Perinatal/Neonatal Casebook &&&&&&&&&&&&&& Radiology Casebook

Philip Stanley, MD, Section Editor On the 16th day of life the UVC was removed because it was shown to Contributed by Richard C. Lussky, MD be proximal to the ductus venosus on the chest radiograph. A PCVL was placed through the left saphenous vein at the lateral malleolus to continue central parenteral nutrition. An abdominal radiograph was performed (Figure 1). The line was initially judged to be centrally Umbilical venous catheters and percutaneously placed central venous lines placed in the inferior vena cava (IVC), but on further review it was play an integral role in the management of critically ill newborn infants. determined to be in the ascending lumbar vein. This vein is in close Health care providers involved with the placement of these catheters must be proximity to the IVC, and drains the veins of the vertebral plexuses familiar with, and able to diagnose, subtle sites for catheter misplacements. into the common iliac vein and the IVC. The key to the correct Three cases are presented illustrating potential sites of misplacement. The interpretation was the segmental nature of the contrast material. The indications, placement, and associated complications of central venous lines Silastic catheter was immediately removed, and a PCVL was placed reported in the literature are briefly reviewed. through the right saphenous vein. No adverse clinical sequelae Journal of Perinatology 2000; 20:562±564. resulted from the initial placement, and the infant was discharged home at 50 days of age in good health.

Patient 2 The management of critically ill and low-birth-weight infants The patient was a male infant weighing 1345 g, born at 30 has become increasingly complex as survival rates continue to weeks' gestation to a 28-year-old gravida 3, para 2 woman improve. Central lines (e.g., umbilical venous catheters [UVCs] through a spontaneous vaginal delivery. Apgar scores were 7 and 9 and percutaneously placed central venous lines [PCVLs] ) are an at 1 and 5 minutes, respectively. She was admitted to the NBICU essential part of neonatal medicine. Central venous access is used for for prematurity. emergency delivery of resuscitative medications and fluids, parenteral On the day of admission, both a UVC and a PCVL were placed for nutrition, central venous pressure monitoring, blood drawing, long- central venous access for long-term central parenteral nutrition and term administration of medications, and exchange transfusions. administration of cardiac medications. A chest radiograph was The literature on central lines extensively details the various performed. As shown in Figure 2, the UVC entered the right atrium infectious, mechanical, and thrombotic/embolic complications through the ductus venosus and the IVC. It then entered the coronary related to their use. The diagnosis and management of catheter sinus and cannulated a persistent left superior vena cava. The key to misplacement is rarely discussed. In this article the misplacement of correct radiographic interpretation is observation of the left-sided UVCs and PCVLs in three patients is described. position of the superior portion of the UVC, as opposed to the normal right-sided position of the superior vena cava. The PCVL was placed through the right cephalic vein. After entering the right atrium, it CASE REPORTS Patient 1 entered the right ventricle and cannulated a pulmonary artery. We know that it entered the right ventricle, as opposed to entering the left The patient was a female infant weighing 1145 g, born at 29 weeks' gestation to a 31-year-old gravida 2, para 1 woman. A cesarean atrium through the foramen ovale and cannulating a pulmonary vein (the more typical course for a catheter) because the location of section was performed for a transverse lie. Apgar scores were 6 and 8 at 1 and 5 minutes, respectively. The infant was intubated in the the foramen ovale is just inferior to the carina, which is approximately 2 cm superior to where the PCVL crosses the midline delivery room and given surfactant for respiratory distress syndrome. in this radiograph. The catheters were repositioned, and no adverse She was placed on mechanical ventilation on arrival in the newborn intensive care unit (NBICU). clinical sequelae resulted from these catheter misplacements. The infant was discharged home at 30 days of age in good health.

Department of Pediatrics, Hennepin County Medical Center, Minneapolis, MN. Patient 3 Address correspondence and reprint requests to Richard C. Lussky, MD, Department of The patient was a female infant weighing 1018 g, born at 28 weeks' Pediatrics Ð 867B, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, MN 55415. gestation to a 22-year-old gravida 3, para 2 woman. A cesarean

Figure 3. Anterior±posterior radiograph of the chest. Percutaneous Silastic catheter in cervical vertebral vein, with contrast injection through catheter.

