Fatal neurologic complication of parenteral feeding through a central vein catheter
M. A. Kelly, N. N. Finer and L. G. Dunbar
A 9-month-old male infant, born at 32 weeks' gestation, had neonatal
necrotizing enterocolitis and required long-term parenteral nutrition. At 9
months of age, a central venous catheter was inserted through the left
saphenous vein into the inferior vena cava, and the infant died nine days
later. Shortly before death, a lumbar puncture yielded milky fluid with an
extremely high glucose and protein content. A postmortem barium injection
through the central catheter demonstrated free barium in the
retroperitoneal cavity and epidural space, and autopsy findings confirmed
that the catheter had entered an ascending lumbar vein with a large
retroperitoneal abscess. This case emphasized the need to confirm central
venous catheter position at the time of insertion and pointed out yet
another risk of parenteral alimentation.
