Peripherally inserted central venous catheters (PICCs) are widely used in neonates who need prolonged venous route for total parenteral nutrition and prolonged therapy. Although the PICC line is the safest way for venous access in neonatal intensive care units, there are common adverse events such as infection, occlusion, migration, and thrombosis.[1] Life-threatening complications such as extravasation of the fluid into the tissue spaces, cardiac arrhythmia, and endocarditis have been also reported.[2] Among these, the most life-threatening complication is pericardial effusion (PCE) with cardiac tamponade. These uncommon complications usually result from the incorrect position of the catheter.[3,4] Although it can develop any time following the catheter insertion, the median duration is three days.[5] Extremely unusual complication of catheter is the formation of an intracardiac thrombus.[6]

Herein, we present a 53-day-old male infant with a gestational age of 28 weeks with a birth weight of 670 grams who was born by C-section delivery. A 28-gauge polyurethane (PremiCath) central venous catheter was inserted into his right arm on Day 47 due to nosocomial sepsis and necrotizing enterocolitis. At the sixth day of the treatment, his overall condition deteriorated abruptly. His blood pressure decreased and he did not respond inotropic agents and volume load. The infant had tachypnea, tachycardia, and an increased need for oxygen and ventilation support. Plain radiography showed that the shadow of the heart was wide and the tip of the catheter was in the right ventricle (Figure 1). Following confirmation of the suspicion of PCE with cardiac tamponade by echocardiography, percutaneous subxiphoid pericardiocentesis was immediately performed using a 22-gauge needle and 51 mL fluid, which was compatible with total parenteral nutrition solution, was drained (Figure 2a). The catheter was removed and the oxygen and inotropic requirement, then, decreased significantly. Echocardiography performed on the following day demonstrated no PCE, but a thrombus formation in the right ventricle. After pericardiocentesis and removing the catheter, PCE and cardiac tamponade did not recur. Thrombus formation (4.11x2.71 mm) in the right ventricle (Figure 2b) was treated with low-molecular weight heparin (1.5 mg/kg/day) for two weeks and the right ventricular thrombus resolved. The infant was discharged from the hospital without any sequelae associated with this complication.

Figure 1: The tip of the line was in the right ventricle and the shadow of the heart was wide.

Figure 2: (a) Pericardial effusion was demonstrated by echocardiography and pericardiocentesis was performed simultaneously. (b) Following pericardiocentesis, a thrombus formation was noticed in the right ventricle.

Catheter associated PCE and cardiac tamponade is seen 1 to 3% of neonates.[7,8] About 30 to 50% result in death.[6] The only preventive attempt is to insert the line exact position. However, we should check the position on a regular basis, as it may move on over time. The common incorrect position of the tip of the catheter is the right atrium and the thrombus is usually formed in this location.[9] Interestingly, in our case, the tip of the catheter and the thrombus formation was in the right ventricle.

The aim of this case report is to emphasize that if sudden cardiovascular collapse occurs in an infant with a peripherally inserted central venous catheter, the possibility of catheter complications, particularly cardiac tamponade, should be primarily considered. Our experience shows that early diagnosis of cardiac tamponade and timely pericardiocentesis can be lifesaving in most of the cases.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

References

1) Pizzuti A, Parodi E, Abbondi P, Frigerio M. Cardiac tamponade and successful pericardiocentesis in an extremely low birth weight neonate with percutaneously inserted central venous line: a case report. Cases J 2010;3:15.

2) Pettit J. Assessment of infants with peripherally inserted central catheters: Part 2. Detecting less frequently occurring complications. Adv Neonatal Care 2003;3:14-26.

3) Ohki Y, Maruyama K, Harigaya A, Kohno M, Arakawa H. Complications of peripherally inserted central venous catheter in Japanese neonatal intensive care units. Pediatr Int 2013;55:185-9.

4) Tekelioğlu ÜY, Gürses EL, Saçar M, Sungurtekin H. Malpositions of central venous catheter: three case reports. Turk Gogus Kalp Dama 2011;19:276-8.

5) Warren M, Thompson KS, Popek EJ, Vogel H, Hicks J. Pericardial effusion and cardiac tamponade in neonates: sudden unexpected death associated with total parenteral nutrition via central venous catheterization. Ann Clin Lab Sci 2013;43:163-71.

6) Haass C, Sorrentino E, Tempera A, Consigli C, De Paola D, Calcagni G, et al. Cardiac tamponade and bilateral pleural effusion in a very low birth weight infant. J Matern Fetal Neonatal Med 2009;22:137-9.

7) Ohki Y, Maruyama K, Harigaya A, Kohno M, Arakawa H. Complications of peripherally inserted central venous catheter in Japanese neonatal intensive care units. Pediatr Int 2013;55:185-9.

8) Haass C, Sorrentino E, Tempera A, Consigli C, De Paola D, Calcagni G, et al. Cardiac tamponade and bilate.ral pleural effusion in a very low birth weight infant. J Matern Fetal Neonatal Med 2009;22:137-9.

9) dos Santos Modelli ME, Cavalcanti FB. Fatal cardiac tamponade associated with central venous catheter: a report of 2 cases diagnosed in autopsy. Am J Forensic Med Pathol 2014;35:26-8.