Cannula tip intravascular migration in an infant

Journal of Perinatology (2006) 26, 650–652 r 2006 Nature Publishing Group All rights reserved. 0743-8346/06 $30 www.nature.com/jp PERINATAL/NEONATAL CASE PRESENTATION Cannula tip intravascular migration in an infant F Morini, J Rechichi, MP Ronchetti, F Savignoni and C Corchia Department of Medical and Surgical Neonatology, ‘Bambino Gesu`’ Children’s Hospital, Rome, Italy In infants, the tip of a cannula is sometimes used as introducer during peripherally inserted central catheters placement. We report a rare complication of this procedure, characterized by intravascular migration of the cannula tip during peripheral insertion of a central venous catheter. We review this unlikely complication and treatment options. Journal of Perinatology (2006) 26, 650–652. doi:10.1038/sj.jp.7211566 Keywords: cardiac tamponade; embolized foreign body; intravenous cannula; percutaneous catheter; preterm infant Introduction In infants requiring long-term parenteral nutrition or drugs administration, peripherally inserted central venous catheters (PICCs) have been demonstrated to be an invaluable tool for providing intravascular access. However, percutaneous central venous cannulation may be associated with a number of complications, including occlusion, infection, thrombosis, breakage, migration and displacement.1 Less common complications include extravasation of fluid into the peritoneal, retroperitoneal or pleural spaces, pericardial effusions, cardiac arrhythmias and endocarditis.2,3 We report the case of a preterm infant with a rare complication occurred during peripheral insertion of a central venous catheter. slipped into the vein. Immediate surgical retrieval was attempted, but failed, and the cannula fragment migrated further. The following day the patient was referred to our tertiary neonatal referral center. On admission to our Department general conditions were fair, weight was 1785 g, and clinical examination was unremarkable. The cannula fragment was not visible at chest roentgenogram, suggesting a radio-transparent foreign body. Cardiac evaluation and electrocardiogram were normal but echocardiogram (Figure 1) showed a linear hyperecoic image, approximately 2-cm-long, at the confluence between the right subclavian vein and internal jugular vein. Percutaneous retrieval under radiological guidance was planned, but during the following hours, the infant presented with severe bradycardia and desaturation, not responding to resuscitation measures, including intubation and mechanical ventilation, cardiac massage, administration of epinephrine and isoproterenol. A repeat echocardiogram demonstrated massive pericardial effusion with cardiac tamponade and extremely reduced cardiac output. Emergency pericardiocentesis led to discharge of blood, and a subsequent subxyfoid pericardiotomy revealed the presence of the migrated cannula fragment (Figure 2) in the pericardial sac. Postoperative clinical conditions progressively deteriorated despite maximal resuscitative measures, and the infant eventually Case report A 48-day-old female infant was referred to our Department because of a foreign body in her right subclavian vein. She was born at 29 weeks of gestation with a birth weight of 1150 g. The baby had respiratory distress syndrome, intracranial hemorrhage, mycotic sepsis and Cytomegalovirus infection. In the referring hospital, the infant underwent placement of a 27-gauge PICC via the right antecubital vein to deliver parenteral nutrition and antiviral and antimycotic therapy. A 24-gauge intravenous cannula was used as introducer, cutting off the hub. However, during insertion of the PICC, the cut tip of the cannula Correspondence: Dr C Corchia, Neonatology Department, ‘Bambino Gesù’ Children’s Hospital, Piazza Sant’Onofrio, 4, 00165 Rome, Italy. E-mail: [email protected] Received 3 January 2006; revised 18 May 2006; accepted 24 May 2006 Figure 1 Echocardiogram performed on admission showing the intravenous cannula fragment (arrow) at the confluence between the right subclavian and internal jugular veins. SVC: superior vena cava. Cannula tip intravascular migration F Morini et al 651 Figure 2 The migrated 24-gauge cannula tip after removal by subxyfoid pericardiotomy. died on postoperative day 2. The parents did not consent to post-mortem examination. Discussion To our knowledge, this is the first report of fatal hemopericardium and cardiac tamponade secondary to embolization of an intravenous cannula tip used for PICC placement. PICCs are being used with increasing frequency in the pediatric population in part because of the lower risk of complications as compared with tunneled central venous lines.4 However, in a large series of preterm infants, excluding abnormal PICC position and displacement, 89 complications occurred in 280 PICCs, including breakage (35 cases), occlusion (34 cases), migration (nine cases), pleural or pericardial effusions (six cases), and cardiac tamponade (five cases).5 The most ominous complication is cardiac tamponade, with an estimated incidence of 0.3–2/100 PICCs and a 62 to 100% mortality rate.2 A recent survey of the period between 1995 and 2000 in the US showed that nearly 30% of NICUs have seen at least one case of perforation of the myocardium and 20% have reported at least one death caused by cardiac tamponade related to PICC.1 In infants with PICCs, cardiac tamponade is considered a consequence of myocardial perforation owing to malposition or migration of the catheter, which may lead to sudden death1,6,7 even in the absence of any antemortem symptom or sign.6 Successful resuscitation depends on timely pericardiocentesis.5 In our patient, cardiac tamponade was due to perforation of either the myocardium or the superior vena cava by an embolized cannula fragment, used as an introducer for PICC placement. In premature infants, the use of a precut tip