Anestezjologii i Intensywnej Terapii
Collegium Medicum w Bydgoszczy
Uniwersytetu Mikołaja Kopernika w Toruniu
ul. M. Curie-Skłodowskiej 9, 85-094 Bydgoszcz
tel.: 52 585 47 50, fax: 52 585 40 22
e-mail: kikanest@cm.umk.pl

Received: 16.11.2009
Accepted: 25.02.2010