Accidental intracranial hyperalimentation infusion

Subdural extravasation of crystalloids and blood products through a scalp peripheral intravenous catheter into the subdural space of a neonate on veno-arterial extracorporeal membrane oxygenation

We describe a rare and devastating complication of a malpositioned scalp peripheral intravenous catheter (PIV) that resulted in subdural extravasation of infused fluids and midline shift in a critically ill neonate who required extracorporeal membrane oxygenation (ECMO). Recognition of increased intracranial pressure was hindered by the hemodynamic changes of being on ECMO and only identified by routine surveillance ultrasonography. Awareness of this complication may lead providers to seek alternate sites for vascular access in such patients, and encourage closer monitoring for this complication when an alternate site is unavailable.

Scalp Intravenous Catheter Infiltration Leading to Subdural and Intraparenchymal Fluid Collection and Severe Neurologic Sequelae: A Case Report

INTRODUCTION

Preterm infants require intravenous (IV) access for administration of medications, IV fluids, and parenteral nutrition. The scalp is a common site for obtaining IV access, and in children with hydrocephalus or wide fontanelles and sutures, there is a high probability of penetrating the meninges and brain matter with the scalp IV needle. If this penetration occurs and remains unnoticed, the contents of the IV infusion can infiltrate into the brain and cause severe brain damage.

CASE PRESENTATION

A 3-day-old female neonate, born with myelomeningocele, was receiving total parenteral nutrition through a scalp-vein IV. She experienced a sudden increase in head circumference, a bulging fontanelle, and respiratory distress. Magnetic resonance images demonstrated subdural fluid collection, and the patient underwent emergency surgery. The dura, when opened, exuded milky-white fluid consistent in color with parenteral nutrition. Postoperative imaging showed a parenchymal abnormality caused by the intracranial and intraparenchymal infusion of parenteral nutrition. Four years later, the child had a shunt and had mild cognitive impairment.

DISCUSSION

In cases of accidental intracranial administration of parenteral nutrition, we recommend that aggressive therapy be pursued to minimize the risks of developing comorbidities such as meningitis and to allow for maximal functional recovery.

Accidental intracranial infusion of parenteral nutrition in a preterm neonate

Vascular access in the neonate can be challenging, especially in preterm infants. When other access is not available, superficial scalp veins can be safely used for vascular access. However, rare and potentially catastrophic complications can occur due to unique features of the neonatal skull and soft-tissue anatomy. The authors report a rare complication of vascular access in a preterm infant, which led to the direct infusion of parenteral nutrition into the intracranial space. The child had an excellent outcome after open drainage and irrigation of bilateral intracranial spaces and the spinal thecal sac. Relevant anatomy is illustrated, and an outcome-based literature review is presented on this rarely reported condition. Surgical and conservative management strategies are discussed, along with clinical and radiographic follow-up. Drainage and irrigation is advocated in patients with mass effect, viscous effusions, or declining neurological examination findings.

The delivery of nutritional support. A potpourri of new devices and methods

With continued interest and increasing awareness of nutritional support to patients, both hospitalized and at home, many new developments in the field of devices and methods of delivering nutritional support have occurred. The indications, methods of use, and the associated complications related to feeding via nasogastric tube, tube esophagostomy, gastrostomy, and jejunostomy in the light of new devices and methods are outlined. The authors' experience shows that postoperative enteral feeding is a reliable and efficient method of providing supportive nutrition, provided the appropriate patients are selected. Home enteral nutritional support via gastrostomy allows stable cancer patients to maintain their nutritional status and enjoy life independent of the hospital setting for an extended period of time. When feeding via the gastrointestinal tract is neither feasible nor desirable, for both short-term and long-term nutritional support, access to the central venous system becomes necessary because peripheral vein feeding has limited cost-effectiveness. Delivery of nutrients into the superior vena cava by long antecubital catheters has been advocated, and the use of Hickman/Broviac catheters, instead of conventional subclavian catheters, is becoming an increasingly common practice. Experience with the use of arteriovenous fistulae and the Infuse-A-Port (Infusaid Corp.) are reviewed; the method used for declotting infected and thrombosed catheters is outlined. Current trends in the use of three-liter bags containing a fat emulsion with glucose and amino acids are mentioned.