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Herniation of the appendix into the umbilical cord complicating umbilical vessel cannulation
Journal of Pediatric Surgery Case Reports 40 (2019) 69–70
Contents lists available at ScienceDirect
Journal of Pediatric Surgery Case Reports journal homepage: www.elsevier.com/locate/epsc
Herniation of the appendix into the umbilical cord complicating umbilical vessel cannulation
T
Mohammad Mahdi Khazravia, Marjan Joodib,c, Shiva Ghaderifard, Mehdi Fathic,e, Reza Nazarzadef, Hossein Mohsenzadef, Maryam Joudig,∗ a
Fellowship of Pediatric Surgery, Mashhad University of Medical Sciences, Mashhad, Iran Department of Pediatric Surgery, Mashhad University of Medical Sciences, Mashhad, Iran c Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran d Master of Science in Environmental Health Engineering, Medical Educational and Research Center of Akbar Pediatric Hospital, Mashhad University of Medical Sciences, Mashhad, Iran e Department of Anesthesiology, Mashhad University of Medical Sciences, Mashhad, Iran f Department of Pediatrics, Medical Educational and Research Center of Akbar Pediatric Hospital, Mashhad University of Medical Sciences, Mashhad, Iran g Allergy Research Center, Mashhad University of Medical Sciences, Mashhad, Iran b
A R T I C LE I N FO
A B S T R A C T
Keywords: Umbilical catheter Complication
Umbilical catheters (UC) have become the most common way to access neonatal veins and arteries especially after the increasing the number of preterm newborns. Significant clinical complications have been reported with this increased usage of UC. We present a rare complication of umbilical catheterization in a newborn with asphyxia that had meconium discharge after UC.
Umbilical catheters (UC) have become the most common way to access neonatal veins and arteries especially after the increasing the number of preterm newborns and improving intensive care units for these patients [1]. Significant clinical complications have been reported with this increased usage of UC. These complications are including umbilical infection, umbilical vein, and artery thrombosis, embolic events, hemorrhage, hypertension, disorders of the heart rhythm, necrotizing enterocolitis and death [2,3]. Some of these are related to the wrong placement of the tip of the cannula, and another are knowing complication of surgery or iatrogenic [2]. In this study, we want to present a rare and unprecedented trauma caused by insertion of the umbilical catheter.
the cause of discharge. Symptoms of the patient in the initial examination included a soft abdomen, a brief distention and lack of fever. The patient was tachypneic and tachycardia. The surgeon suspected the patient of having omphalomesenteric trauma. Abdominal radiography and ultrasonography were done for the patient that was normal then explored the abdomen by an incision on peri umbilical area. In the exploration, intra peritoneal meconial secretions were observed. Ileum and jejunum were intact. The discharge of meconial secretions from the mid appendix shaft was evident at the site of the cecum. The appendix was cut sharp by the operator. Other parts of the abdomen were normal so appendectomy was done and surgery finished (Fig. 1). 2. Discussion
1. Case report A 32 week preterm newborn with a birth weight of 1600 g was born by normal vaginal delivery. The baby was hospitalized for asphyxia in ICU in a children's hospital. Due to the need for the intravenous catheter, it was inserted by the conventional method with an incision on the umbilical cord section. The pediatrician noticed the discharge of meconial and bloody secretions into the catheter and at the catheter site then surgery stopped, catheter removed and umbilicus repaired. Then the patient was referred to the Pediatric Surgery Center to investigate
∗
Umbilical catheterization is used for the administration of parenteral nutrition, blood sampling, checking blood pressure, drug infusion and exchange of blood in newborns and infants [4]. And also used in some cases with respiratory distress, asphyxia, heart disease, pneumothorax, blood infections, hyperbilirubinemia, and aspiration [3]. Our case also had asphyxia and required a catheter. Umbilical catheterization is a widely used procedure, but it is not always safe. Successful umbilical catheterization occurs in 69–88% cases [5]. In a study that investigated umbilical artery catheterization
Corresponding author. E-mail address: [email protected] (M. Joudi).
