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Radiological Case of the Month
John G. Walsh, MB, MRCPCH;
Martin J. O'Sullivan, MB, FRCI;
C. Anthony Ryan, MB, MRCPCH
From the Departments of Paediatrics and Child Health (Drs Walsh and
Ryan) and Surgery (Dr O'Sullivan), Cork University Hospital, Cork, Ireland.
Arch Pediatr Adolesc Med. 2001;155:523-524.
AN INFANT weighing 1530 g and born at 31 weeks' gestation by emergency
cesarean delivery was intubated in the delivery room because of respiratory
distress. Endotracheal surfactant was administered, and she was transferred
to the neonatal intensive care unit. Within an hour, high-frequency oscillation
ventilation was started because of difficulty maintaining oxygenation with
conventional ventilation. A double-lumen 3F catheter was inserted into an
umbilical vein. The baby's clinical condition improved rapidly over the next
2 days, and she was extubated and maintained on continuous positive airway
pressure. At age 4 days, she was breathing room air spontaneously.
On day 5, her abdomen was distended, and she developed respiratory distress
and was intubated. The umbilical venous catheter (UVC) was removed because
of clinical suspicion of necrotizing enterocolitis. A radiograph of the abdomen
was obtained (Figure 1). An ultrasound
examination of the abdomen showed echolucency in both flanks indicating free
fluid. The kidneys were not identified, but the liver and spleen were normal.
Pigtail catheters (4F) were inserted by ultrasound guidance into the flank
regions bilaterally. Ninety milliliters of opalescent, blood-stained fluid
was aspirated, 50 mL from the right flank and 40 mL from the left flank. Contrast
medium was injected via the catheters (Figure
2). Ultrasound following this procedure showed normal kidneys. A
laparotomy was performed and showed no necrotizing enterocolitis, perforated
viscus, or any other intraperitoneal abnormality. The infant recovered, and
findings from ultrasound examination of the abdomen prior to discharge on
day 53 was normal.
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Figure 1.
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Figure 2.
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Denouement and Discussion: Perforation of the Inferior Cava As a Cause of Neonatal Free Intra-Abdominal Air
Figure 1. Radiograph of the abdomen showing free air around the liver.
Figure 2. Contrast media in the retroperitoneal space inserted via draining
catheters.
Free intra-abdominal air on radiography is an ominous sign, usually
indicating perforation of a viscus. In the premature neonate, the cause is
usually necrotizing enterocolitis.1, 2
The term "free air" usually refers to air within the peritoneal cavity, but
in this case, the air was in the retroperitoneal space along with extravasated
parenteral nutrition fluid. Apparently, the UVC eroded the wall of the inferior
vena cava, resulting in extravasation of total parenteral nutrition (TPN)
fluid. The origin of free air was either direct catheter air embolus or represented
accumulation of microbubbles from the TPN fluid. Biochemical analysis of the
fluid aspirated confirmed it as lipid-containing TPN fluid.
A total of 700 mL of crystalloid and TPN was infused through the UVC
during the 5-day period from its insertion to its removal. If the vena caval
perforation occurred at the time of insertion of the UVC, a larger volume
of fluid would have been expected on paracentesis. Therefore, there was likely
gradual erosion of the vena cava wall after insertion of the UVC.
Complications previously recognized with UVC insertion include thrombosis,
embolism, vasospasm, vessel perforation, hemorrhage, infection intestinal,
and renal and limb damage.3 Small air emboli
have been described following insertion of peripheral or central venous catheters.4, 5 This report highlights an unusual
hazard of umbilical vessel catheterization and a radiological sign: vena cava
erosion and perforation with accumulation of retroperitoneal gas. To our knowledge,
this cause of radiological diagnosed free intra-abdominal air in a neonate
has not previously been described.
AUTHOR INFORMATION
Accepted for publication May 10, 2000.
Reprints: C. Anthony Ryan, MD, MRCPCH, Neonatal Intensive Care Unit,
Erinville Hospital, Western Road, Cork, Ireland (e-mail: crryan{at}indigo.ie).
REFERENCES
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1. Pokorny WJ, Garcia-Prats JA, Barry YN. Necrotising enterocolitis: incidence, operative care and outcome. J Pediatr Surg. 1986;21:1149-1154.
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2. Harms K, Ludtke FE, Lepsien G, et al. Idiopathic intestinal perforations in premature infants without evidence
of NEC. Eur J Pediatr Surg. 1995;5:30-33.
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3. Green C, Yohannan MD. Umbilical arterial and venous catheters: placement, use and complications. Neonatal Netw. 1998;17:23-28.
4. Groell R, Schaffler GJ, Rienmuller R. The peripheral intravenous cannula: a cause of venous air embolism. Am J Med Sci. 1997;314:300-302.
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5. Waggoner SE. Venous air embolism through a Groshong catheter. Gynecol Oncol. 1993;48:394-396.
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SECTION EDITOR: BEVERLY P. WOOD, MD
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