Introduction: The need for prolonged venous access for the treatment of preterm newborn is frequent and peripherally inserted central catheters (PICC) have a known effectiveness in this function. We report the case of a pleural effusion associated with the insertion of PICC, consequent to perforation of the pulmonary vein from an anomalous and very rare path.

Report of case: Premature newborns hospitalized in an intensive care unit were submitted to PICC insertion with subsequent infusion of parenteral nutrition. He evolved with respiratory discomfort, requiring orotracheal intubation. Chest X-ray revealed left pleural effusion and thoracocentesis showed the presence of parenteral nutrition in the left hemithorax. Thoracic drainage was performed, resulting in improvement of respiratory discomfort. Echocardiogram showed the presence of the catheter tip inside the left atrium and a contrast test confirmed this location, with the catheter doing a 90-degree angle to cross the patent foramen ovale. An external traction of the catheter was performed, adequately repositioning the tip of the catheter in the inferior vena cava and allowing its reuse.

Conclusion: Although the insertion of the PICC is considered a low risk procedure, it is not free of complications. Some standardization of the technique is required, such as measuring the length of the catheter to be introduced as well as confirming its adequate position through radiography. We reiterate the peculiarity of the case, due to the anomalous and potentially damaging path of the catheter, evidencing the importance of creating specific protocols for the entire insertion and maintenance of central venous catheters.

Pleural effusion, PICC, Anomalous path, Newborn

Silva Rego AG, Barbosa Rêgo MN, Lima FF, Lima EP, Silva Junior LC, et al. (2018) Pleural Effusion Associated to Aberrant Path of Peripherally Inserted Central Catheter (Picc) in Newborn. Arch Emerg Med Crit Care 3(1): 1038.

PICC: Peripheral Insertion Central Venous Catheter; CPAP: Continuous Positive Airway Pressure; VD: Venous Dissection; NICU: Neonatal Intensive Care Unit

Prolonged venous access is often necessary for the treatment of preterm infants, because of this central venous catheterization is a common practice in neonatal intensive care units. Its advantages include the possibility of parenteral nutritional support, the possibility of hemodynamic monitoring, the safe administration of fluids, and the greater ease of maintaining viable access, avoiding new interventions [1].

Intravenous therapy in the neonate presents some peculiarities, ranging from the choice of access to the administration of medications. Peripherally inserted central catheters (PICCs) have been used in the treatment of newborns for a long time, and their effectiveness in ensuring prolonged central venous access has been demonstrated because they are considered less invasive when compared to the traditional central venous access by central puncture or dissection [2].

For its insertion the vein should be palpable, gauge and straight enough for the placement and suitability of the introductory needle. In a lot of centers, ultrasound-guided puncture is mandatory and facilitates the process, in addition to bringing greater safety and comfort to the patient during the procedure [3]. The successful insertion of PICC is achieved when the tip of the catheter is positioned centrally, that is, in the superior vena cava. If the tip progresses beyond the superior vena cava, traction maneuvers will be applied to the catheter for repositioning [4].

Complications can occur when the tip of the catheter is positioned in incorrect locations, such as the right atrium or migration into the right atrium. Displacement of the catheter tip is a common problem known to neonatologists. Therefore it is recommended to the professionals working in the management of the PICC, as a safety measure after the insertion procedure of the device, to ensure the correct location of the tip of the PICC. Positioning of the catheter should be verified and assured, shortly after its insertion, through radiography. Another way of checking the position of the PICC is to check the external length of the catheter daily, thus avoiding a predictable complication [4].

Although the PICC offers many advantages and a muchreduced risk of complications [5-8], especially with ultrasoundguided central lines being done routinely, it is not exempt from them. Pericardial and pleural effusions associated with PICC are a rare risk and may occur at any time after their insertion. In a study by Sertic (2017), an incidence of 0.43% of perforations caused by PICC was found. Of these, 0.14% caused pericardial effusion and 0.29% caused pleural effusion. In the literature there is a variation between 0.3% and 2%.

The case of a pleural effusion associated with the insertion of a PICC is presented, consequent to the perforation of a pulmonary vein from an anomalous and very rare path of the catheter, once it is installed in the great circulation.

