migrated from inferior vena cava into the right renal vein leading to its perforation and extravasation of alimentation fluid into the renal pelvis. CASE REPORT.
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Extravasation of Parenteral Alimentation Fluid Into the Renal Pelvis — A Complication of Central Venous Catheter in a Neonate Ali M. Nadroo, MD A. M. Al-Sowailem, MD Many complications of central venous catheters, which include perforation of the vessel walls and extravasation of the infusate into pericardial, pleural, and peritoneal cavities, have been reported. We report an infant with a central venous catheter in inferior vena cava who experienced extravasation of parenteral alimentation fluid into the right renal pelvis secondary to perforation of the renal vein. To our knowledge, this rare complication has not been reported earlier. Journal of Perinatology 2001; 21:465 – 466.
INTRODUCTION Central venous catheters are routinely used in the neonatal intensive care units to provide long-term venous access and infusion of hyperosmolar alimentation solutions. Several complications have been reported with the use of central venous catheters including occlusion, infection, thrombosis, breakage, and migration. After initial placement of the catheter tip in a desired position, migration may result and cause perforation of the vessel walls leading to extravasation of the fluid into pleural, pericardial, peritoneal, and retroperitoneal areas. We describe a previously unreported complication of central venous catheter. The catheter in our patient migrated from inferior vena cava into the right renal vein leading to its perforation and extravasation of alimentation fluid into the renal pelvis.
congenital malformations. Surgical repair of omphalocele was performed at the age of 6 hours. A 2.8 French silastic central venous catheter was inserted through the left femoral vein. The tip of the catheter was located in the inferior vena cava, just below the diaphragm, as confirmed by a radiograph. Parenteral alimentation infusion was administered through the catheter from the second day of life. Patient stayed in stable general condition for 5 days when the color of her urine turned milky. The urine was also mildly bloodtinged and its microscopic examination revealed hematuria. The intravenous fluids were shifted to a peripheral line. The milky color of the urine disappeared immediately. Alimentation fluid infused through the catheter at the time the complication was noticed contained 10% dextrose, 1.5% amino acids, and 10% intralipid. Suspicion of an abnormal connection between the inferior vena cava and the renal pelvis was raised. The ultrasonogram of the abdomen did not reveal any extraperitoneal or intraperitoneal collection of fluid. At this point, a dye study was performed. Two milliliters of 60% urografin (sodium amidotrizoate+megluminate amidotrizoate) was injected through the catheter. The study showed filling of the pelvicalceal system and ureter on the right with the contrast material (Figure 1). No intraperitoneal or extraperitoneal leakage of the dye was noticed. The catheter was pulled out and the patient was closely observed. Urine and blood cultures obtained were negative. She suffered from mild hematuria, which cleared in the next 36 hours. Serial ultrasonography did not reveal any intra-abdominal bleed or fluid collection. This presentation confirmed formation of an abnormal tract by a venous catheter between renal vein and renal pelvis.
DISCUSSION CASE REPORT A 37-week gestational age female neonate, weighing 2.5 kg, was diagnosed to have omphalocele major at birth. There were no other
Department of Pediatrics, Division of Neonatology, Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia. Address correspondence and reprint requests to Ali M. Nadroo, MD, Department of Pediatrics, Division of Newborn Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1508, New York, NY 10029.
Extravasation of parenteral nutrition fluid from the intravascular catheter can occur as a result of direct perforation of a vessel or in association with thrombosis. It may present as pleural effusion, pericardial tamponade, ascites, or extravasation into adjacent soft tissues.1 – 3 The precipitating factors leading to perforation are nonocclusive mural thrombosis, localized septic or chemical phlebitis, and erosion of the vessel wall by the catheter.2 Coagulase negative staphylococcal infection has been reported to occur in association with perforation due to central venous catheter.4 No such factor was present in our patient. Occurrence of hydrothorax as a result of
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pelvis. Ohki et al.8 have reported that extension of the lower extremity can lead to displacement of the catheters towards the periphery and subsequent flexion may lead to its migration into the veins connected to inferior vena cava. This mechanism might have caused migration of the catheter in our patient. However, we do not have any evidence to support such a mechanism. The intra-abdominal extravasation usually responds well to catheter removal.2,4,9 However, paracentesis may be necessary if there is respiratory compromise associated with ascites. Al-Omran and Al-Alaiyan6 reported an infant with hydrothorax secondary to perforation of a pulmonary vein by a malpositioned umbilical venous catheter. This patient also recovered after simple withdrawal of the catheter. Whenever such a catheter-related complication is suspected, ultrasonography and contrast study may prove helpful to establish the diagnosis and unnecessary laparotomy may be avoided. Lateral radiograph may be helpful to diagnose the catheter malposition sometimes missed on the frontal radiograph. Daily monitoring of the catheter length at the site of insertion and serial radiographs may be helpful to detect migration of the catheter before it leads to further complications.
Figure 1. Contrast study showing the extravasation of the fluid from the catheter into the renal pelvis.
malpositioned umbilical catheter was reported previously in two patients.5,6 Patients with intra-abdominal extravasation can present with abdominal distention, respiratory distress, or symptoms mimicking necrotizing enterocolitis (NEC). Nour et al.7 reported two patients with inferior vena caval perforation occurring between 2 days and 2 weeks of catheterization. One of them was a preterm infant presenting with an abdominal mass and fixed loops of dilated bowel, who underwent laparotomy for suspected NEC. The mass comprised of retroperitoneally extravasated parenteral alimentation fluid.7 However, several cases of fatal pericardial tamponade have been reported as a result of myocardial perforation secondary to placement of the catheter tip in the right atrium or migration into it from other sites.2 – 4 Mechanism of catheter migration is not fully understood. In our patient, the catheter tip had migrated from its position just below the diaphragm into the renal vein and perforated into the renal
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References 1. Seguin J. Right - sided hydrothorax and central catheters in extremely low birth weight infants. J Perinatol 1992;9:154 – 9. 2. Springs D, Brantely R. Thoracic and abdominal extravasation; a complication of hyperalimentation in infants. Am J Roentgenol 1977;126:419 – 22. 3. Giacoia G. Cardiac tamponade and hydrothorax as complication of central parenteral nutrition in infants. J Parenter Enteral Nutr 1991;15:110 – 3. 4. Bansal V, Straus A, Gyepes M, Kanchanapoom V. Central line perforation associated with Staphylococcus epidermidis infection. J Pediatr Surg 1993;28:894 – 7. 5. Kulkarni P, Dorand R. Hydrothorax; a complication of intracardiac placement of umbilical venous catheter. J Pediatr 1979;94:813 – 5. 6. Al - Omran A, Al - Alaiyan A. Right - sided hydrothorax; a complication of umbilical catheterization. Saudi Med J 1997;18:198 – 9. 7. Nour S, Puntis J, Stringer M. Intra - abdominal extravasation complicating parenteral nutrition in infants. Arch Dis Child 1995;72:F207 – 8. 8. Ohki Y, Nako Y, Morikawa A, Maruyama K, Koizumi T. Percutaneous central venous catheterization via the great saphenous vein in neonates. Acta Pediatr Jpn 1997;39:312 – 6. 9. Krasna I, Krause T. Life - threatening fluid extravasation of central venous catheters. J Pediatr Surg 1991;26:1346 – 8.
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