On the third day of life, a PCVL was inserted for central parenteral nutrition through the right basilic vein. A chest radiograph was performed (Figure 3). The catheter tip was determined to be in the cervical vertebral vein, as reflected by the segmental nature of the Figure 1. Anterior±posterior radiograph of abdomen. Umbilical venous contrast material. It was subsequently repositioned into the superior catheter position unchanged. Percutaneous Silastic catheter in ascending vena cava. No adverse clinical sequelae resulted from the initial line lumbar vein, with contrast injection through catheter. placement, and the infant was discharged home at 54 days of age in good health. section was performed for breech presentation. Apgar scores were 6 and 9 at 1 and 5 minutes, respectively. The infant was intubated in DENOUEMENT AND DISCUSSION the delivery room and given surfactant for respiratory distress syndrome. She was placed on mechanical ventilation on arrival in Unusual Misplacement Sites for Central Venous the NBICU. Catheters: Three Case Reports Umbilical venous catheters and percutaneously placed central venous lines are successfully placed in 85% to 95% of attempts.1 Complication rates vary with the type of catheter used (e.g., Broviac versus PCVL),2,3 the duration of placement, and the size of the infant.4 The mechanical complication rate is between 15% and 25%.5,6 Acute complications around the time of placement may include pneumothorax, vessel perforation, and subsequent hemorrhage, cardiac perforation and tamponade, and air embolisms. With long- term use of catheters, complications may include accidental dislodgement, leaking secondary to catheter tears, occlusions, and catheter migration with extravasation of fluid (e.g., pericardial effusion, hydrothorax). Infectious complications occur at a rate of 10% to 20%, and include bacteremia, sepsis, phlebitis, and endocarditis.7,8 Thrombotic/embolic complications include catheter occlusion, occlusion of a vessel, superior vena cava syndrome, atrial thrombi, valvular vegetations, and pulmonary embolism. The optimal location of the distal tip of the UVC is in the IVC, outside the cardiac silhouette. The optimal location of the tip of the PCVL will depend on the vein used for placement (e.g., posterior Figure 2. Anterior±posterior radiograph of chest. Umbilical venous auricular Ð internal jugular, brachiocephalic vein and superior catheter in persistent left superior vena cava. Percutaneous Silastic catheter vena cava; cephalic Ð subclavian, brachiocephalic vein and in pulmonary artery, with contrast injection through catheter. superior vena cava; saphenous Ð common iliac vein or IVC).

Journal of Perinatology 2000; 20:562 ± 564 563 Stanley and Lussky Radiology Casebook

These are three of the most frequently used veins for access. A References malpositioned central venous catheter increases the risk of 1. Chathas MK, Paton JB, Fisher DE. Percutaneous central venous complications, which include cardiac arrhythmias,9 pericardial catheterization: three years' experience in a neonatal intensive care unit. Am J Dis Child 1990;144:1246±50. effusion/cardiac tamponade,10 thrombotic endocarditis,11 and 2. Shulman RJ, Pokorny WJ, Martin CG, et al. Comparison of percutaneous and hydrothorax.12 In our experience other sites for PCVL misplacements have included the contralateral subclavian vein, the IVC (with upper surgical placement of central venous catheters in neonates. J Pediatr Surg 1986;21:348±50. extremity approaches), and locations within the heart. 3. Mactier H, Alroomi LG, Young DJ, et al. Central venous catheterization in very An understanding of the anatomy of possible catheter misplace- low birth weight neonates. Arch Dis Child 1986;61:449±53. ment sites will improve the rate of successful placement. The position 4. Fleer A, Gerards LJ, Aerts P, et al. Opsonic defense to staphylococcus of the umbilical venous catheter tip can also be assessed clinically by epidermidis in the premature neonate. J Infect Dis 1985;152:930±7. measurement of the venous pressure. Venous pressure is lower in the 5. Goutail-Flaud MF, Sfez M, Berg A, et al. Central venous catheter-related IVC than in the portal system, and there is a larger fall in pressure complications in newborns and infants: a 587-case survey. J Pediatr Surg with inspiration if the catheter tip is in the right atrium. In addition, 1991;26:645±50. venous waves should be visualized on the pressure transducer once 6. Durand M, Ramanathan R, Martinelli B, et al. Prospective evaluation of the catheter tip enters the IVC.13 Some clinicians have also advocated percutaneous central venous Silastic catheters in newborn infants with birth weights of 510 to 3920 grams. Pediatrics 1986;78:245±50. that ultrasound be used to confirm correct placement.14 These cases prompted us to change our NBICUpolicy for central 7. Klein JF, Shavrivar F. Use of percutaneous silastic central venous catheters in venous line placements. At the time of these placements, the typical neonates and the management of infectious complications. Am J Perinatol 1992;9:261±4. approach in our NBICUwas for the catheter to be placed by a resident 8. Loeff DS, Matlak ME, Black RE, et al. Insertion of a small central venous physician under the supervision of a senior experienced neonatal catheter in neonates and young infants. J Pediatr Surg 1982;17:944±9. nurse practitioner. Now our policy calls for immediate review of the 9. Egan EA, Eitzman DV. Umbilical vessel catheterization. Am J Dis Child radiograph by the attending neonatologist. In addition, education of 1971;121:213±8. NBICUstaff and staff physicians has fostered a better understanding 10. Purohit DM, Levkoff AH. Pericardial effusion complicating umbilical venous of the possible sites for misplacements of central venous lines. catheterizations. Arch Dis Child 1977;52:520. 11. Symchych PS, Krouss AN, Winchester P. Endocarditis following intracardiac placement of umbilical venous catheters in neonates. J Pediatr Acknowledgments 1977;90:287±9. I thank Dr Bill Mize, Department of Pediatric Radiology, University of Minnesota for 12. Kulkarni PB, Dorand RD. Hydrothorax: a complication of intracardiac his assistance with radiographic interpretation; Drs David Fisher and Rolf Engel, placement of umbilical venous catheters. J Pediatr 1979;94:813±4. Division of Neonatology, Hennepin County Medical Center (HCMC) for their critical 13. Kitterman JA, Phibbs RH, Tooley WH. Catheterization of umbilical vessels in review of this manuscript; Brad Capouch, graphic artist, HCMC for preparation of newborn infants. Pediatr Clin North Am 1975;17:895±912. graphic materials; and James Kauffman, PhD, Office of Communications, Hennepin 14. Madar RJ, Deshpande SA. Reappraisal of ultrasound imaging of neonatal Faculty Associates for editorial assistance on this manuscript. intravascular catheters. Arch Dis Child 1996;75:F62±4.

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