Premature newborn, born cesarean delivery, by fetal centralization. APGAR 4 and 8 in the first and fifth minutes, respectively, undergoing positive pressure ventilation maneuvers with a balloon and mask and subsequently maintained in a continuous positive airway pressure (CPAP) device. Gestational age of 31 weeks by the method of Capurro and birth weight of 1150 grams. Venous umbilical catheterization was performed and he was admitted to a neonatal intensive care unit (NICU) after 2 hours of life. The next day he evolved without respiratory discomfort or saturation oscillations, remaining eupneic and active, being removed from CPAP and kept in ambient air.

On the third day of life he presented hemodynamic, dehydrated, fine pulses, vomiting and worsening of the respiratory pattern, but without criteria for antibiotic therapy or need for supplemental oxygen. On the fifth day of life, we chose to withdraw the venous umbilical catheter and insert a PICC, due to the need for a long-term central venous access (patient without effective enteral nutrition, need for prolonged parenteral nutrition, very low weight, moderate prematurity; infusion of intravenous fluids), since the venous umbilical catheter should be withdrawn within seven days to avoid complications associated with it.

The insertion of the PICC occurred apparently without complications. The saphenous vein was punctured with a 1.9 French monolumen catheter, distally, in the right lower limb, and progressed adequately. On radiograph of control, tip of the catheter was difficult to visualize, but it was opted to initiate infusion of parenteral nutrition. Patient evolved with respiratory discomfort, with initial need for oxygen supply, and then orotracheal intubation and mechanical ventilation. A new chest X-ray was performed, which showed pleural effusion in the left hemithorax. Because of the possible association with the catheter insertion, we chose to stop the infusion and keep the catheter closed. Left thoracentesis was performed, with identification of a milk-like fluid sent for analysis and confirmed as parenteral nutrition in the left pleural space. We performed left thoracic water-seal drainage, with improvement of respiratory discomfort. Catheter replaced by external traction, by 3 centimeters, still without adequate visualization by radioscopy. An echocardiogram was performed, which showed the presence of the catheter tip inside the left atrium. A new external traction was performed, now guided by contrast test. 1ml of watersoluble, ionic, iodinated contrast agent diluted in distilled water (1:1) was infused to fill the catheter lumen completely and facilitate identification of its path and location of its tip. A chest X-ray was able to confirm location of the catheter tip in left atrial topography, doing a 90-degree angle to cross the patent oval foramen of the patient. The external traction of the catheter was performed for further 3 cm, according to radioscopic measurement, adequately repositioning the tip of the catheter in the inferior vena cava and allowing again the use of the catheter for infusion of parenteral nutrition and intravenous medications in general. There was rapid re-expansion of the left lung, with drainage withdrawal after 5 days. The catheter remained in use for 19 days without further complications and the patient was discharged from the NICU after 18 days.

The PICC is defined as a catheter introduced percutaneously through a peripheral vein until its tip resides in the superior vena cava, right atrium or inferior vena cava, above or at the level of the diaphragm. Its main indication is defined by the need for central venous access for a period longer than three days [1,8].

There are several advantages to using this less invasive technique. It is worth noting the lower risk of infection when compared to other devices with the same purpose, better hemodilution, less pain and discomfort during insertion and during the time of use, besides reducing the patient’s stress. Its contraindications are related to the administration of large bolus volumes under pressure (in case of catheters with small diameters), presence of cutaneous lesions at the insertion site, skin or subcutaneous tissues infections at or near the proposed site of insertion and the structural anatomical changes [6].

The technical competence for nurses to insert, manipulate and withdraw the PICC in Brazil is supported by Decree 94406/87, which regulates Law No. 7,498 / 86, Article 80. The law also provides in Article 11 that it is private authority of the nurse, the more complex technical care requiring scientific knowledge and the ability to make immediate decisions [9]. It is considered lawful for nurses to insert the PICC and they must undergo specific qualification and / or training to insert the catheter [9].

Before inserting the PICC catheter, its extent to be introduced is measured, considering the site of insertion in the superior vena cava. However, in the catheter insertion procedure, the tip may progress to an unplanned location, straying to another venous branch, or even positioning anteriorly or posteriorly to the planned site [4]. It is important to remember that catheter insertion should occur in intact and gauge veins, requiring close attention and care related to the device [8].

