Figure 2 - uploaded by Maria J. Colomina
Content may be subject to copyright.
Source publication
We present a case of cardiac tamponade associated with placement of a central venous catheter (CVC) via a peripheral vein in a 14-year-old girl with idiopathic scoliosis undergoing corrective surgery. A number of complications have been described in association with CVC misplacement. Sporadic cases of cardiac tamponade from this have been reported,...
Context in source publication
Similar publications
Pericardial effusion (PCE) is a rare condition in neonates. The most common cause is iatrogenic due to central venous catheters (CVCs) and symptoms vary from asymptomatic to more severe presentations, such as cardiac tamponade. Treatment of this condition in neonates remains controversial.
The authors present a case report of a preterm neonate with...
Citations
... Femoral, subclavian, and internal jugular veins are the most common sites used for PICC catheterization [3]. Although use of a PICC has many advantages for the treatment of neonates, catheter malposition may result in serious complications that could be life-threatening [4]. These potential complications (sepsis, embolism, intravascular thrombosis, pleural effusion, and pericardial effusion with tamponade) indicate that insertion of a PICC line requires special medical qualification and follow-up examination to ensure its Open Access proper location (the inferior third of the superior vena cava) [5][6][7][8]. ...
... For example, it was reported in one study that pericardial presence of high-potassium infused fluid resulted in electrocardiogram alterations showing a pattern of hyperkalemia instead of a pattern of cardiac tamponade [1, 9,12]. Another study also showed that tamponade was frequently observed in cases with PICC inserted through aperipheral vein compared to a central vein [4]. ...
Background
Although the use of a peripherally inserted central catheter (PICC) has many advantages for the treatment of neonates, catheter malposition may result in serious complications that could be life-threatening. We report the case of a 10-day-old neonate with cardiac tamponade secondary to a PICC line who was successfully treated by pericardiocentesis.
Case presentation
An Iranian (Asian) preterm male neonate was born by Cesarean section with a birth weight of 1190 g and a first-minute Apgar score of 7. Based on an increased respiratory distress syndrome (RDS) score from 4 to 7, resuscitation measures and intubation were performed at the neonatal intensive care unit (NICU). On day 3 after birth, a PICC line was inserted for parenteral therapy. A chest X-ray confirmed that the tip of the PICC line was in the appropriate position. Mechanical ventilation was discontinued 72 h post-NICU admission because of the improved respiratory condition. On the day 10 post-NICU admission, he suddenly developed hypotonia, apnea, hypoxia, hypotension, and bradycardia. Resuscitation and ventilation support were immediately started, and inotropic drugs were also given. Emergency echocardiography showed a severe pericardial effusion with tamponade. The PICC line was removed, and urgent pericardiocentesis was carried out. The respiratory situation gradually improved, the O 2 saturation increased to 95%, and vital signs remained stable.
Conclusions
Dramatic improvement of the neonate's clinical responses after pericardial drainage and PICC removal were suggestive of PICC displacement, pericardial perforation, and cardiac tamponade.
... In a 20 year-old patient, the tip of the PICC line was identi ed within the right atrium, migrated and resulted in cardiovascular arrest due to the extravasation of potassium into the pericardial uid from the PICC. In a 14 year-old patient, where a PICC insertion was approached from the left antecubital fossa, cannulation of the right pericardiophrenic vein led to the development of cardiac tamponade (22). ...
