Vol 44 # 2 June 2012 - Kma.org.kw

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141 KUWAIT MEDICAL JOURNAL June 2012 Case Report Neonatal Cardiac Tamponade: What is the Cause? Mervat F Khalil 1 , Aditya Raina 1 , Majeda S Hammoud 2 1 Department of Neonatology, Al-Sabah Maternity Hospital, Kuwait 2 Department of Pediatrics, Faculty of Medicine, Kuwait University, Kuwait ABSTRACT Kuwait Medical Journal 2012; 44 (2): 141 - 142 We present one case of neonatal cardiac tamponade due to percutaneous jugular venous catheterization, a rare and potentially fatal complication. In neonates with central venous catheters, the incidence of pericardial effusion (PCE) with tamponade is 0.5 - 2%. Perforation usually has a delayed course and results from endothelial injury, caused by the fluids, which leads to necrosis and thrombosis. This fluid then diffuses transmurally across the myocardium into the pericardium. Even if the catheter tip is placed properly and checked immediately after placement, it can migrate, an incidence which implies that the position of the catheter be checked at least twice a week after insertion. KEY WORDS: myocardium, newborn, ventilation INTRODUCTION Central venous catheterization is frequently used in infants in the neonatal intensive care setting and is associated with several complications, including occlusion, infection, thrombosis, breakage, displacement and migration of the catheter plus perforation of the vessel wall [1] . We present a case of neonatal cardiac tamponade due to percutaneous jugular venous catheterization, a rare and potentially fatal complication. CASE REPORT A 27-week preterm male baby born by normal vaginal delivery with a birth weight of 1.080 kg was admitted immediately and ventilated after birth in Al-Sabah Maternity NICU with a diagnosis of hyaline membrane disease. The baby received two doses of surfactant and was on high frequency oscillatory ventilation since 10 hrs of age. He improved gradually and was extubated after eight days. Feeds were started and gradually increased while the baby was shifted to special care unit to continue his care. At 51 days of age, a percutaneous central catheter was electively inserted through the left external jugular vein and placed at the root of the superior vena cava. The position was confirmed by chest X–ray. Intravenous fluids were started through this route. The baby remained stable for six days initially and then he had sudden desaturation and bradycardia for which he was shifted back to the NICU, intubated and was put on mechanical ventilation. His BP was 76/49 mmHg, MAP 35 mmHg and HR was 157 bpm. A chest X-ray taken at this stage showed cardiomegaly and there was migration of the catheter tip from superior vena cava to the right ventricle. Echocardiography (ECHO) confirmed significant pericardial effusion with tamponade. Intravenous fluids were immediately stopped and the percutaneous jugular catheter was removed. The pericardial effusion was drained immediately by ECHO guided subxiphoid pericardiocentesis. Approximately 32 ml of clear fluid was aspirated from the sac. Biochemical analysis of this fluid proved it to be the infusate. ECHO done 12 hrs later, showed complete clearing of the fluid. The baby improved after this and was extubated and later discharged in a satisfactory condition. DISCUSSION Pericardial effusion (PCE) with tamponade is a rare complication of central venous catheters associated with high mortality [1] . In neonates with central venous catheters, the incidence of PCE with tamponade is 0.5 - 2%, and mortality varies from 45 to 67% [2] . A study by Beardsall et al estimated the frequency of PCE with cardiac tamponade occurring with percutaneous long lines to be 1.8 / 1000 lines [3] . High fatality is due to its sudden onset and fast deterioration. Address correspondence to: Dr. Mervat F. Khalil, MRCPch (UK), Dept. of Neonatology, Al Sabah Maternity Hospital Kuwait. Tel: 25319486, 97125527 (M), Fax: 25338940 E-mail: asiyatasneem57@yahoo.com
