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Complications of umbilical vein catheterization: Neonatal total parenteral nutrition ascites after surgical repair of congenital diaphragmatic hernia
Complications of Umbilical Vein Catheterization: Neonatal Total Parenteral Nutrition Ascites After Surgical Repair of Congenital Diaphragmatic Hernia By Britt Nakstad, Pål Aksel Naess, Charlotte de Lange, and Ole Schistad Oslo, Norway
A 2-day-old girl was admitted to surgery for repair of a left-sided diaphragmatic hernia (CDH). Preoperatively, an umbilical vein catheter (UVC) was inserted with the tip in the left hypochondrium. The UVC tip position was unchanged radiographically peroperatively. At the fifth postopertive day abdominal distension and signs of gastric outlet obstruction appeared. Explorative laparotomy found
liver necrosis at the site of the catheter tip and parenteral nutrition ascites. J Pediatr Surg 37:E21. Copyright 2002, Elsevier Science (USA). All rights reserved.
I
discharged from the hospital at 7 weeks of age, now developing as a healthy 2-year-old girl with a moderate gastroesophageal reflux.
NSERTION OF UMBILICAL vein catheters (UVCs) is a commonly used procedure for intravenous access in neonatal intensive care units (NICUs). The UVC facilitates the administration of parenteral nutrition and intraveneous medication and blood sampling. The use of UVC, however, may cause complications such as infection,1 thrombus formation,1,2 and catheter tip migration.3,4 We report a case of total parenteral nutrition (TPN) ascites 5 days after surgical closure of a left-sided congenital diaphragmatic hernia (CDH). CASE REPORT
In a newborn girl, born at the 36th gestational week, birth weight 2,300 grams, a left-sided CDH had been diagnosed prenatally by ultrasound scan. Postpartum chest x-ray showed the stomach and intestine in the left hemithorax and a mediastinal shift to the right indicating a left diaphragmatic hernia. She was given surfactant and was ventilated by high-frequency oscillation for 2 days until pulmonary vascular resistance was normalized. A UVC was placed below the diaphragm at the level of the 11th thoracic vertebra (T11) with the tip in the left hypochondrium (Fig 1A). On the second postnatal day the girl was admitted for surgical repair of the CDH. Parts of the left hepatic lobe, the stomach, small and large intestine, and the spleen were found herniated into the left hemithorax. All organs were returned into the abdominal cavity before the diaphragmatic defect was closed. The UVC location was unchanged (Fig 1b). Postoperatively, the patient needed ventilatory support. TPN was given through the UVC from the second postoperative day. Hyperglycemia developed, and she was given insulin repeatedly. Feeding through a nasogastric tube was unsuccessful because of increasing aspirate volumes. Abdominal distension and radiologic signs of gastric outlet obstruction (Fig 2) led to relaparotomy. The peritoneal cavity was filled with TPN ascites, and a focal necrosis on the lower surface of the left liver lobe was found. Bolus infusion of saline through the UVC immediately leaked out from this necrotic area. Postoperatively, intestinal obstruction developed, and a third laparatomy was performed in the third postoperative week for release of intestinal adhesions. Eight days after the last operation, all nutrients were given orally, and the further course was uneventful. She was Journal of Pediatric Surgery, Vol 37, No 8 (August), 2002: E21
INDEX WORDS: Umbilical vein catheter, ascites, congenital diaphragmatic hernia, liver necrosis.
