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Indian Pediatr 2013;50:
1157-1158 |
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Bilateral Pleural Effusion Complicating
Umbilical Venous Catheterization
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Neeraj Kumar and Srinivas Murki
From Department of Pediatrics, Fernandez Hospital,
Hyderabad, Andhra Pradesh
Correspondence to: Dr Srinivas Murki,
Consultant Neonatologist, Fernandez Hospital,
Hyderabad 500 001, Andhra Pradesh.
Email:
[email protected]
Received: June 12, 2013;
Initial review: June 19, 2013;
Accepted: September 05, 2013.
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Background: Umbilical venous lines are sometimes complicated with
pleural and or pericardial effusion, often due to line migration.
Case Characteristics: Bilateral chylous pleural effusion without
pericardial effusion in a 28 weeks, extremely low birth infant who was
on total parenteral nutrition. Observations/Investigations:
Investigations including chest x ray and 2D echocardiogram showed
bilateral chylous pleural effusions but appropriate tip position of the
umbilical venous line. Outcome: Removal of the umbilical venous
line and cessation of total parenteral nutrition resulted in complete
resolution of the pleural effusion. Message: In any newborn with
central venous catheter in situ, acute deteriorations specially, those
related to pleural and pericardial effusions should alert the clinicians
to remove the catheter and should not be misguided by apparently
appearing normal correct catheter position by x-ray or 2D
echocardiogram.
Keywords: Complication, Central line,
Parenteral nutrition, Pleural effusions, Umbilical vein.
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A preterm extremely low birth weight (ELBW) infant
developed recurrent apneas and bilateral pleural effusions secondary to
umbilical venous catherization. The infant was managed by prompt
drainage of the pleural fluid, supportive care and removal of the
umbilical catheter. Although pericardial effusion and unilateral pleural
effusion as complication of umbilical venous lines were previously
reported [1-4], bilateral pleural effusion without pericardial effusion
is not reported in newborns.
Case Report
A preterm ELBW infant was born to a Gravida 3 mother
at 28 weeks of gestation by emergency lower cesarean section secondary
to doppler compromise and antepartum hemorrhage. Apgars at 1 and 5
minutes were 8 and 9, respectively. Antenatal period was complicated
with maternal hypothyroidism and mother was diagnosed with autoimmune
thyroiditis. The infant was admitted to NICU at 30 minutes of life and
was started on nasal prong oxygen in view of mild respiratory distress.
Chest radiograph at admission was normal. An umbilical venous line was
inserted at 3 hours of life for partial parenteral nutrition. Position
and tip of the line was confirmed with chest radiograph and 2D
echocardiogram. On the second day of life, the infant was started on
total parenteral nutrition with a protein of 3g/kg/day and lipid of
2gm/kg/day.
At 46 hours of life, the infant had an apnea, with
cessation of breathing, cyanosis and bradycardia. Apnea was managed with
continuous positive airway pressure and caffeine citrate. Blood sugar,
calcium, electrolytes were normal. Screen for intracranial hemorrhage
was negative. Chest radiograph showed haziness of the right lung field.
Blood cultures were sterile. Over the next few hours, the newborn showed
worsening capillary perfusion, recurrent apneas and off color. It was
intubated and started on mechanical ventilation. Ultrasound chest at 50
hours of life showed bilateral pleural effusion with fluid collection
more on the left side and there was no pericardial effusion. Twenty ml
of milky white chylous fluid was drained from the pleural cavities.
Pleural fluid evaluation revealed 500/mm 3
cell count with neutrophilic predominance (78%), protein
of 0.4 g/dL, lactage dehydrogenase of 73 units/liter, triglycerides of
453 mg/dl and 30,000/mm3 red
blood cells . Infant screening for hypothyroidism showed high TSH (17.22
µIU/mL), low Free T3 (6.6 pg/mL) and low Free T4 (1.46 ng/dL). Repeat
chest radiograph showed good lung expansion, resolution of haziness and
umbilical line in appropriate position. Ultrasound abdomen also showed
umbilical vein catheter in position. However, the line was removed at 52
hours of life, the infant was extubated at 78 hours of life and was
supported with nasal prong oxygen. Thyroxine was started orally at 15
mcg/kg on day 4 of life. Trophic feeds were started on day 4 of life and
parenteral nutrition was restarted on day 5 of life after establishing a
peripherally inserted percutaneous venous line in the lower limb. Full
enteral feeds (150 mL/kg/day) with fortified human milk were achieved on
day 13 of life. There was no recurrence of pleural effusion or
respiratory distress. Infant regained birth weight on day 16 of life.