https://doi.org/10.1016/j.epsc.2018.10.021 Received 23 October 2018; Received in revised form 31 October 2018; Accepted 31 October 2018 Available online 04 November 2018 2213-5766/ © 2018 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Journal of Pediatric Surgery Case Reports 40 (2019) 69–70
M.M. Khazravi et al.
malpositioned catheter [12]. However, they are not precise enough to confirm appropriate placement in a patient with abnormal anatomy [11]. So it is important to be careful about identification umbilical vein and its route and outflow and the location of the catheter and anatomy. Adjacent areas must be thoroughly investigated. Also checking the blood flow is necessary after incision on the umbilical cord section. 3. Conclusion In conclusion, if you encountered an organ that had meconium discharge after incision, catheterization path is wrong. Never push the organ back into the abdomen. Fix it with one or two stitches and refer the patient to the pediatric surgical center. Patient consent Consent to publish the case report was not obtained. This report does not contain any personal information that could lead to the identification of the patient. Funding No funding or grant support.
Fig. 1. Appendix is sharp cut in the mid shaft for the wrong pathway catheterization.
Authorship
in the newborn, from 381 catheterizations they had 46 failures [6]. There are different complications of catheterization. Hebal et al. surveyed catheter complications of 228 children. The most common complications were line malfunctions, bleeding, multiple complications, infiltration, and hematoma, respectively [7]. In literature, various cases of UC complications have been published. Silahli et al. reported a case with gluteal necrosis due to the incorrect placement of the umbilical catheter [8]. Barrios et al. published a case report in which liver abscess occurred following umbilical venous catheterization [9]. Another complication related to the liver was reported by Yigiter et al. that incorrect placement of umbilical vein catheter caused hepatic laceration [1]. The possibility of an intestinal trauma after catheterization has been reported in a few cases. Costa et al. reported a 1-day-old premature baby with perforation of the diverticulum after UC. Catheterization was done through a tenuous lumen in the umbilical cord that was connected to Meckel's diverticulum instead of umbilical vein [10]. In this case report, we presented a rare complication that is not similar to any published umbilical catheter complications. In our case, the procedure was performed openly, under local anesthesia and with adequate surgical instrument supplies in the intensive care unit. Hernia of the appendix to the cord area and its apparent similarity to the umbilical vein Led to make a mistake in choosing the vein, and an additional procedure was imposed on the patient (appendectomy). It is recommended that the location of the cord be firstly evaluated regarding a hernia or related disorders. Raisanen et al. reported a case with left-sided congenital diaphragmatic hernia that UC insertion caused hepatic extravasation [11]. Another serious mistake, in this case, is returning of the catheterized organ to the abdomen and closes the umbilicus. In such a situation, the catheterized organ must be suture on the umbilical cord not pushing it back into the abdomen for further investigation. Meconium discharge during catheterization is certainly accompanied by intestinal trauma. The most common cause is Omphalomesenteric injuries. In all cases, surgical exploration is required. Rare and severe intestinal complications may occur in newborns with umbilical cord hernia. So considering this complication is very important and we should be more careful during catheterization. Radiography and echocardiography can help to have an appropriate placement of the UC and minimize the complications of the