of a 20-gauge cannula as an introducer has been suggested to overcome the difficulties found in advancing the PICC through a 24-gauge cannula or inserting a larger cannula in the small size vessels.8 However, embolization of a cannula fragment has been described as a possible complication of this technique,9 which can be fatal as demonstrated by our case. Therefore, this technique should be avoided when possible. If the tip of a cannula is used as introducer, every effort must be carried in order to avoid the risk of its embolization. The cannula tip may be secured by adhesive tape or with a stitch, or a tourniquet may be put at the base of the limb to hamper its migration. In any case, a radio-opaque cannula should be used in order to facilitate its tracing in case of accidental embolization. In our patient, an ultrasound examination showed that the cannula fragment was stable at the site of embolization. In spite of this quite reassuring finding, the fragment migrated further and perforated the wall of the superior vena cava or the myocardium, eventually leading to fatal hemopericardium. Treatment options for foreign bodies embolized into the heart or great vessels should be tailored in relation to symptoms and possible associated risks. Prompt surgical removal is mandatory in symptomatic patients, especially when cardiac tamponade is suspected.10 In asymptomatic patients, indication for surgery depends on the nature and location of the foreign body. Symbas et al.11 suggest that foreign bodies completely embedded in the myocardium can be left in place, whereas intracavitary foreign bodies and those partially embedded in the myocardium should be removed because of the risk of infection or embolization. Recent reports on infants and children suggest that surgical removal of foreign bodies in the heart and great vessels may be safe also several months after they have initially embolized.12,13 In infants, however, we would recommend that embolized foreign bodies, especially stiff ones, be retrieved as soon as possible, since embolization into the heart and myocardial perforation may occur. When retrieval of a foreign body embolized into the heart or great vessels is decided, both surgical and nonsurgical options are available. Surgical approach may be through a thoracotomy or a median sternotomy, with or without cardiopulmonary bypass, depending on the localization of the foreign body.10 In infants, percutaneous removal may be a valid option, especially in small preterm babies since it may avoid the need for surgery.12,14 Several devices can be used, including snares, biopsy forceps, tip-deflecting wires, basket devices and pigtail catheters. In our patient an attempt to percutaneous retrieval had been planned, in spite of the possible difficulties for the radiotransparency of the cannula tip. However, the fragment suddenly migrated before the procedure could be carried out. In conclusion present case suggests that the use of a cannula tip as introducer for PICC insertion is not to be recommended. The development of a friendly introducer for tiny babies is encouraged, with a funnel-shaped hub facilitating the insertion of a PICC. In case of cannula tip migration, immediate removal is highly Journal of Perinatology Cannula tip intravascular migration F Morini et al 652 recommended, because embolization into the heart is possible and potentially lethal. Acknowledgments We are grateful to Dr M Bevilacqua (Cardiology Department) and to all the colleagues who helped in the management and discussion of the case. References 1 Nadroo AM, Lin J, Green RS, Magid MS, Holzman IR. Death as a complication of peripherally inserted central catheters in neonates. J Pediatr 2001; 138: 599–601. 2 Hogan MJ. Neonatal vascular catheters and their complications. Radiol Clin N Am 1999; 37: 1109–1125. 3 Thiagarajan RR, Ramamoorthy C, Gettmann T, Bratton SL. Survey of the use of peripherally inserted central venous catheters in children. Pediatrics 1997; 99: E4. 4 Denny Jr DF. Placement and management of long-term central venous access catheters and ports. AJR Am J Roentgenol 1993; 161: 385–393. 5 Pezzati M, Filippi L, Chiti G, Dani C, Rossi S, Bestini G et al. Central venous catheters and cardiac tamponade in preterm infants. Intens Care Med 2004; 30: 2253–2256. Journal of Perinatology 6 Aiken G, Porteous L, Tracy M, Richardson V. Cardiac tamponade from a fine silastic central venous catheter in a premature infant. J Paediatr Child Health 1992; 28: 325–327. 7 Garg M, Chang CC, Merritt RJ. An unusual case presentation: pericardial tamponade complicating central venous catheter. J Perinatol 1989; 9: 456–457. 8 Fischer JE, Fanconi S. Percutaneous central venous catheterization in premature infants: a method for facilitating insertion of silastic catheters via peripheral veins. Pediatrics 1998; 101: 477–479. 9 De Paoli AG, Dargaville PA, O’Donnell CP, Casalaz DM, Taylor RG, Coombs CJ et al. Embolization of cannula fragments during insertion of central catheters. J Pediatr 2003; 143: 690–691. 10 Actis Dato GM, Arslanian A, Di Marzio P, Filosso PL, Ruffini E. Posttraumatic and iatrogenic foreign bodies in the heart: report of fourteen cases and review of the literature. J Thorac Cardiovasc Surg 2003; 126: 408–414. 11 Symbas PN, Picone AL, Hatcher CR, Vlasis-Hale SE. Cardiac missiles. A review of the literature and personal experience. Ann Surg 1990; 211: 639–647. 12 Andrews RE, Tulloh RMR, Rigby ML. Percutaneous retrieval of central venous catheter fragments. Arch Dis Child 2002; 87: 149–150. 13 Farrell AG, Parikh SR, Darragh RK, Girod DA. Retrieval of ‘old’ foreign bodies from the cardiovascular system in children. Cathet Cardiovasc Diagn 1998; 44: 212–216. 14 Chow LM, Friedman JN, Macarthur C, Restrepo R, Temple M, Chait PG. Peripherally inserted central catheter (PICC) fracture and embolization in the pediatric population. J Pediatr 2003; 142: 141–144.