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Pleural effusion as a complication of a remotely placed catheter in a preterm infant

Journal of Perinatology volume 33, pages 982–984 (2013)Cite this article

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The placement of PICC has become a routine part of the intensive care management of preterm infants. These catheters are relatively safe when placed and monitored by trained practitioners. They provide reliable access for fluid management, nutritional support and administration of medications.1 However, the incidence of catheter-related complications, such as septicemia (5.2%), localized infiltration (7%) or pericardial effusion (1% to 3%), remains a major concern.1 Catheter-associated complications such as hydrothorax are uncommon,1 but have been reported on several occasions, usually in preterm patients with catheters’ tips placed near the SVC2, 3 or in the IVC, above4 or below the diaphragm.5 Pleural effusions related to catheters placed in the IVC have been linked to either a direct extravasation of parenteral fluids3, 4 or an extension of ascites fluid into the pleural space.5 Catheters, placed below the diaphragm and far from pleural effusions, seem safe and may be hard to implicate, mainly if they were not associated with ascites. Although uncommon, this complication should be suspected immediately as pleural effusions are associated with high mortality rates.2, 3

In this preterm infant, the pleural fluid was readily recognizable on a plain X-ray. On the other hand, the cause of the effusion was not apparent until the results of the cytological and biochemical fluid analyses became available. Low levels of LDH, triglyceride and protein associated with a predominant number of mesothelial cells in the pleural fluid indicated its transudate nature. Moreover, the presence of an elevated pleural fluid glucose to blood glucose ratio implicated the catheter. As the tip of the catheter was located at the level of T12, and as there was no clinical or radiological evidence of ascites, a contrast study through the catheter was performed. This study demonstrated that the tip of the catheter was located in one of the tributaries of the azygos vein. Indeed, a posterior deviation in the track of the catheter at the level of the third to fourth lumbar intervertebral space (L3–L4) marked its exit from the IVC (Figure 2b). In addition, the contrast solution emerged from the catheter into small, medial, pre-vertebral vessels before flowing into the left ascending lumbar vein located at the level of the second lumbar vertebrae, that is, the lateral root of the azygos venous system.6 Finally, the course of the injected contrast traced a path similar to the path of the azygos vein, ending in the superior part of the thorax after turning anteriorly at the level of the fourth thoracic vertebrae (Figure 2b).

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Authors and Affiliations

  1. Department of Pediatrics, University of South Alabama Children’s and Women’s Hospital, Mobile, AL, USA

    K L Kua & W Alrifai

  2. Division of Neonatology, Department of Pediatrics, University of South Alabama Children’s and Women’s Hospital, Mobile, AL, USA

    R M Whitehurst Jr & M M Zayek

  3. Division of Pediatric Radiology, Department of Radiology, University of South Alabama, Mobile, AL, USA

    T B Standley

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  1. K L Kua
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  2. R M Whitehurst Jr
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Correspondence to K L Kua.

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Kua, K., Whitehurst, R., Alrifai, W. et al. Pleural effusion as a complication of a remotely placed catheter in a preterm infant. J Perinatol 33, 982–984 (2013). https://doi.org/10.1038/jp.2013.76

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