Background Peripherally inserted central venous catheters (PICC) are increasingly used in critically ill patients for the ease of access, long-term medication and total parenteral nutrition administration. There is a perception of equivalent utility of PICC lines with a lower incidence of complications as compared to central venous lines. Despite the perception of relative safety, complications can occur. Case Presentation We describe a case of a patient who developed increasing signs and symptoms of sepsis, shortness of breath, and hypoxemia following combined liver and renal transplant 11 days following the initial procedure. Computerised tomography of neck and chest demonstrated pneumo-mediastinum, extensive retropharyngeal and subcutaneous emphysema. The patient returned to theatre on post-operative day 12, for flexible bronchoscopy, video-assisted thoracoscopic surgery and mediastinal washout. Following a further clinical and imaging review, an un-anticipated diagnosis of extravasated peripherally inserted central venous cannula (PICC) as a causative factor of multiple pathologies was made. PICC line was removed. Mediastinal and thoracoscopic examinations were performed and drains inserted. The patient returned to the intensive care unit for ongoing supportive management, with a gradual improvement of sepsis and resolution of mediastinal air distribution. Conclusions Peripherally inserted central venous catheters have an ease of insertion and appreciable favourable health economic outcomes. Recent reviews however have demonstrated an increased risk of catheter tip malposition, in addition to increased risk of thrombosis as compared to central venous lines. Due to the characteristic mobility of these devices, mediastinal and intra-thoracic extravasation of these catheters can occur with consequent severe morbidity. Awareness of the tip position and accompanying clinical and radiological enquiry, must be performed both in the differential diagnosis of chest pathology and prior to use of PICC lines in critically ill patients.
... Todos os nossos pacientes com derrame pericárdico associado ao PICC apresentavam a ponta do cateter em íntimo contato com a parede do ventrículo direito, detectado pela USG à beira do leito.As alterações hemodinâmicas do tamponamento cardíaco levam a um choque obstrutivo grave e de alta letalidade. Mecanismos fisiológicos compensatórios associados a um suporte médico intensivo em geral permitem a manutenção da vida por períodos variáveis de tempo, geralmente horas e, eventualmente alguns dias, mas a efetiva drenagem do líquido pericárdico é fundamental no tratamento desses pacientes13 . O aumento do número de vagas em UTI neonatal no Brasil tem o potencial de elevar o número absoluto dessas complicações. ...
Objective:
to determine the incidence of pericardial effusion with cardiac tamponade in preterm infants in a pediatric intensive care unit, with emphasis on the relationship between pericardial effusion and peripherally inserted central catheter, and to evaluate the role of bedside ultrasound in approaching these cases.
Methods:
we conducted a retrospective analysis of patients admitted to a pediatric intensive care unit between July 2014 and December 2016, who presented pericardial effusion with hemodynamic repercussion, evaluated by ultrasonography.
Results:
we studied 426 patients admitted to the five beds of the neonatal unit. In the period, there were 285 bedside ultrasound exams. We found six cases of pericardial effusion, four of which with obstructive shock and need for pericardial drainage. There was no procedure-related mortality, and all patients evolved with hemodynamic improvement after the procedure. The incidence of pericardial effusion was 2.4 cases per year.
Conclusion:
the incidence of pericardial effusion is low in neonates, but early diagnosis is fundamental due to high morbidity and mortality, especially in cases of abrupt onset. All cases were diagnosed by bedside ultrasonography, demonstrating its importance in the screening of these cases, especially in shocks of uncertain etiology and neonates with sudden onset hemodynamic instability who are using central venous access.
... 3 Even though cardiac tamponade as a complication of PICC placement is well described in neonatal medicine, this complication also can occur in older pediatric patients. 5,6 The clinical presentation of cardiac tamponade can be either acute cardiovascular collapse or subacute cardiovascular instability, with a requirement for increasing inotropic or respiratory support. Classic clinical presentations of pericardial effusion or cardiac tamponade, such as jugular venous distension, pericardial rub, and pulsus paradoxus are not commonly detected in premature infants. ...
A 31 and 1/7–week gestation premature male infant with a birth weight of 1730 g developed sudden onset of desaturations (oxygen saturation 30%), bradycardia (heart rate 40/min) and hypotension (mean blood pressure <15 mm Hg) at 6 days of age. He was born by a cesarean delivery for maternal preeclampsia, received nasal continuous positive airway pressure for 3 days after birth, and was in room air at the time of the acute event. On day 2 of life, a peripherally inserted central venous catheter (PICC) (L-Cath PICC Polyurethane catheter, 28 GA/1.2 F; Argon Medical Devices, Inc. Athens, TX) was inserted through the basilic vein in the right antecubital fossa to provide total parenteral nutrition. Catheter tip was located at the right atrium/superior vena cava (SVC) junction.