Discussion
Chronology of events, drainage of chylous fluid from
the pleural cavities, no recurrence of pleural collection after removal
of umbilical venous line, high triglycerides in the pleural fluid
support an association of umbilical vein catheter with bilateral pleural
effusions in our index infant on parenteral nutrition. Two possible
explanations for umbilical line induced pleural effusions are, line
migration and hyperosmolar endothelial damage. Migration of catheter tip
may occur because of movement of head and extremities and flushing of
umbilical venous catheter by nursing staff. The umbilical vein catheter
could perforate the pericardial sac to the mediastinum and cause
bilateral pleural effusions. In the index case there was no evidence of
catheter perforation of vessel wall or migration of catheter tip.
Increased osmolality of the parenteral fluid causing endothelial damage
may be the most plausible explanation for pleural effusions in this
infant. Although, congenital hypothyroidism is rarely associated with
chylothorax [5], the rapidity of improvement and the chronology of
events make this association unlikely in the index case.
Sridhar, et al. [1] reported left pleural
effusion in a 31 week preterm infant due to peripherally inserted
central catheter migration 24 hours after insertion. They confirmed the
line position with contrast X-ray which showed the tip in the
left pulmonary artery and dye in the left lung field. The effusion
resolved with removal of catheter. Pabalan, et al. [2] reported
right sided pleural effusion in a 28 week preterm infant following
umbilical venous catheterization. The complication occurred nearly 40
hours after the line placement. Chest X ray revealed normal tip
position of the catheter. Drainage and catheter removal helped in
complete resolution of the pleural effusion. Hong, et al. [3]
reported umbilical venous line related pleural and pericardial effusion
in a 34 week preterm infant [3]. In their case, the newborn was started
on parenteral nutrition on day 2 of life, developed pleural effusion 5
days and pericardial effusion 8 days after insertion of umbilical venous
catheter. The symptoms cleared only after removal of catheter on day 13
of life. The catheter position and tip was always appropriate and there
was no evidence of line migration. Madhavi, et al. [4] reported
right pleural effusion in a 26 week extremely preterm infant secondary
to migration of a central venous catheter into pulmonary vasculature.
They confirmed the catheter tip in right pulmonary artery by
radiographic contrast examination. The baby improved after aspiration of
pleural fluid and removal of central venous catheter. Similar cases of
pericardial and unilateral pleural effusions [6] related to umbilical
venous catheter or peripherally inserted central catheter placements
have been well reported. However, bilateral pleural effusions without
pericardial fluid complicating umbilical line placements are rare and
not reported previously in newborns.
References
1. Sridhar S, Thomas N, Kumar ST, Jana AK. Neonatal
hydrothorax following migration of a central venous catheter. Indian J
Pediatr. 2005;72:795-6.
2. Pabalan MJ, Wynn RJ, Reynolds AM, Ryan RM, Youssfi
M, Manja V, et al. Pleural effusion with parenteral nutrition
solution: an unusual complication of an "appropriately" placed umbilical
venous catheter. Am J Perinatol. 2007;24:581-5.
3. Hong EJ, Lee KA, Bae H, Kim MJ, Han HS. Umbilical
venous Line related pleural and pericardial effusion causing cardiac
tamponade in premature neonate. Korean J Pediatr. 2006;49:686-9.
4. Madhavi P, Jameson R, Robinson MJ. Unilateral
pleural effusion complicating central venous catheterisation. Arch Dis
Child Fetal Neonatal Ed. 2000;82:F248-249.
5. Noseda C, Putet G. [Congenital chylothorax and
hypothyroidism: a case report and a review of the literature]. Arch
Pediatr. 2009;16:1470-3.
6. Beardsall K, White DK, Pinto EM, Kelsall AW.
Pericardial effusion and cardiac tamponade as complications of neonatal
long lines: are they really a problem? Arch Dis Child Fetal Neonatal Ed.
2003;88:F292-5.
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