DISCUSSION
In the current case, abdominal distension and signs of gastric outlet obstruction occurred shortly after surgical repair of CDH. Surprisingly, explorative laparotomy showed massive TPN ascites. Leakage from the tip of an UVC through a focal necrosis in the left liver lobe had led to the extravasation of TPN fluid. To our knowledge, this is the first report of TPN ascites in a neonate occurring shortly after major abdominal surgery. Before repair of the diaphragmatic defect, herniated abdominal organs, including part of the left liver lobe, were returned to the abdominal cavity. The tip of the UVC, tightly secured at skin level, might have perforated the liver parenchyma during this procedure. Alternatively, hypertonic solutions, like TPN, may produce focal hepatic damage.5-7 TPN ascites as a complication of UVC is rare with only 10 patients reported.5,8,9 In contrast to the current case, the majority of those babies were preterm with birth weight less than 1,500 g, and none had a history of previous surgery. The preferred position of the UVC tip is at or above the diaphragm in the inferior vena cava, which may be difficult to obtain, especially in CDH patients because of liver displacement. A subdiaphragmatic UVC can be accepted. In the current case, the UVC tip was at the From the Departments of Pediatrics, Pediatric Surgery, and Pediatric Radiology, Ullevaal University Hospital, Oslo, Norway. Address reprint requests to Britt Nakstad, Department of Pediatrics, Rikshospitalet University Hospital, N-0027 Oslo, Norway. Copyright 2002, Elsevier Science (USA). All rights reserved. 1531-5037/02/3708-0036$35.00/0 doi:10.1053/jpsu.2002.34497 1
2
NAKSTAD ET AL
Fig 2. Abdominal radiograph shows absence of air-filled bowel and lack of delineation of abdominal organs. The nonionic contrast agent did not advance beyond the stomach indicating gastric outlet obstruction.
level of T11 (Fig 1A and B), indicating intrahepatic location. Seguin et al10 reported a 92% initial success rate for UVC placement, but only two thirds were reported to be above the diaphragm. Greenberg et al11 showed that two thirds of UVC tips located at T10 were found to be within the liver, whereas all tips located from T7 to T9 radiographically were positioned within the right atrium or inferior vena cava. Our case, after abdominal surgery and TPN therapy, illustrates that the use of of an subdiaphragmatically located UVC is associated with the risk of vascular perforation. Signs of abdominal distension in newborns receiving hyperosmolar fluid therapy through an UVC may be associated with liver necrosis and subdiaphragmatic vein perforation ultimately leading to TPN ascites. REFERENCES
Fig 1. (A) Preoperative chest and abdominal radiograph. The stomach (with gastric tube) and herniated air-filled bowel are in the left hemithorax, and the mediastinal structures are shifted into the right hemithorax. Note the position of the umbilical vein catheter (UVC) with the tip at the level of T11 (arrow). (B) Postoperative chest and abdominal radiograph. A hypoplastic lung in the left hemithorax and the stomach (with gastric tube) and bowel in the abdominal cavity. Note the position of the UVC tip at T11 (arrow).
1. Anagnoastakis D, Kamba A, Petrochilou V, et al: Risk of infection associated with umbilical vein catheterization: A prospective study in 75 newborn infants. J Pediatr 86:759-765, 1975 2. Oski FA, Allen DM, Diamond LK: Portal hypertension—A complication of umbilical vein catheterization. Pediatrics 31:297, 1963 3. Weber AL, Deluca S, Shannon DC: Normal and abnormal position of the umbilical artery and venous catheter on the roentgenogram and review of complications. Am J Roentgenol 20:361-367, 1974 4. Kulkarni PB, Dorand RD: Hydrothorax: A complication of intracardiac placement of umbilical venous catheters. J Pediatr 94:813, 1979 5. Coley BD, Seguin J, Cordero L, et al: Neonatal total parenteral
COMPLICATIONS OF UMBILICAL VEIN CATHETERIZATION
nutrition ascites from liver erosion by umbilical vein catheters. Pediatr Radiol 28:923-927, 1998 6. Scott JM: Iatrogenic lesions in babies following umbilical vein catheterization. Arch Dis Child 40:426-429, 1965 7. Wigger HJ, Bransilver BR, Blanc WA: Thromboses due to catheterization in infants and children. J Pediatric 76:1-11, 1970 8. Rejjal AR, Gala MO, Nazer HM, et al: Complications of parenteral nutrition via an umbilical vein catheter. Eur J Pediatrics 152:624, 1993
3
9. Panetta J, Morley C, Betheras R: Ascites in a premature baby due to parenteral nutrition from an umbilical venous catheter. J Pediatric Child Health 36:197-198, 2000 10. Seguin J, Fletcher MA, Landers S, et al: Umbilical venous catheterizations: Audit by the study group for complications of perinatal care. Am J Perinatol 11:67-70, 1994 11. Greenberg M, Movahed H, Peterson B, et al: Placement of umbilical venous catheters with use of bedside real-time ultrasonography. J Pediatr 126:633-635, 1995
A 2-day-old girl was admitted to surgery for repair of a left-sided diaphragmatic hernia (CDH). Preoperatively, an umbilical vein catheter (UVC) was inserted with the tip in the left hypochondrium. The UVC tip position was unchanged radiographically peroperatively. At the fifth postopertive day abdominal distension and signs of gastric outlet obstruction appeared. Explorative laparotomy found
liver necrosis at the site of the catheter tip and parenteral nutrition ascites. J Pediatr Surg 37:E21. Copyright 2002, Elsevier Science (USA). All rights reserved.
