Current Concepts ⅢⅢⅢⅢⅢⅢⅢⅢⅢⅢⅢⅢⅢⅢ Focal Neurological Manifestations Following Aberrant Central Venous Catheter Placement

Home , Ascending lumbar vein, Hemiazygos vein, Intervertebral veins, Lumbar veins

Vigna Rajan, MD On day 14, infant B acutely developed sustained tonic-clonic Feizal Waffarn, MD movements affecting the lower extremities; these movements were clinically diagnosed as focal seizures and were treated with an anti- An infant developed focal tonic clonic movements of both lower limbs convulsant. A lumbar puncture performed to rule out meningitis 3 while receiving total parenteral nutrition through a left saphenous yielded cloudy fluid consisting of 34,114/mm red blood cells and 3 percutaneous central venous catheter. Radiographic studies using a 749/mm white blood cells with 3% lymphocytes and 97% poly- contrast confirmed that the catheter tip was located in the ascending morphs. The glucose and protein content of the fluid was 3943 mg/dl lumbar vein in close proximity to the epidural space. Withdrawal of the and 127 mg/dl, respectively. Blood and lumbar puncture fluid cul- catheter abated all clinical symptoms. This case emphasizes the need to tures grew coagulase-negative staphylococcus sensitive to vancomy- 3 confirm central venous catheter placement and illustrates yet another cin. A repeat lumbar puncture specimen showed 50,250/mm red 3 risk associated with the infusion of parenteral alimentation. blood cells, 1,515/mm white blood cells, and 7,348 mg/dl glucose. There was a continuous leakage of serous fluid at the site of the lumbar puncture, with a glucose level of Ͼ800 mg/dl. Serum glucose levels remained between 80 and 120 mg/dl during this period. A lat- Central venous access for long-term total parenteral nutrition eral radiograph of the abdomen and pelvis showed the catheter loca- (TPN) is a standard practice in neonatology, and associated com- tion posterior to the lumbar vertebral column. A contrast study using plications due to aberrant percutaneous central venous catheter (PCVC) locations1–7 have been well documented. These include cardiac tamponade caused by penetration of the myocardium1 and fluid collections in the thorax following pleural perforation into the thoracic cavity or obstruction of the lymphatic drainage.2,3 Less frequent complications include extravasation of TPN causing retroperitoneal abscess formation and dystrophic calcification of the epidural veins.4–7 We report a previously undocumented complication following the inadvertent location of the PCVC in the ascending lumbar vein of a very low birth weight infant. Report of a Case Infant B was a 988-gm infant girl born at 28 weeks’ gestation who was admitted to the Neonatal Intensive Care Unit at University of California-Irvine Medical Center. The infant was on mechanical ventilatory support for the first 9 days of life and underwent surgi- cal ligation of the patent ductus on day 4 of life. A PCVC was placed through the left saphenous vein for parenteral alimentation on day 7 of life, with radiographic confirmation showing the catheter tip at the level of the fifth lumbar vertebra (Figure 1). The infusate contained 15% dextrose with protein and intralipid sup- plements.

Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of California, Irvine Medical Center, Orange, CA.

Current address (V. R.): Pediatric Critical Care Medical Group, 6430 Sunset Boulevard, Suit 600, Los Angeles, CA 90028. Figure 1. Anterior-posterior radiograph of the abdomen showing the tip of the Reprints of this article are not available. PCVC at the level of the fifth lumbar vertebra.

Journal of Perinatology (1999) 19(6) 447–449 © 1999 Stockton Press. All rights reserved. 0743–8346/99 $12 http://www.stockton-press.co.uk 447 Rajan and Waffarn Focal Neurological Manifestations Following Catheter Placement

The tonic-clonic activity of the lower limbs lasted for ϳ24 hours and subsequently abated. The anticonvulsant was discontinued at 72 hours after cessation of the tonic-clonic activity. Increased muscular tone and decreased active movements of both lower limbs that were noted during the acute episode gradually improved over 2 weeks. The coagulase-negative staphylococcus that was present in the fluid ob- tained by the lumbar puncture was presumed to be a likely contami- nant of the bloody fluid. This presumption was based on the lack of clinical and neurologic signs of central nervous system involvement. The infant received a 10-day course of vancomycin. The infant was subsequently discharged without any residual neurologic findings Discussion This case report documents a previously unreported PCVC complication of focal neurological symptoms in the very low birth weight infant. Previous reports have included a variety of complications secondary to aberrant PCVC location during the infusion of hyperosmolar TPN solutions.1–7 Whereas more common complications have been confined to the thorax and heart, PCVC complications with respect to the vertebral column and spinal nerve roots have been relatively rare.4–7 Percutaneous cannulation of the inferior vena cava in adults Figure 2. Anterior-posterior radiograph of the chest and abdomen showing con- using a straight catheter with or without a guide wire has shown that trast to occupy the epidural space extending from the sacral region to the midthoracic entry into the ascending lumbar vein is common.8 In addition to the region. anatomic proximity of this vein, passive venous dilatation caused by an increase in intra-abdominal and intrathoracic pressure may facili- Optiray (Mallinckrodt Medical, St. Louis, MO) infused into the PCVC tate the inadvertent passage of the catheter into this location. showed the contrast to enter the epidural space extending from the The ascending lumbar vein passes anterior to the transverse sacral region to the midthoracic region (Figure 2). The catheter was processes of the lumbar vertebrae and most commonly gives origin to removed immediately. the azygos vein on the right side and to the hemiazygos vein on the

Figure 3. Schematic illustration showing the relationship between the ascending lumbar vein, vertebral veins, vertebral venous plexus, and epidural space.