All authors attest that they meet the current ICMJE criteria for Authorship. Conflict of interest The following authors have no financial disclosures: (Mohammad Mahdi Khazravi, Marjan Joodi, Shiva Ghaderifar, Mehdi Fathi, Reza Nazarzade, Hossein Mohsenzade *Maryam Joudi). Acknowledgements The authors would like to thank from Mashhad University of Medical Sciences (MUMS) and also Akbar Pediatric Hospital for their cooperation. References [1] Yiğiter M, Arda İS, Hiçsönmez A. Hepatic laceration because of malpositioning of the umbilical vein catheter: case report and literature review. J Pediatr Surg 2008;43(5):e39–41. [2] Bothur-Nowacka J, Czech-Kowalska J, Gruszfeld D, Nowakowska-Rysz M, Kościesza A, Polnik D, et al. Complications of umbilical vein catherisation. Case Rep Polish J Radiol 2011;76(3):70. [3] Lin SJ, Koltz PF, Davis W, Vicari F. Lower extremity ischemia following umbilical artery catheterization: a case study and clinical update. Int J Surg 2009;7(3):182–6. [4] Almeida MMd, Tavares WGdS, Furtado MMAA, Fontenele MMFT. Neonatal atrial flutter after insertion of an intracardiac umbilical venous catheter. Revista Paulista de Pediatria 2016;34(1):132–5. [5] Gupta V, Kumar N, Jana AK, Thomas N. A modified technique for umbilical arterial catheterization. Indian Pediatr 2014;51(8):672. [6] Gupta J, Roberton N, Wigglesworth J. Umbilical artery catheterization in the newborn. Arch Dis Child 1968;43(229):382. [7] Hebal F, Sparks HT, Rychlik KL, Bone M, Tran S, Barsness KA. Pediatric arterial catheters: complications and associated risk factors. J Pediatr Surg 2018;53(4):794–7. [8] Silahli M, Gokmen Z, Arpaci E. A rare complication of umbilical catheterization: gluteal necrosis. Ann Vasc Med Res 2017;4(2):1053. [9] Carvajal-Barrios GA, Corrales-Cobos IF, Cuenca-Arias MC, Troncoso-Moreno GA. Liver abscess secondary to umbilical catheterization in a newborn. Infection 2014;18(4):158–61. [10] Costa S, De Carolis MP, Savarese I, Manzoni C, Lacerenza S, Romagnoli C. An unusual complication of umbilical catheterisation. Eur J Pediatr 2008;167(12):1467–9. [11] Raisanen P, Cassel I, Martin G, Graziano K. Umbilical venous catheter complication in an infant with left-sided congenital diaphragmatic hernia: extravasation owing to hepatic vein catheterization. J Pediatr Surg 2010;45(12):e33–5. [12] Ades A, Sable C, Cummings S, Cross R, Markle B, Martin G. Echocardiographic evaluation of umbilical venous catheter placement. J Perinatol 2003;23(1):24.
70
Contents lists available at ScienceDirect
Journal of Pediatric Surgery Case Reports journal homepage: www.elsevier.com/locate/epsc
Herniation of the appendix into the umbilical cord complicating umbilical vessel cannulation
T
Mohammad Mahdi Khazravia, Marjan Joodib,c, Shiva Ghaderifard, Mehdi Fathic,e, Reza Nazarzadef, Hossein Mohsenzadef, Maryam Joudig,∗ a
Fellowship of Pediatric Surgery, Mashhad University of Medical Sciences, Mashhad, Iran Department of Pediatric Surgery, Mashhad University of Medical Sciences, Mashhad, Iran c Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran d Master of Science in Environmental Health Engineering, Medical Educational and Research Center of Akbar Pediatric Hospital, Mashhad University of Medical Sciences, Mashhad, Iran e Department of Anesthesiology, Mashhad University of Medical Sciences, Mashhad, Iran f Department of Pediatrics, Medical Educational and Research Center of Akbar Pediatric Hospital, Mashhad University of Medical Sciences, Mashhad, Iran g Allergy Research Center, Mashhad University of Medical Sciences, Mashhad, Iran b
A R T I C LE I N FO
A B S T R A C T
Keywords: Umbilical catheter Complication
Umbilical catheters (UC) have become the most common way to access neonatal veins and arteries especially after the increasing the number of preterm newborns. Significant clinical complications have been reported with this increased usage of UC. We present a rare complication of umbilical catheterization in a newborn with asphyxia that had meconium discharge after UC.