I
discharged from the hospital at 7 weeks of age, now developing as a healthy 2-year-old girl with a moderate gastroesophageal reflux.
NSERTION OF UMBILICAL vein catheters (UVCs) is a commonly used procedure for intravenous access in neonatal intensive care units (NICUs). The UVC facilitates the administration of parenteral nutrition and intraveneous medication and blood sampling. The use of UVC, however, may cause complications such as infection,1 thrombus formation,1,2 and catheter tip migration.3,4 We report a case of total parenteral nutrition (TPN) ascites 5 days after surgical closure of a left-sided congenital diaphragmatic hernia (CDH). CASE REPORT
In a newborn girl, born at the 36th gestational week, birth weight 2,300 grams, a left-sided CDH had been diagnosed prenatally by ultrasound scan. Postpartum chest x-ray showed the stomach and intestine in the left hemithorax and a mediastinal shift to the right indicating a left diaphragmatic hernia. She was given surfactant and was ventilated by high-frequency oscillation for 2 days until pulmonary vascular resistance was normalized. A UVC was placed below the diaphragm at the level of the 11th thoracic vertebra (T11) with the tip in the left hypochondrium (Fig 1A). On the second postnatal day the girl was admitted for surgical repair of the CDH. Parts of the left hepatic lobe, the stomach, small and large intestine, and the spleen were found herniated into the left hemithorax. All organs were returned into the abdominal cavity before the diaphragmatic defect was closed. The UVC location was unchanged (Fig 1b). Postoperatively, the patient needed ventilatory support. TPN was given through the UVC from the second postoperative day. Hyperglycemia developed, and she was given insulin repeatedly. Feeding through a nasogastric tube was unsuccessful because of increasing aspirate volumes. Abdominal distension and radiologic signs of gastric outlet obstruction (Fig 2) led to relaparotomy. The peritoneal cavity was filled with TPN ascites, and a focal necrosis on the lower surface of the left liver lobe was found. Bolus infusion of saline through the UVC immediately leaked out from this necrotic area. Postoperatively, intestinal obstruction developed, and a third laparatomy was performed in the third postoperative week for release of intestinal adhesions. Eight days after the last operation, all nutrients were given orally, and the further course was uneventful. She was Journal of Pediatric Surgery, Vol 37, No 8 (August), 2002: E21
INDEX WORDS: Umbilical vein catheter, ascites, congenital diaphragmatic hernia, liver necrosis.
DISCUSSION
In the current case, abdominal distension and signs of gastric outlet obstruction occurred shortly after surgical repair of CDH. Surprisingly, explorative laparotomy showed massive TPN ascites. Leakage from the tip of an UVC through a focal necrosis in the left liver lobe had led to the extravasation of TPN fluid. To our knowledge, this is the first report of TPN ascites in a neonate occurring shortly after major abdominal surgery. Before repair of the diaphragmatic defect, herniated abdominal organs, including part of the left liver lobe, were returned to the abdominal cavity. The tip of the UVC, tightly secured at skin level, might have perforated the liver parenchyma during this procedure. Alternatively, hypertonic solutions, like TPN, may produce focal hepatic damage.5-7 TPN ascites as a complication of UVC is rare with only 10 patients reported.5,8,9 In contrast to the current case, the majority of those babies were preterm with birth weight less than 1,500 g, and none had a history of previous surgery. The preferred position of the UVC tip is at or above the diaphragm in the inferior vena cava, which may be difficult to obtain, especially in CDH patients because of liver displacement. A subdiaphragmatic UVC can be accepted. In the current case, the UVC tip was at the From the Departments of Pediatrics, Pediatric Surgery, and Pediatric Radiology, Ullevaal University Hospital, Oslo, Norway. Address reprint requests to Britt Nakstad, Department of Pediatrics, Rikshospitalet University Hospital, N-0027 Oslo, Norway. Copyright 2002, Elsevier Science (USA). All rights reserved. 1531-5037/02/3708-0036$35.00/0 doi:10.1053/jpsu.2002.34497 1
2
NAKSTAD ET AL
Fig 2. Abdominal radiograph shows absence of air-filled bowel and lack of delineation of abdominal organs. The nonionic contrast agent did not advance beyond the stomach indicating gastric outlet obstruction.