June 2012 Timely diagnosis and drainage has been proven to be life-saving. In the Beardsall study the median time from CV line insertion to presentation was three days (range of 0 - 37 days), with nearly two-third cases presenting as sudden cardiovascular collapse, and most of the rest having unexplained cardiorespiratory instability [3] . In our case, the interval between line insertion and the clinical deterioration was six days. Myocardial perforation and effusion can either occur at the time of cannulation or later due to slow damage to the integrity of the vascular wall. Most frequently, perforation has a delayed course and results from endothelial injury caused by the hyperosmolar fluids, leading to transmural necrosis and thrombosis. The risk appears to be greatest when the end of the catheter creates an acute angle to the vessel or cardiac wall. This may then cause injury because a jet of abrasive fluid is directed at a small area of the wall, assisted by reactive thrombus attaching the catheter tip to the endothelium. This is most likely to happen with: (a) A redundant length of free catheter in the heart (for PCE); or (b) a catheter tip in the left innominate vein at its junction with the superior vena cava [4] . Subsequently, the fluid diffuses transmurally across the myocardium into the pericardium. It usually presents as a sudden, unexplained cardiac arrest and sometimes it can present as unexplained cardio-respiratory instability such as hypotension, bradycardia and desaturation [4] . The picture was the similar in our case. It is estimated that “a volume of 11.4 ± 1.5 ml/kg body weight is enough to result in tamponade” [5] . In our case we could remove 32 ml/kg aspirate, which was similar in composition to the infusate. Several risk factors have been proposed that increase the risk of PCE with cardiac tamponade in a neonate with CVC, namely, (a) Neonatal cardiac atrium is more susceptible to damage as some areas have very little musculature, (b) PCE is most commonly described with catheter tips placed within cardiac outline, though extra-cardiac positioning does not completely abolish the risk of PCE, and (c) Catheter inserted via neck or arm vein have more chances of migration which increases the risk of PCE [6] . KUWAIT MEDICAL JOURNAL 142 Polyethylene or polyurethane catheters in contrast to silastic catheters have more risk of PCE [6,7] . The food and drug administration (FDA) of the United States of America recommends that for safe placement of CVC “the catheter tip position should be confirmed by X-ray or other imaging modality and rechecked periodically [8] . CONCLUSION PCE and cardiac tamponade should be considered in any infant with a central venous line who develops a rapid, unexplained clinical deterioration. PCE is most commonly described with catheter tips placed within cardiac outline, though extra-cardiac positioning does not completely abolish the risk of PCE. As migration of the catheter tip can occur, we suggest that its position should be checked immediately after insertion and bi-weekly, thereafter. REFERENCES 1. Khilnani P, Toce S, Reddy R. Mechanical complications from very small percutaneous central venous silastic catheters. Crit Care Med 1990; 18:1477-1478. 2. Kabra NS, Kluckow MR. Survival after an acute pericardial tamponade as a result of percutaneously inserted central venous catheter in a preterm neonate. Indian J Pediatr 2001; 68:677-680. 3. Beardsall K, White D, Pinto E, Kelsall A. Pericardial effusion and cardiac tamponade as complications of neonatal long lines: are they really a problem? Arch Dis Child Fetal and Neonatal Ed 2003; 88:F292-F295. 4. Menon G. Neonatal long lines. Arch Dis Child Fetal Neonatal Ed 2003; 88:292-295. 5. Nowlen T, Rosenthal GL, Johnson GL. Pericardial effusion and tamponade in infants with central catheters. Pediatr 2002; 110:137-142. 6. Keeney SE, Richardson CJ. Extravascular extravasation of fluid as a complication of central venous lines in the neonate. J Perinatol 1995; 15:284-288. 7. Aggarwal R, Downe L. Neonatal pericardial tamponade from a silastic central venous catheter. Indian Pediatr 2000; 37:564-566. 8. Nadroo AM, Glass RB, Lin J, Green RS, Holzman IR. Changes in upper extremity position cause migration of peripherally inserted central catheters in neonates. Pediatr 2002; 110:131-136.
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