Aspiration of parenteral nutrition – a previously unreported complication of central venous access in an infant: a case report
© Jardine et al; licensee BioMed Central Ltd. 2008
Received: 18 November 2007
Accepted: 26 February 2008
Published: 26 February 2008
The insertion of percutaneous central venous catheters is a common procedure in neonatal intensive care nurseries. Placement of the catheter tip in a large central vein is most desirable. Occasionally, due to difficult venous access, catheter tips are left in places that are less than ideal.
A female infant with a complicated gastroschisis developed signs of short bowel syndrome post surgery. She was treated with a combination of parenteral nutrition and enteral feeds. A central venous line was inserted through a scalp vein. The tip was noted to be in a vessel at the level of the mandible. She subsequently became unwell with large milky pharyngeal aspirates and episodes of bradycardia. Chest radiography revealed aspiration. The central venous line was removed because of presumed extravasation. This is the first reported case of parenteral nutrition extravasation into the pharynx causing aspiration in an infant.
This complication may have been prevented by recognising that the tip of the catheter was not correctly placed. When catheters are in unusual positions it may be useful to obtain a second radiograph from a different angle or an ultrasound scan to confirm the positioning of the catheter tip.
The insertion of percutaneous central venous catheters is a common procedure in neonatal intensive care nurseries. Placement of the catheter tip in a large central vein is most desirable. Occasionally, due to difficult venous access, catheter tips are left in places that are less than ideal. Here we present an unusual complication in an infant with a central venous catheter located in a vein of the upper neck.
A female infant with an antenatal diagnosis of gastroschisis was born by emergency caesarean section for fetal bradycardia at 33+3 weeks post menstrual age. Her 23 year old mother was G2P1, Hepatitis C positive and on Methadone (90 mg daily). Birth weight was 1450 grams.
Initial examination revealed a complicated gastroschisis with a segment of small bowel atresia. The remainder of her clinical examination was otherwise normal. During the first six weeks of life she had three laparotomies with reduction of her abdominal contents, resection of two atretic segments, end to end anastomoses, iatrogenic small bowel perforation, adhesionolysis and the eventual formation of a divided colostomy. Other complications included two episodes of infection in the laparotomy wound requiring intravenous antibiotics. During this period she had two peripherally inserted central venous lines and multiple peripheral intravenous cannulae.
It was suspected that the aspirates contained parenteral nutrition and a sample was sent for microscopy and chemistry. The results were consistent with parenteral nutrition.
On stopping the lipids and parenteral nutrition, a dramatic decrease in the oral secretions was noted and they changed from a milky to clear. The central venous line was then removed because of presumed extravasation. Her condition continued to improve and she was extubated on day 84. She has remained well since extubation apart from ongoing problems with short bowel syndrome.
While extravasation is a recognised complication of central venous catheters, to our knowledge this is the first reported case of parenteral nutrition extravasation into the pharynx causing aspiration in an infant. Frequently reported sites of extravasation include the pleural and pericardial cavities [2, 3]. Rarely reported sites of extravasation include the pulmonary parenchyma [4, 5], renal pelvis , scrotum , retroperitoneal space , spinal epidural space  and subdural space .
This complication might have been prevented by recognising that the tip of the catheter was not in the internal jugular vein. It is difficult to accurately locate the catheter tip with a single view.
When catheters are in unusual positions it may be useful to obtain a second radiograph from a different angle or an ultrasound scan to confirm the positioning of the catheter tip.
Informed consent was obtained from the patient's parents for publication of this case report and accompanying images. A copy of the consent is available for review by the Editor-in-Chief of this journal.
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