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Andrew B. Kairalla MD, Editor

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Methods. A retrospective case review was conducted of CVC-related PCE at university and private neonatal intensive care units. Data from our cases were combined with published case reports and included clinical presentation and outcome; biochemical evaluation of pericardial fluid; days until diagnosis; cardiothoracic ratios; and CVC characteristics, insertion site, and tip placement site.

Results. In our cases, 6 different neonatology groups cared for 14 patients at 6 different hospitals in 2 cities. These data were combined with 47 cases reviewed from the literature. Pericardial fluid was obtained in 54 cases from the combined group and was described qualitatively as consistent with the infusate in 53 of 54 cases (98%). Biochemical analysis was performed in 37 cases, and in 36 of 37 cases (97%), the pericardial fluid was consistent with the infusate. The median gestational age at birth was 30.0 weeks (range: 23.5–42). The median time from CVC insertion to diagnosis was 3.0 days (range: 0.2–37; n = 59). Sudden cardiac collapse was reported in 37 cases (61%), and unexplained cardiorespiratory instability was reported in 22 cases (36%). The CVC tip was last reported within the pericardial reflections on chest radiograph in 56 cases (92%) at the time of PCE diagnosis. The mean cardiothoracic ratio increased 17% (n = 14). No patients died among our cases. Among the reviewed cases, 45% mortality was reported. For the combined group, mortality was 34%. For the combined group, mortality was 8% (3 of 37) in the patients who underwent pericardiocentesis versus 75% (18 of 24) for the patients who did not. In 21 patients, the catheter was withdrawn and remained in use. Survivors and nonsurvivors had comparable gestational age at birth, birth weight, days to PCE diagnosis, and day of life of PCE symptoms/diagnosis. Access site, catheter type, and catheter size were not associated with mortality. An association between larger catheters and shorter time to PCE may be present. Access site and catheter type were not associated with time to PCE. Autopsy specimens reported 6 cases of myocardial necrosis/thrombus formation, 9 cases of perforation without myocardial necrosis/thrombus formation, and 2 cases in which both were reported.

Conclusions. The pericardial fluid found in CVC-associated PCE is consistent with the infusate. We speculate that there are several mechanisms, ranging from frank perforation that seals spontaneously to CVC tip adhesion to the myocardium with diffusion into the pericardial space. Routine radiography should be performed, and the CVC tip should be readily identifiable. The CVC tip should remain outside the cardiac silhouette but still within the vena cavae (approximately 1 cm outside the cardiac silhouette in premature infants and 2 cm in term infants). A change in cardiothoracic ratio may be diagnostic of a PCE, and pericardiocentesis is associated with significantly reduced mortality. Increased awareness of this complication may decrease the mortality associated with CVC-related PCE.

Comment.   This life-threatening complication of central or umbilical venous catheterization is not uncommon, and can usually be prevented by keeping the CVC tips at least 1 cm outside the cardiac silhouette. Pericardial effusion and tamponade should be suspected in infants with CVCs in place who have signs of circulatory collapse or cardio-respiratory decompensation. The diagnosis of PCE can be confirmed by finding an increased cardiothoracic ratio on chest xray, or by demonstrating a pericardial effusion on  echocardiogram. In these cases, emergency pericardiocentesis can be life saving. ABK.

Additional Comments:

Date:        24 Jul 2002
Time:        06:14:39

I have noticed , when there is difficulty advancing PICC and it is shoved in, it infilterates early in few days. It could be avoided by pulling back catheter 1-3 cm back before taping it ( if using that line). It may be due to that effect that normaly PICC tip moves freely and changes it position as the limb(insertion site) is placed in different position and thus irritaion effect of infusate is distributed over larger area with some healing in between when tip has moved to other place. But when tip does not advance and one keep pushing and then tapes, there is some curling or waving of catheter in vessel. This catheter may straighten or become more wavy but tip stays at one point thus injuring vessel wall continously without chance to repair. Also 3-4 cases I remember temponade with UVL it was always 2-3 cms above the diaphram. It will be interesting to see in your series if UVL were also well above the diaphragm or some of it were barely in the heart( < one cm above the diaphragm). We had another 2 cases with PICC. all but two cases were referred from outside and all but one were diagnosed by ECHO. The one without echo was term (recovering PPHN) acutely decompensated and I had no time for ECHO so as last resort assumed it to be temponade and centesis saved this baby. If I remember right, all of these babies survived.  If my memory is right, all but one had centesis done (the one without had not full fledged temponade). The fluid always resembled infusate (At least extrmely high glucose) but   the RBC were always low to preclude frank perforation. 

UserName:    Bikramjit Sangha MD
Institution: Kaiser Permanente Hspital, Los Angeles
telephone:   323-783-1659
email:       bikramjit.s.sangha@kp.org

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