level of T11 (Fig 1A and B), indicating intrahepatic location. Seguin et al10 reported a 92% initial success rate for UVC placement, but only two thirds were reported to be above the diaphragm. Greenberg et al11 showed that two thirds of UVC tips located at T10 were found to be within the liver, whereas all tips located from T7 to T9 radiographically were positioned within the right atrium or inferior vena cava. Our case, after abdominal surgery and TPN therapy, illustrates that the use of of an subdiaphragmatically located UVC is associated with the risk of vascular perforation. Signs of abdominal distension in newborns receiving hyperosmolar fluid therapy through an UVC may be associated with liver necrosis and subdiaphragmatic vein perforation ultimately leading to TPN ascites. REFERENCES
Fig 1. (A) Preoperative chest and abdominal radiograph. The stomach (with gastric tube) and herniated air-filled bowel are in the left hemithorax, and the mediastinal structures are shifted into the right hemithorax. Note the position of the umbilical vein catheter (UVC) with the tip at the level of T11 (arrow). (B) Postoperative chest and abdominal radiograph. A hypoplastic lung in the left hemithorax and the stomach (with gastric tube) and bowel in the abdominal cavity. Note the position of the UVC tip at T11 (arrow).
1. Anagnoastakis D, Kamba A, Petrochilou V, et al: Risk of infection associated with umbilical vein catheterization: A prospective study in 75 newborn infants. J Pediatr 86:759-765, 1975 2. Oski FA, Allen DM, Diamond LK: Portal hypertension—A complication of umbilical vein catheterization. Pediatrics 31:297, 1963 3. Weber AL, Deluca S, Shannon DC: Normal and abnormal position of the umbilical artery and venous catheter on the roentgenogram and review of complications. Am J Roentgenol 20:361-367, 1974 4. Kulkarni PB, Dorand RD: Hydrothorax: A complication of intracardiac placement of umbilical venous catheters. J Pediatr 94:813, 1979 5. Coley BD, Seguin J, Cordero L, et al: Neonatal total parenteral
COMPLICATIONS OF UMBILICAL VEIN CATHETERIZATION
nutrition ascites from liver erosion by umbilical vein catheters. Pediatr Radiol 28:923-927, 1998 6. Scott JM: Iatrogenic lesions in babies following umbilical vein catheterization. Arch Dis Child 40:426-429, 1965 7. Wigger HJ, Bransilver BR, Blanc WA: Thromboses due to catheterization in infants and children. J Pediatric 76:1-11, 1970 8. Rejjal AR, Gala MO, Nazer HM, et al: Complications of parenteral nutrition via an umbilical vein catheter. Eur J Pediatrics 152:624, 1993
3
9. Panetta J, Morley C, Betheras R: Ascites in a premature baby due to parenteral nutrition from an umbilical venous catheter. J Pediatric Child Health 36:197-198, 2000 10. Seguin J, Fletcher MA, Landers S, et al: Umbilical venous catheterizations: Audit by the study group for complications of perinatal care. Am J Perinatol 11:67-70, 1994 11. Greenberg M, Movahed H, Peterson B, et al: Placement of umbilical venous catheters with use of bedside real-time ultrasonography. J Pediatr 126:633-635, 1995