It is worth emphasizing the importance of ultrasonography in the PICC insertion process, since the ecoguided implant has a high technical success rate in some studies due to the lower risk of inadequate puncture provided by ultrasonography when compared to puncture based only on anatomical parameters [10,11].

When evaluating the complications related to catheter insertions in central venous position, it is observed that the PICC is associated with low risks when compared to direct insertion in the subclavian or jugular vein, such as pneumothorax, hemothorax, brachial plexus injury and gas embolism, thus being considered quite safe [8]. In addition, the vascular access by PICC consists in the introduction of a catheter, most of the time made of silicone, through peripheral venipuncture and going into the central venous system, without the need of any type of anesthesia, and may also be performed by a doctor or nurse who is properly trained and qualified, and is not exclusive to the surgeon, whereas access by venous dissection (VD) consists of the introduction of a catheter, usually made of polyurethane, through a phlebotomy surgical approach, which can be performed in any vein, provided that it has appropriate gauge, under local anesthesia, by medical professional. Both techniques can be performed in the NICU, in a crib or incubator. The vein used for catheter insertion by the PICC technique can be reused while that used in the DV technique is rendered unusable for other accesses [12].

It is worth mentioning that the occurrence of complications can lead to damages to the proposed therapy [7]. According to a study published by Jesus (2007), the main complications related to IPCC were occlusion, phlebitis, poor positioning, sepsis, thrombosis, local infection, rupture, embolization, and difficulty in catheter removal. Many of these complications were attributed to the breakdown of aseptic technique and inadequate manipulation of the device. For Franceschi (2010), there was a higher prevalence of mechanical adverse events, predominating catheter occlusion as the main adverse event related to PICC (19.44%), followed by catheter rupture (8.8%). Thus, for the success of this practice to be achieved, it is necessary for professionals to seek technical and scientific knowledge through training and qualifications, aiming to minimize complications and to know how to intervene in the face of already installed problems, not forgetting to qualify the entire assistance team seeking to avoid complications resulting from inadequate manipulation of the catheter (Figure 1).

Figure 1: Sequence of X-rays. (A) - Normal, prior to venipuncture; (B) - Left pleural effusion, post-puncture; (C) - Left atrial catheter, pleural drainage and contrast injection through catheter; (D) - Right atrial folded catheter, manual post-traction; (E) - Right atrium high catheter; (F) - Catheter in inferior vena cava, final position. (*) - Position of the catheter tip.

The relevance of the use of the PICC is the guarantee of a reliable venous access for the hospitalized newborn, who needs the administration of solutions and medicines, and the nursing team has the permanent theoretical and practical training in the face of increasing technological advances [13]. In addition of allowing the opportunity to perform the intravenous therapy with reduction of the stress produced by the multiple peripheral venous punctures, it favors the infusion of solutions with different concentrations with a lower risk of iatrogenics [6].

It is worth remembering that in premature infants we have a greater fragility of the tissues, which makes them more susceptible to perforations. However, their etiology is not well understood. It is suggested that perforations may be associated with trauma during guide wire use, catheter tip position, its material and size, patient age, and osmotic injury due to infusion of hyperosmolar fluids [5].

In the case described, besides the pleural perforation, already well described in association with the presence of central catheters, it is worth mentioning the anomalous and inadvertent path followed by the catheter, since it crossed the patent foramen ovale (PFO), reaching the left atrium and progressing through the pulmonary vein (Figure 2).

Figure 2: Diagnostic echocardiogram in sequence. An abnormal pathway of the catheter was observed, passing through the inferior vena cava (VCI), right atrium (AD) and left atrium (AE), after initial manual traction.

FOP is patent in up to ¼ of the population and in some cases ½ of the population presents it in this way up to 2 years old. The pathway performed by the catheter in an accidental manner is the same used therapeutically in some cases of correction of inter-atrial communication [14,15].

In this way, we reiterate the peculiarity of the case, which highlights the importance of knowing the proper technique and emphasizes that the procedure is not free of complications, despite the various advantages over other types of central access. We emphasize the need for each service to create specific protocols for the whole process of insertion of central venous catheters, including the formal use of ultrasound guidance; to monitor the success rate in the positioning of the catheter tip in order to detect the causal and intervenings factors in the failures; to plan measures to improve the success rate of these procedures and to minimize the complications since the damage can be fatal.

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