Intraperitoneal extravasation of total parenteral nutrition: A rare but life-threatening complication of umbilical vein catheter, two case reports

Selahattin Akar

doi:10.4103/jcn.jcn_163_20

CASE REPORT

Year : 2021 | Volume : 10 | Issue : 2 | Page : 120-123

Intraperitoneal extravasation of total parenteral nutrition: A rare but life-threatening complication of umbilical vein catheter, two case reports

Selahattin Akar
Department of Neonatology, Adiyaman University Training and Research Hospital, Neonatal Intensive Care Unit, Adiyaman, Turkey

Date of Submission	05-Oct-2020
Date of Decision	20-Mar-2021
Date of Acceptance	22-Mar-2021
Date of Web Publication	15-May-2021

Correspondence Address:
Selahattin Akar
Department of Neonatology, Adiyaman University Training and Research Hospital, Neonatal Intensive Care Unit, Adiyaman
Turkey

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcn.jcn_163_20

Abstract

Umbilical vein catheter (UVC) is a commonly used intervention in neonatal intensive care units for total parenteral nutrition (TPN), antibiotic therapy, and investigations, especially in very low birth weight infants. In this report, a rare but life-threatening complication of UVC developed in two preterm infants was presented. Of two infants admitted to our neonatal intensive care unit due to prematurity, the first infant developed abdominal distension and a decreased urinary output on the 2^nd day and the second infant on the 5^th day. Enteral intake of the patients was discontinued with the presumed diagnosis of necrotizing enterocolitis, and broad-spectrum antibiotic therapy was initiated. There were free ascites on the abdominal ultrasonography. Macroscopic and microscopic examination of the fluid sample taken by paracentesis was compatible with TPN. Intraperitoneal extravasation of UVC, which is a rare but life-threatening complication of UVC and can be confused with necrotizing enterocolitis, should be kept in mind, especially in infants receiving TPN infusion from the UVC.

Keywords: Intraperitoneal extravasation, preterm, total parenteral nutrition, umbilical vein catheter

How to cite this article:
Akar S. Intraperitoneal extravasation of total parenteral nutrition: A rare but life-threatening complication of umbilical vein catheter, two case reports. J Clin Neonatol 2021;10:120-3

How to cite this URL:
Akar S. Intraperitoneal extravasation of total parenteral nutrition: A rare but life-threatening complication of umbilical vein catheter, two case reports. J Clin Neonatol [serial online] 2021 [cited 2023 Mar 21];10:120-3. Available from: https://www.jcnonweb.com/text.asp?2021/10/2/120/316177

Introduction

Umbilical vein catheter (UVC) is a commonly used intervention in neonatal intensive care units for total parenteral nutrition (TPN), antibiotic therapy, and investigations, especially in very low birth weight infants. Various complications up to 20%–37% may be seen when the position and length of the umbilical catheter are not suitable.^[1] Pericardial effusion, arrhythmia, cardiac tamponade, pleural effusion, thrombosis, endocarditis, liver hematoma, hepatic necrosis, and portal hypertension are the leading complications.^[2],[3],[4] In this report, a rare complication of UVC, which suggested necrotizing enterocolitis in two preterm infants, was presented.

Case Reports

Case 1

An infant who was born in the 26^th gestational week with a weight of 900 g from the 4^th pregnancy of the 29-year-old mother as the first live was hospitalized in our neonatal intensive care unit due to prematurity. The patient was put into the previously heated incubator and monitored. The patient, who was considered to have respiratory distress syndrome clinically and radiologically, was intubated, and surfactant treatment was administered endotracheally. Ampicillin and gentamicin antibiotic treatment was initiated in the patient, whose congenital pneumonia could not be ruled out. A 5 Fr UVC was inserted into the patient under sterile conditions. In the ultrasonography performed immediately after catheter insertion, the tip of the catheter was seen in the ductus venosus. On the 1^st day, TPN containing dextrose, amino acid, lipid, and calcium was initiated at a dose of 80 cc/kg/day. Minimal enteral feeding was initiated with breast milk, and the enteral intake of the patient was increased daily. Urinary outflow was detected on the 1^st day and stool excrement on the 2^nd day. Urinary output was decreased on the postnatal 2^nd day in the patient who developed abdominal distension. On the standing direct abdominal X-ray, the umbilical catheter was visible at the level of T9 vertebra. Free ascites were detected on the abdominal ultrasonography. The enteral intake of the patient, whose necrotizing enterocolitis could not be ruled out, was discontinued. The infant was taken to the orogastric free drainage, and broad-spectrum antibiotic therapy was started. Paracentesis was performed and 90-mL milk-color fluid was collected. The content of the fluid sample was found to be compatible with TPN. Peritoneal fluid analysis chemistry showed protein: 1224 mg/dL, triglyceride: 632 mg/dL, and glucose: 584 mg/dL. It was considered as intraperitoneal extravasation of TPN, UVC was removed, and peripherally inserted central venous catheter was opened. At the clinical follow-up, urinary output was normal, abdominal distension of the patient regressed, and full enteral nutrition was provided on the postnatal 19^th day. The patient was discharged on the postnatal 72^th day with recovery.