At the time of acute decompensation, the infant was resuscitated with bag and mask ventilation, endotracheal intubation, chest compressions, and administration of intravenous epinephrine through the PICC without improvement in his condition.
When there is no significant change in the patient condition with cardiopulmonary resuscitation, providers should search for and treat possible contributing factors (H’s: hypovolemia, hypoxia or hypercarbia, hydrogen ion (acidosis), hypo/hyperkalemia, hypoglycemia, hypothermia; and T’s: toxins, tamponade (cardiac), tension pneumothorax, thrombosis, trauma).
### Case Continuation
Endotracheal tube placement was confirmed by chest rise, auscultation, and tube position on chest radiograph. Pneumothorax was ruled out both clinically by transillumination and radiographically. Two normal saline fluid boluses were given. Bedside capillary blood gas measurement revealed severe acidosis but normal electrolyte and glucose levels. The chest radiograph demonstrated that the tip of the PICC was coiled within the right atrium (Fig 1). Due to poor response to resuscitative measures, a cardiac tamponade was suspected, consistent with the tip …
... Sixty-two articles published between 1971 and 2014 were found, reporting 110 pediatric CVC-related cardiac tamponade cases in 89 neonates (1 to 31 days) [6, 7, 9, 10, 14, 17-20, 24, 28, 29, 31, 32, 34-36, 38-41, 44-51, 53-59, 61, 63-68, 71-74], 11 infants (1 to 12 months) [11, 12, 24-27, 47, 51, 62, 69, 70], 7 children (1 to 15 years) [14,27,30,37,52,60,74], and 3 patients with no age given [17,34]. The CVC was inserted for cardiac surgery in 2 of the 110 cases (both survivals) and for TPN, hyperalimentation, or fluid management in the remaining 108 cases. ...
Pediatric central venous catheter (CVC) placement is useful but associated with complications such as cardiac tamponade. We aimed to identify risk factors for death in cardiac tamponade. Published articles on pediatric CVC-associated cardiac tamponade were obtained by searching PubMed and Google and retrospectively reviewed to analyze risk factors for death. Factors examined for their effect on mortality risk included patient age, weight, CVC size, days from CVC insertion to tamponade occurrence, substances administered, insertion site, treatment, CVC material, and initial CVC tip position. Of 110 patients reported in 62 articles, 69 survived and 41 died. Among survivors, 55 of 69 patients were treated; among deaths, only 7 of 38 (OR 537.9, 95 % CI 29.3-9,877, p < 0.0001). Multiple regression analysis in 44 cases showed that treatment (p < 0.0001) and initial CVC tip position (p = 0.020) were independent predictive factors related to improved cardiac tamponade survival. Past studies have mainly discussed how to avoid pediatric cardiac tamponade; by contrast, the present study focused on how to avoid deaths. The findings of this review suggest that cardiac tamponade survival is better when tamponade is detected early and treated promptly and might be affected by initial CVC tip position.
We report a 60‐yr‐old female who had a peripherally inserted central catheter (PICC) for parenteral nutrition (TPN). Insertion was uneventful although the line was seen to extend into the right ventricle. The line was re‐positioned but soon after commencing TPN she collapsed. Computerised tomography pulmonary angiography (CTPA) demonstrated a pericardial effusion with a high fat content. Pericardiocentesis revealed fluid with a high triglyceride content and confirmed pericardial placement of ther tip of the catheter. The patient subsequently made an uneventful recovery.
We could only find one other case in the literature of pericardial tamponade after PICC placement in an adult. The exact anatomical course of this line remains unclear despite careful review of radiological imaging. We discuss methods to gauge appropriate line length, possible signs on chest radiography and the immediate management of pericardial tamponade. Resuscitation via a malpositioned line may prove catastrophic; if doubt exsists the line should not be used.
