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Peripherally inserted central catheter extravasation of fluid in a neonate: A dreadful complication
*Corresponding author: H. A. Venkatesh, Department of Neonatology, Manipal Hospital, Bengaluru, Karnataka, India. venkatveena46@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Venkatesh HA, Panigrahi N, Reddy AS, Patel S, Kannur N, Devaranavadagi R. Peripherally inserted central catheter extravasation of fluid in a neonate: A dreadful complication. Karnataka Paediatr J. 2026;41:46-8. doi: 10.25259/KPJ_33_2025
Abstract
A peripherally inserted central catheter (PICC) is of utmost importance in the management of critically ill neonates for the administration of nutrition and medication. It can cause complications including displacement, perforation, infection, occlusion, extravasation and breakage causing morbidity and mortality if not recognised and managed in time. Here, we report an interesting case of catecholamine-resistant shock in an extreme preterm neonate due to displacement of the PICC and causing perforation of the vein with extravasation of total parenteral nutrition fluid. Early recognition and management led to his survival. He is on full enteral feeds with no morbidity at discharge.
Keywords
Bedside ultrasound
Extravasation
Peripherally inserted central catheter
Preterm
INTRODUCTION
Central vein catheterisation is highly essential in the management of preterm neonates. The displacement of the catheter and perforation of the vein led to the extravasation of fluid into the subcutaneous tissue, causing shock, which was managed successfully. This highlights the importance of performing a bedside ultrasound to locate the tip of the peripherally inserted central catheter (PICC) after insertion and during serial monitoring.
CASE REPORT
A 28-week-old preterm neonate weighing 1100 g was born to a non-consanguineous union by caesarean section. He required intubation at birth, was connected to a ventilator and received a dose of surfactant and vitals were stable. His blood glucose was normal. The umbilical catheters were placed and started on total parenteral nutrition (TPN) and invasive blood pressure was monitored continuously. He was stable throughout. He started on gavage feeding. On day 3 of life, he was extubated to continuous positive airway pressure. The PICC was inserted into the left saphenous vein and the tip position was confirmed by point-of-care ultrasound and the umbilical catheters were removed [Figure 1a]. Two days later, he became suddenly unwell with tachycardia and hypotension. He was re-intubated and connected to a ventilator. On examination, the swelling was noted around the PICC line involving the complete left aspect of the abdomen and chest including the scrotum [Figure 1b and c]. The X-ray showed the PICC line moved down with the fluid extravasated to subcutaneous tissue. Immediately, the TPN was stopped and the PICC line was removed. Echocardiography demonstrated poor contractility of the heart with low-volume chambers. His blood workup including sepsis markers, electrolytes including serum calcium, and cranial ultrasound was normal. He was started on normal saline bolus followed by inotropes norepinephrine, dobutamine, and a dose of hydrocortisone due to catecholamine-resistant shock. Gradually, the swelling reduced and he maintained adequate blood pressure. He developed non-oliguric renal failure with high creatinine and urea and gradually normalised over time.
- (a) Ultrasound demonstrating the tip of peripherally inserted catheter at the junction of inferior vena cava (IVC) and right atrium (arrow). The Chest X-ray and abdomen demonstrates extravasation of fluid in the subcutaneous plane including chest and abdomen. (b) The black arrow shows the displaced PICC line tip. (c) Clearance of fluid after the removal of the PICC line. PICCL: Peripherally inserted central catheter.
DISCUSSION
Parenteral nutrition is an integral part of managing preterm neonates, and it should be initiated as early as possible. Usually, it is started either through the umbilical vein or through the PICC line. Even after taking the utmost care throughout the PICC line procedure complications still can happen in the form of sepsis, displacement, blockage, break in the catheter and perforation of the vein.[1,2] The migration of the catheter causing cardiac tamponade and extravasation into subcutaneous tissue as seen in our case can lead to acute catastrophe causing more morbidity and mortality. Mostly erosion of the vein can lead to subcutaneous extravasation of the fluid. As the TPN fluid is hyperosmolar, it can diffuse into the subcutaneous tissue, causing tamponade of the subcutaneous area and compressing the thoracic part, which might have caused recurrent apnoea in our index case. Usually, cardiac tamponade does not give time, and most of the neonates succumb unless a quick diagnosis is made and managed urgently.[3] The 3rd space fluid loss can make the neonate develop hypovolemic shock and in turn refractory shock depending on the amount of fluid in the subcutaneous tissue. Usually, the cardiac tamponade requires pericardiocentesis immediately to make the neonate survive after stopping TPN and removing the PICC. When fluid accumulates in the subcutaneous tissue just stopping the TPN and the PICC line removal helps in the recovery as seen in our index case. Usually, the X-ray or ultrasound is performed to confirm the tip position once inserted in our index case; the bedside ultrasound confirms the tip position and is kept at the junction of the right atrium and inferior vena cava. Studies reported that there are no statistically significant differences in fracture rates between upper and lower limb PICCs.[4] The objective assessment of sickness in neonates using sonography (OASIS) strongly recommends the critical performance of ultrasound to look for causes of deterioration.[5,6] According to The UK Department of Health and Food and Drug Administration united stated, the tip of the PICC line is kept outside the pericardiac sheath at the junction of the superior vena cava and the right atrium and confirmed by bedside ultrasound.[7] Bundle strategies such as enhancement of catheter fixation, daily monitoring of the exposed length of the catheter and alternate day point-of-care ultrasounds to locate the catheter tip position are highly recommended to decrease deadly complications.[8] This case warrants us to perform the tip position check every day using ultrasound.
CONCLUSION
PICC is a life-saving procedure in preterm neonates. The prompt recognition and management of complications will bring down mortality and morbidity. The OASIS is the best strategy to act quickly.
Ethical approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
The authors certify that they have obtained all appropriate parental consent forms. In the form, the parents have given consent for the patient's images and other clinical information to be reported in the journal. The parents understand that the patient's names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
References
- Percutaneous silastic catheters in newborn and premature infants. A report of experiences with 497 catheters in 5 years. Monatsschr Kinderheilkd. 1992;140:464-71.
- [Google Scholar]
- Mechanical complications from very small percutaneous central venous silastic catheters. Crit Care Med. 1990;18:1477-8.
- [CrossRef] [PubMed] [Google Scholar]
- Cardiac tamponade in a neonate: A dreadful condition--need for functional echo. BMJ Case Rep. 2014;2014:bcr2014207040.
- [CrossRef] [PubMed] [Google Scholar]
- Unveiling peripherally inserted central catheter fractures and related complications in the neonatal intensive care unit: A concise review. Cureus. 2023;15:e47572.
- [CrossRef] [Google Scholar]
- Objective assessment of sickness in neonates using sonography. Perinatology. 2024;25:43.
- [Google Scholar]
- Ultrasound guided confirmation of tip of peripherally inserted central catheter in neonates. Indian Pediatr. 2020;57:858-9.
- [CrossRef] [PubMed] [Google Scholar]
- Positioning long lines: Contrast versus plain radiography. Arch Dis Child Fetal Neonatal Ed. 2001;84:F129-30.
- [CrossRef] [PubMed] [Google Scholar]