Case 2

An infant who was born in the 29^th gestational week with a weight of 1390 g was hospitalized in our neonatal intensive care unit due to prematurity. The patient was put into the previously heated incubator and monitored. Nasal CPAP support was started and the patient was intubated upon the increased respiratory distress findings at the follow-up, and surfactant therapy was initiated endotracheally. Ampicillin and gentamicin antibiotic treatment was initiated in the patient, whose congenital pneumonia could not be ruled out. A 5 Fr UVC was inserted into the patient under sterile conditions. Ultrasonographic evaluation performed immediately after catheter insertion showed the tip of the catheter at the level of the ductus venosus. TPN and minimal enteral nutrition were started in the patient within the first 24 h. Enteral intake was limited and gradually increased. Urinary outflow and stool excrement were detected on the 1^st day. Urinary outflow decreased on the 5^th day, and the patient developed nutritional intolerance and abdominal distention [Figure 1]. On the standing direct abdominal X-ray, the umbilical catheter was visible at the level of T9–T10 vertebrae. Free ascites and an abscess-like hyperechogenic focus were detected on the abdominal ultrasonography [Figure 2] and [Figure 3]. The enteral intake of the patient, whose necrotizing enterocolitis, sepsis, and acute abdomen could not be ruled out, was discontinued. The infant was taken to the orogastric free drainage, and broad-spectrum antibiotic therapy was started. Paracentesis was performed and 105-mL milk-color fluid was collected [Figure 4]. The content of the fluid sample was found to be compatible with TPN. It was considered as intraperitoneal extravasation of TPN, UVC was removed, and peripherally inserted central venous catheter was opened. At the clinical follow-up, the patient was rapidly improved, antibiotic therapy was completed for 7 days, and full enteral nutrition was provided on the 18^th day. It was found that the hyperechogenic focus in the liver disappeared completely before discharge [Figure 5]. The patient, whose general status was good and weighed 2160 g during the clinical follow-up, was discharged on the postnatal 75^th day with recovery and suggestions, providing to come for controls.

Figure 1: View of abdominal distension developed in Case 2 on the postnatal 5^th day

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Figure 2: Diffuse-free ascites on the abdominal ultrasonography in Case 2 on the postnatal 5^th day

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Figure 3: Hyperechogenic focus of 12 mm × 23 mm in the liver related to total parenteral nutrition extravasation on the abdominal ultrasonography of Case 2 (area shown by white arrow)

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Figure 4: 105-mL milk-color fluid taken from Case 2 by paracentesis

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Figure 5: Hyperechogenic focus in the liver was completely disappeared on the abdominal ultrasonography of Case 2 before discharge

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Discussion

Early started TPN in preterm infants is most commonly given through UVC. Most frequently, direct X-ray is taken after insertion of an UVC in order to evaluate whether the position of the catheter is suitable. The most suitable anatomical localization for UVC is inferior vena cava-right atrium (IVC-RA) junction, which is known to correspond to the level of T7–T9 vertebrae on direct X-ray.^[5],[6] There are limited studies in the literature reporting that the right atrium is a suitable position for the catheter.^[4],[5] However, it should be remembered that intracardiac catheter can lead to life-threatening complications such as thrombus, arrhythmia, endocarditis, and pericardial effusion. In addition, a catheter in the right atrium may pass to the left atrium through the foramen ovale, increasing the risk of hemodynamic impairment. The catheter tip was visible in normal localization at the level of T9 vertebra in our Case 1 and T9–T10 vertebrae in Case 2.