Umbilical catheters (UC) have become the most common way to access neonatal veins and arteries especially after the increasing the number of preterm newborns and improving intensive care units for these patients [1]. Significant clinical complications have been reported with this increased usage of UC. These complications are including umbilical infection, umbilical vein, and artery thrombosis, embolic events, hemorrhage, hypertension, disorders of the heart rhythm, necrotizing enterocolitis and death [2,3]. Some of these are related to the wrong placement of the tip of the cannula, and another are knowing complication of surgery or iatrogenic [2]. In this study, we want to present a rare and unprecedented trauma caused by insertion of the umbilical catheter.
the cause of discharge. Symptoms of the patient in the initial examination included a soft abdomen, a brief distention and lack of fever. The patient was tachypneic and tachycardia. The surgeon suspected the patient of having omphalomesenteric trauma. Abdominal radiography and ultrasonography were done for the patient that was normal then explored the abdomen by an incision on peri umbilical area. In the exploration, intra peritoneal meconial secretions were observed. Ileum and jejunum were intact. The discharge of meconial secretions from the mid appendix shaft was evident at the site of the cecum. The appendix was cut sharp by the operator. Other parts of the abdomen were normal so appendectomy was done and surgery finished (Fig. 1). 2. Discussion
1. Case report A 32 week preterm newborn with a birth weight of 1600 g was born by normal vaginal delivery. The baby was hospitalized for asphyxia in ICU in a children's hospital. Due to the need for the intravenous catheter, it was inserted by the conventional method with an incision on the umbilical cord section. The pediatrician noticed the discharge of meconial and bloody secretions into the catheter and at the catheter site then surgery stopped, catheter removed and umbilicus repaired. Then the patient was referred to the Pediatric Surgery Center to investigate
∗
Umbilical catheterization is used for the administration of parenteral nutrition, blood sampling, checking blood pressure, drug infusion and exchange of blood in newborns and infants [4]. And also used in some cases with respiratory distress, asphyxia, heart disease, pneumothorax, blood infections, hyperbilirubinemia, and aspiration [3]. Our case also had asphyxia and required a catheter. Umbilical catheterization is a widely used procedure, but it is not always safe. Successful umbilical catheterization occurs in 69–88% cases [5]. In a study that investigated umbilical artery catheterization
Corresponding author. E-mail address: [email protected] (M. Joudi).
https://doi.org/10.1016/j.epsc.2018.10.021 Received 23 October 2018; Received in revised form 31 October 2018; Accepted 31 October 2018 Available online 04 November 2018 2213-5766/ © 2018 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Journal of Pediatric Surgery Case Reports 40 (2019) 69–70
M.M. Khazravi et al.
malpositioned catheter [12]. However, they are not precise enough to confirm appropriate placement in a patient with abnormal anatomy [11]. So it is important to be careful about identification umbilical vein and its route and outflow and the location of the catheter and anatomy. Adjacent areas must be thoroughly investigated. Also checking the blood flow is necessary after incision on the umbilical cord section. 3. Conclusion In conclusion, if you encountered an organ that had meconium discharge after incision, catheterization path is wrong. Never push the organ back into the abdomen. Fix it with one or two stitches and refer the patient to the pediatric surgical center. Patient consent Consent to publish the case report was not obtained. This report does not contain any personal information that could lead to the identification of the patient. Funding No funding or grant support.
Fig. 1. Appendix is sharp cut in the mid shaft for the wrong pathway catheterization.