448 Journal of Perinatology (1999) 19(6) 447–449 Focal Neurological Manifestations Following Catheter Placement Rajan and Waffarn

left. Inferiorly, it drains in to the common iliac vein through the the potential to cause injury to the spinal nerve roots. To prevent such iliolumbar vein and forms an anastomosis between the superior and a complication, we now advocate obtaining anterioposterior and inferior vena caval systems.9 The lumbar vertebral venous plexus lateral radiographs of the abdomen and thorax to ascertain catheter communicates with the ascending lumbar veins through the interver- position before the infusion of parenteral fluids. tebral and lumbar veins (Figure 3). Batson10 discovered that the venous plexus of the vertebral column constitutes a system that parallels the caval system, and that during periods of increased intra-ab- References domino-pelvic pressure, a considerable amount of blood flows 1. Opitz JC, Toyama W. Cardiac tamponade from central venous catheterization: through the vertebral plexus rather than through the inferior caval two cases in premature infants with survival. Pediatrics 1982;70:139–40. system. Contrast injection into the ascending lumbar vein fills the 2. Dhande V, Kattwinkel J, Alford B. Recurrent bilateral pleural effusions secondary vertebral and paravertebral venous plexuses, with subsequent drain- to superior vena cava obstruction as a complication of central venous catheter- age into the hemiazygos vein.11,12 ization. Pediatrics 1983;72:109–13. In the present case report, we were able to radiographically dem- 3. Seguin JH. Right-sided hydrothorax and central venous catheters in extremely onstrate malposition of the catheter at the anatomic location of the low birth weight infants. Am J Perinatol 1992;9:154–8. ascending lumbar vein; we were also able to confirm the communica- tion of the catheter with the epidural space by the injection of con- 4. Kelly MA, Finer NN, Dunbar LG. Fatal neurologic complication of parenteral trast. This finding, when taken together with the evidence of high red feeding through a central vein catheter. Am J Dis Child 1984;138:352–3. blood cell count, elevated glucose levels, and the cloudy appearance of 5. Math MP, Fain JS, Hall SL, Wood BP. Radiological case of the month. Am J Dis the fluid withdrawn from the lumbar region, suggests that this fluid Child 1991;145:1439–40. was from the epidural venous plexus, representing a mixture of blood and TPN fluid rather than cerebrospinal fluid. The rapid clinical 6. Karanauskas S, Starshak RJ, Sty JR. Heterotopic Tc-99m MDP uptake secondary improvement following withdrawal of the catheter and the absence of to phlebitis. Clin Nucl Med 1991;16:329–31. generalized neurological findings would also support this conclusion. 7. Lussky RC, Trower N, Fisher D, Engel R, Cifuentes R. Unusual misplacement We propose that the mechanism leading to the clinical symptoms sites of percutaneous central venous lines in the very low birth weight neonate. was due to the location of the catheter in the ascending lumbar vein, Am J Perinatol 1997;14:63–7. with the hyperosmolar TPN fluid entering the epidural venous plexus through the intervertebral veins. The hyperosmolar TPN solution 8. Pillari G, Baron MG. Avoiding the ascending lumbar vein. Angiology 1980;31: 725–8. most probably caused an irritative thrombophlebitis13 of the thin- walled epidural veins, causing extravasation of TPN fluid into the 9. Gray H. Gray’s Anatomy. 38th ed. New York: Churchill Livingstone, Inc. 1995. p. epidural space. The highly irritating and hyperosmolar TPN solution 1595–600. in direct contact with the spinal nerve roots resulted in focal tonic- 10. Batson OV. The function of the vertebral veins and their role in the spread of clonic activity that promptly abated with the removal of the PCVC. metastases. Ann Surg 1940;112:138–49. The accumulation of fluid and the inflammatory edema in the epidural space could also have contributed to these neurologic signs. 11. Gargano FP, Meyer JD, Sheldon JJ. Transfemoral ascending lumbar catheteriza- Previous case reports describe findings that are consistent with these tion of the epidural veins in lumbar disk disease. Radiology 1974;111:329–36. 4–7 proposed mechanisms. 12. Kistler MW, Pribram HW. Epidural venography in the diagnosis of lumbar disc Conclusion disease. Surg Neurol 1976;5:287–91. Inadvertent placement of PCVC in to the ascending lumbar vein dur- 13. Makarewicz PA, Freeman JB, Fairfull-Smith, R. Prevention of superficial phlebitis ing cannulation of the inferior vena cava is a rare complication with during peripheral parenteral nutrition. Am J Surg 1986;151:126–9.

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