The number of studies reporting that ultrasonography or echocardiography is superior over direct X-ray for the evaluation of the position and length of UVC is increasing.^[7],[8] Ades et al. stated that IVC-RA varied between the 6^th and 11^th thoracic vertebrae on chest X-ray and the correlation between chest X-ray and ultrasonography was weak.^[9] Michel et al. evaluated the position of UVC with chest X-ray and ultrasonography in preterm infants of 34.7 ± 4.2 weeks and reported that ultrasonography provided more accurate results in showing position of the catheter. Again, in the same study, the authors stated that the sensitivity of chest X-ray in showing position of the catheter reduced as the birth weight decreased.^[8]

Since TPN content is hypertonic and alkalic in the cases of low localized UVC, liver-related complications such as intraparenchymal hematoma, subcapsular hematoma, abscess, necrosis, and laceration are more commonly observed.^[2],[10] When injury to the liver capsule or perforation in the umbilical vein develops, intraperitoneal TPN extravasation occurs and requires urgent diagnosis and treatment. Our both patients developed abscess-like hyperechogenic lesions in the liver due to TPN. TPN that leaks into the abdomen leads to abdominal distension and nutritional intolerance. As intravascular fluid is decreased, urine output may decrease and acute renal failure may develop, as in our cases. These patients may be misdiagnosed as necrotizing enterocolitis, sepsis, and acute abdomen.

Intraperitoneal extravasation of TPN is usually seen in the postnatal 1^st week.^[11],[12] However, it should be remembered that this serious complication may be developed as long as UVC is in place, even if the position of UVC is suitable. It is recommended not to use UVC from the 14^th day due to the increased risk of complications.^[13] If there is still a need for TPN or intensive intravenous treatment after the postnatal 14^th day, UVC should be removed and peripherally inserted central venous catheter (PICC-line catheter) should be inserted.

Conclusion

Various complications may be seen due to UVC, especially in preterm infants. Intraperitoneal extravasation of TPN should be remembered, especially in the case of low localized UVC. Detection of ascites on abdominal ultrasonography, followed by paracentesis application, appearance and biochemical examination of the collected fluid sample provide a definitive diagnosis. Removal of the UVC, complete removal of ascites by paracentesis, and opening the peripheral vascular access provide curative treatment and prevent possible surgical intervention.

Consent

Written consent was obtained from the families to present the cases and use the images.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Mahajan V, Rahman A, Tarawneh A, Sant'anna GM. Liver fluid collection in neonates and its association with the use of a specific umbilical vein catheter: Report of five cases. Paediatr Child Health 2011;16:13-5.
2.	Lim-Dunham JE, Vade A, Capitano HN, Muraskas J. Characteristic sonographic findings of hepatic erosion by umbilical vein catheters. J Ultrasound Med 2007;26:661-6.
3.	Khaldkar SM, Gujarathi A, Kulkarni VM, Singh A. Hepatic necrosis due to umbilical vein catheter malposition: A case report with review of literature. Med J DY Patil Univ 2014;7:793-6.
4.	Narla LD, Hom M, Lofland GK, Moskowitz WB. Evaluation of umbilical catheter and tube placement in premature infants. Radiographics 1991;11:849-63.
5.	Oestreich AE. Umbilical vein catheterization--Appropriate and inappropriate placement. Pediatr Radiol 2010;40:1941-9.
6.	Symansky MR, Fox HA. Umbilical vessel catheterization: İndications, management, and evaluation of the technique. J Pediatr 1972;80:820-6.
7.	Franta J, Harabor A, Soraisham AS. Ultrasound assessment of umbilical venous catheter migration in preterm infants: A prospective study. Arch Dis Child Fetal Neonatal Ed 2017;102:F251-5.
8.	Michel F, Brevaut-Malaty V, Pasquali R, Thomachot L, Vialet R, Hassid S, et al. Comparison of ultrasound and X-ray in determining the position of umbilical venous catheters. Resuscitation 2012;83:705-9.
9.	Ades A, Sable C, Cummings S, Cross R, Markle B, Martin G. Echocardiographic evaluation of umbilical venous catheter placement. J Perinatol 2003;23:24-8.
10.	Shervani P, Vire A, Anand R, Jajoo M. Umbilical venous catheterization gone: Hepatic complications. Indian J Radiol Imaging 2016;26:40-3.
11.	Panetta J, Morley C, Betheras R. Ascites in a premature baby due to parenteral nutrition from an umbilical venous catheter. J Paediatr Child Health 2000;36:197-8.
12.	Oztan MO, Ilhan O, Abay E, Koyluoglu G. An umbilical venous catheter complication presented as acute abdomen: case report. Arch Argent Pediatr 2016;114:e429.
13.	Greenberg M, Movahed H, Peterson B, Bejar R. Placement of umbilical venous catheters with use of bedside real-time ultrasonography. J Pediatr 1995;126:633-5.