Authorship
in the newborn, from 381 catheterizations they had 46 failures [6]. There are different complications of catheterization. Hebal et al. surveyed catheter complications of 228 children. The most common complications were line malfunctions, bleeding, multiple complications, infiltration, and hematoma, respectively [7]. In literature, various cases of UC complications have been published. Silahli et al. reported a case with gluteal necrosis due to the incorrect placement of the umbilical catheter [8]. Barrios et al. published a case report in which liver abscess occurred following umbilical venous catheterization [9]. Another complication related to the liver was reported by Yigiter et al. that incorrect placement of umbilical vein catheter caused hepatic laceration [1]. The possibility of an intestinal trauma after catheterization has been reported in a few cases. Costa et al. reported a 1-day-old premature baby with perforation of the diverticulum after UC. Catheterization was done through a tenuous lumen in the umbilical cord that was connected to Meckel's diverticulum instead of umbilical vein [10]. In this case report, we presented a rare complication that is not similar to any published umbilical catheter complications. In our case, the procedure was performed openly, under local anesthesia and with adequate surgical instrument supplies in the intensive care unit. Hernia of the appendix to the cord area and its apparent similarity to the umbilical vein Led to make a mistake in choosing the vein, and an additional procedure was imposed on the patient (appendectomy). It is recommended that the location of the cord be firstly evaluated regarding a hernia or related disorders. Raisanen et al. reported a case with left-sided congenital diaphragmatic hernia that UC insertion caused hepatic extravasation [11]. Another serious mistake, in this case, is returning of the catheterized organ to the abdomen and closes the umbilicus. In such a situation, the catheterized organ must be suture on the umbilical cord not pushing it back into the abdomen for further investigation. Meconium discharge during catheterization is certainly accompanied by intestinal trauma. The most common cause is Omphalomesenteric injuries. In all cases, surgical exploration is required. Rare and severe intestinal complications may occur in newborns with umbilical cord hernia. So considering this complication is very important and we should be more careful during catheterization. Radiography and echocardiography can help to have an appropriate placement of the UC and minimize the complications of the
All authors attest that they meet the current ICMJE criteria for Authorship. Conflict of interest The following authors have no financial disclosures: (Mohammad Mahdi Khazravi, Marjan Joodi, Shiva Ghaderifar, Mehdi Fathi, Reza Nazarzade, Hossein Mohsenzade *Maryam Joudi). Acknowledgements The authors would like to thank from Mashhad University of Medical Sciences (MUMS) and also Akbar Pediatric Hospital for their cooperation. References [1] Yiğiter M, Arda İS, Hiçsönmez A. Hepatic laceration because of malpositioning of the umbilical vein catheter: case report and literature review. J Pediatr Surg 2008;43(5):e39–41. [2] Bothur-Nowacka J, Czech-Kowalska J, Gruszfeld D, Nowakowska-Rysz M, Kościesza A, Polnik D, et al. Complications of umbilical vein catherisation. Case Rep Polish J Radiol 2011;76(3):70. [3] Lin SJ, Koltz PF, Davis W, Vicari F. Lower extremity ischemia following umbilical artery catheterization: a case study and clinical update. Int J Surg 2009;7(3):182–6. [4] Almeida MMd, Tavares WGdS, Furtado MMAA, Fontenele MMFT. Neonatal atrial flutter after insertion of an intracardiac umbilical venous catheter. Revista Paulista de Pediatria 2016;34(1):132–5. [5] Gupta V, Kumar N, Jana AK, Thomas N. A modified technique for umbilical arterial catheterization. Indian Pediatr 2014;51(8):672. [6] Gupta J, Roberton N, Wigglesworth J. Umbilical artery catheterization in the newborn. Arch Dis Child 1968;43(229):382. [7] Hebal F, Sparks HT, Rychlik KL, Bone M, Tran S, Barsness KA. Pediatric arterial catheters: complications and associated risk factors. J Pediatr Surg 2018;53(4):794–7. [8] Silahli M, Gokmen Z, Arpaci E. A rare complication of umbilical catheterization: gluteal necrosis. Ann Vasc Med Res 2017;4(2):1053. [9] Carvajal-Barrios GA, Corrales-Cobos IF, Cuenca-Arias MC, Troncoso-Moreno GA. Liver abscess secondary to umbilical catheterization in a newborn. Infection 2014;18(4):158–61. [10] Costa S, De Carolis MP, Savarese I, Manzoni C, Lacerenza S, Romagnoli C. An unusual complication of umbilical catheterisation. Eur J Pediatr 2008;167(12):1467–9. [11] Raisanen P, Cassel I, Martin G, Graziano K. Umbilical venous catheter complication in an infant with left-sided congenital diaphragmatic hernia: extravasation owing to hepatic vein catheterization. J Pediatr Surg 2010;45(12):e33–5. [12] Ades A, Sable C, Cummings S, Cross R, Markle B, Martin G. Echocardiographic evaluation of umbilical venous catheter placement. J Perinatol 2003;23(1):24.
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