INTRODUÇÃO A utilização de cateter central de inserção periférica (PICC) é realizada em recém-nascidos (RN) desde os anos de 1970, inicialmente para administração de nutrição parenteral 1,2 , mas posteriormente tornou-se procedimento rotineiro nas unidades de terapia intensiva neonatal (UTIN). Complicações associadas ao uso do PICC são similares às da inserção de outros cateteres centrais, como hemorragias, embolia do cateter, arritmias, infecção do sítio de inserção e sepse 3,4. O derrame pericárdico decorrente de um PICC também pode ocorrer, mas é ainda mais raro do que os relacionados a outros tipos de cateter central 4,5. Alguns estudos relacionam o acúmulo de líquido pericárdico associado ao PICC a uma erosão da ponta do cateter através da parede do átrio direito, levando ao derrame e tamponamento pericárdico. Outros autores admitem uma reação inflamatória local da ponta do cateter em contato com o endocárdio, levando a um exsudato inflamatório 6. Embora relatos iniciais descrevessem essa complicação em crianças a termo, sua ocorrência em prematuros é bem estabelecida 6-10. O objetivo deste trabalho é determinar a incidência de derrame pericárdico com tamponamento cardíaco em recém-natos (RNs) prematuros de uma UTIN, com ênfase na relação entre o derrame pericárdico e a inserção do PICC. Objetivou-se, ainda, avaliar o papel da ultrassonografia (USG) à beira do leito na abordagem desses casos. MÉTODOS Análise retrospectiva a partir Objetivo: determinar a incidência de derrame pericárdico com tamponamento cardíaco em recém-natos prematuros em uma unidade de terapia intensiva pediátrica, com ênfase na relação entre o derrame pericárdico e a inserção de cateter central de inserção periférica, e avaliar o papel da ultrassonografia à beira do leito na abordagem desses casos. Métodos: análise retrospectiva dos pacientes internados em unidade de terapia intensiva pediátrica, entre julho de 2014 e dezembro de 2016, que apresentaram derrame pericárdico com repercussão hemodinâmica, avaliados por ultrassonografia. Resultados: foram estudados 426 pacientes admitidos na unidade neonatal de cinco leitos, com realização 285 ultrassonografias à beira do leito. Foram encontrados seis casos de derrame pericárdico, sendo quatro casos com choque obstrutivo e necessidade de realização de drenagem pericárdica, sem mortalidade relacionada ao procedimento e com melhora hemodinâmica em todos os pacientes após o procedimento. A incidência de derrame pericárdico foi de 2,4 casos por ano. Conclusão: a incidência de derrame pericárdico é baixa em neonatos, porém o diagnóstico precoce é fundamental devido à alta morbimortalidade, especialmente nos casos de instalação abrupta. Todos os casos foram diagnosticados pela ultrassonografia à beira do leito, demonstrando sua importância no rastreio desses casos, especialmente em nos quadros de choque de etiologia incerta e neonatos com instabilidade hemodinâmica de início súbito que estão em uso de acesso venoso central. Descritores: Derrame Pericárdico. Tamponamento Cardíaco. Recém-Nascido Prematuro. Unidades de Terapia Intensiva Neonatal. R E S U M O
Objective To evaluate tip location of peripherally inserted central catheter (PICC) by using the carina as evaluation mark, so as to provide clinical references for blinding manipulation of PICC. Methods A retrospective analysis about the effects of tip location of PICC by using the carina as evaluation mark on inpatients with malignant tumor was conducted in tumor centre of the West China Hospital from March 2013 to April 2014. Chest X radiography was applied to evaluate the tip location of PICC. Statistical analysis was performed using SPSS software (version 19.0) and the outcomes were presented by frequency and percentage. Results A total of 612 cases of blinding manipulation of PICC were evaluated, of which, 502 (82%) were located in the central venous and 110 (18%) were located in the non-central venous. The numbers of those with the catheter tips located in the non-central venous were 38 in the right atrium, 33 in the internal jugular vein, 24 in the innominate vein, 8 in the axillary vein, and 7 in the subclavian vein, respectively. Conclusion The effects of blinding manipulation of peripherally-inserted central catheter by using the carina as evaluation mark are relatively good. But it still needs to be improved.
