Fatal pericardial tamponade complicating total parenteral nutrition via a silastic central vein catheter

The carina as a landmark for central venous catheter placement in small children

Central venous devices are frequently used in children to monitor haemodynamic status, to administer fluids, medication, parenteral nutrition and for blood sampling. Life-threatening complications that may occur on insertion if the central venous catheter (CVC) is misplaced, are cardiac tamponade or a hydro-/haemopericardium. There is still controversy over the optimum catheter tip position in paediatric patients, whether to place the CVC tip in the superior vena cava, outside the pericardial boundaries or in the right atrium. However, the exact location of the pericardium cannot be seen on a normal chest x-ray. The carina is a radiographic marker for CVC placement, suggested on the basis of studies with conserved and fresh adult cadavers. In order to confirm this landmark for children, the present study was performed with 31 fresh cadavers of small children (mean age 12.5+/-3.4 months) that had been selected for autopsy in the Institute of Legal Medicine. Results clearly demonstrate that the carina was 0.5+/-0.04 cm above the pericardial duplication as it transversed the SVC. In no infant cadaver was the carina inferior to the pericardium. Thus, the results are analogous to those in adults and confirm that the carina is a simple anatomical-radiological landmark, superior to the pericardial reflection, that can be used to identify the placement of CVC even in newborn and small children.

Perforation complications of percutaneous central venous catheters in very low birthweight infants

OBJECTIVE

To prospectively survey perforation complications of consecutively inserted percutaneous central venous catheters (PCVC) in very low birthweight (VLBW) infants over a 2 year period.

METHODOLOGY AND RESULTS

Three serious perforation complications were encountered in a series of 100 consecutive PCVC. One infant (birthweight 685 g) developed pericardial effusion and fatal cardiac tamponade during the use of a polyurethane PCVC. At autopsy, the pericardial sac contained 8 mL fluid with a glucose concentration of 109 mmol/L and the catheter tip was embedded in the right ventricular wall. The second infant (birthweight 1380 g) showed pleural effusion and transient immobility of the right diaphragmatic leaf after perforation of a similar PCVC into the right pleural cavity. The third perforation, causing subcutaneous oedema, occurred in a 655 g infant who had a silastic PCVC.

CONCLUSIONS

The data suggest a 3% incidence for PCVC-associated symptomatic perforation complications and a 1% incidence for fatal perforations, despite a policy of careful placement. The data also indicate that perforation complications occur regardless of the size or material of the PCVC. Proper visualization of the PCVC and vigilant attention to its location is required to prevent these rare but potentially fatal complications.

Depth of central venous catheter insertion in adults: an audit and assessment of a technique to improve tip position

A technique of subclavian vein catheterization is described, tailored to the individual patient, to reduce the risk of right atrial placement with central venous catheter (CVC) insertion. Using data gathered retrospectively for Quality Improvement purposes, CVC tip location was assessed. The standard technique used in our cardiac anaesthesia unit at that time was to insert all CVCs to a depth of 15 cm from the skin. We then compared CVC tip location using a new "tailored" technique. The tailored method involved measuring the distance from the skin at which venepuncture occurred and using this distance to determine depth of CVC insertion. Using the tailored technique significantly decreases the frequency with which CVC tips enter the right atrium (P < 0.001). An advantage of the tailored technique is that the distance between the most proximal and the distal ports of multi-lumen CVCs is taken into consideration, reducing the risk of extravasation via the proximal port.

Rare complications of vascular access devices

OBJECTIVE

To provide an overview of rare complications of vascular access devices in terms of etiology, assessment, management, and follow-up.

CONCLUSIONS

Rare complications of vascular access devices are serious and in some cases life-threatening. These complications include pinch-off and catheter fracture, catheter malposition and migration, cardiac perforation, extravasation, breakage, and defective devices. Knowledge and awareness of these complications can contribute to accurate identification and immediate management. Documentation and reporting of complications to the Food and Drug Administration helps to ensure the safety and efficacy of vascular access devices.

IMPLICATIONS FOR NURSING PRACTICE

Developing the expertise needed to manage these types of complications is a continual challenge to the oncology nurse. Although managing rare complications is usually performed by a physician, recognizing the clinical manifestations will alert the nurse to seek medical advice immediately, thus decreasing the risk of mortality. All health care professionals are responsible for continually monitoring vascular access devices, consistently documenting findings, and communicating recommendations for care.

Cardiac tamponade in an infant. A rare complication of central venous catheterisation

A 2994 g infant suffered cardiac tamponade from an infusion of total parenteral nutrition through an indwelling central venous catheter. The infant survived as a result of early diagnosis and aggressive therapeutic intervention. Cardiac tamponade secondary to central venous catheterisation is rare, but potentially lethal. Possible mechanisms are direct puncture by the catheter tip, or osmotic injury from the use of hypertonic solutions. To avoid this complication, the catheter tip should be prevented from entering the right atrium and its position should be checked periodically by chest X ray. Cardiac tamponade should be considered in any patient with a central venous catheter whose clinical condition deteriorates suddenly. Diagnostic or therapeutic pericardiocentesis should be employed as the first measure and time should not be wasted on other diagnostic procedures.

Long-term central venous catheters: issues for care

Long-term central venous catheters allow the safe administration of chemotherapy, blood and blood products, total parenteral nutrition, fluids, and other medications. Despite their benefits, the risk of certain complications (e.g., fibrin sleeve and mural thrombus formation, infection, catheter occlusion, extravasation, and catheter malposition) exist for every person who has a catheter. Thus, preventative measures, recognition of early signs and symptoms of complications, and adequate care of utmost importance.

Total parenteral nutrition in the pediatric patient

Over the past 50 years, tremendous advances have been made in the management of children who cannot receive enteral nutrition. Challenges for the future include devising techniques to decrease catheter sepsis, particularly in children with a short bowel, who have a disproportionate number of septic episodes, possibly related to bacterial translocation. The delineation of risk factors for cholestasis associated with total parenteral nutrition and refinement of administration of such nutrition in premature neonates to decrease the incidence of this complication, as well as the morbidity of osteopenia, will extend our ability to help these children.

Cardiac tamponade and hydrothorax as complications of central venous parenteral nutrition in infants

The recent use of soft catheters made of silastic polymeric silicone or polyurethane has decreased the incidence of perforation of great veins or right-sided heart chambers but has not eliminated it as had been hoped. Two premature infants who presented with cardiac tamponade more than 24 hr after the insertion of a 23-gauge silastic catheter for total parenteral nutrition (TPN) administration are described. In one infant, bilateral hydrothorax preceded the occurrence of cardiac tamponade. Osmotic injury to great vessels and/or myocardium seems to be the common mechanism but which these complications of intraluminal catheters are produced. Review of the pediatric literature revealed a proportion of low birth weight infants among the reported cases. Despite a prohibitively high mortality rate, early recognition can prevent a fatal outcome.