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Back to Journal »Neonatology Research and Report» Volume 11

Acute Management of Total Parenteral Nutrition (TPN) Abdominal Extravasation in Very Premature Infants: Case Reports and Literature Review

Author Majid A, Barrett J, Meyer MP

Published on November 27, 2021, the 2021 volume: 11 pages 77-81

DOI https://doi.org/10.2147/RRN.S325774

Single anonymous peer review

Editor who approved for publication: Dr. Robert Schelonka

Atif Majid, Jonathan Barrett, Michael P Meyer Neonatal Intensive Care Unit, Middlemore Hospital, Auckland, New Zealand Communications: Michael P Meyer Neonatal Intensive Care Unit, Middlemore Hospital, 100 Hospital Road, Otahuhu, Auckland, New Zealand Phone +64 21 714 190 email [email protection] Purpose: Because of the ease of insertion and long-term vascular access, the use of umbilical cord catheters is a standard practice in neonatal intensive care units. Complications of umbilical venous catheters, including total parenteral nutrition (TPN) extravasation, are rare, but once they occur, mortality and morbidity can be high. Umbilical venous catheters will move over time and their position may change, so high suspicion should be maintained. Our purpose is to describe a case of parenteral nutrition extravasation and review the medical literature. Patients and methods: case report. Results: The baby was born at 28 weeks of gestation (1510 grams). On day 6, he developed non-specific abdominal distension, hypotension, worsening breathing, metabolic acidosis, and became critically ill. Due to the misplacement of the umbilical venous catheter, the radiology and ultrasound results were consistent with TPN ascites. A bedside paracentesis without laparotomy was performed. Despite the ups and downs, the baby recovered and the liver damage combined with hyperbilirubinemia improved within a few months. Conclusion: Emergency bedside ultrasound and extubation may save lives and avoid caesarean surgery for premature infants who are already severely unwell. Keywords: total parenteral nutrition, extravasation, ascites, umbilical venous catheter in premature infants, medical treatment

Since 1947, placement of umbilical vein and arterial catheters in neonatal intensive care units has been common practice. 1 A properly placed umbilical venous catheter (UVC) is a convenient way to ensure central venous access and has many advantages compared with peripheral venous cannulation. UVC enables the use of higher osmotic pressure fluids, such as total parenteral nutrition (TPN), to safely administer drugs such as inotropic drugs, and to eliminate the pressure and pain associated with repeated peripheral venipuncture. 2 Although this is a relatively easy procedure to perform, previous experience with UVC placement has shown that the ideal catheter tip position (the upper boundary of T8 to the lower boundary of the T9 vertebral body) is not reached in approximately 31.9% of cases. 3 Unfortunately, these central venous catheterization procedures are also associated with many complications. These include blood-borne catheter-related infections, blood loss during catheter insertion or catheter separation, air embolism, catheter tip displacement, thromboembolic complications, pericardial tamponade, arrhythmia, and pericardial or pleural effusion. 4-9 Although considered uncommon, ultrasound has noticed complications such as air in the portal system (20%), portal vein thrombosis (6%), and liver disease (7%). 8 Improper position of UVC can cause hypertonic parenteral nutrition to leak into the liver tissue, severely damage liver parenchyma, liver necrosis and ascites. 4-6,10 It is important to place the umbilical vein catheter correctly to avoid the above-mentioned catheter-related complications. When the position on the X-ray is uncertain, point-of-care ultrasound (POCUS) can be used to determine the position of the catheter tip relative to the portal system, inferior vena cava (IVC), and heart. In a prospective study of 65 very low birth weight infants, when POCUS reconfirmed the catheter tip position, only 38% of the catheter tip was in the optimal position. According to reports, the catheter shifted up to 50% in the first week after birth. %. 3, 11 Active monitoring of the tip position of the catheter, through X-rays or POCUS if professional knowledge is available, is essential to prevent (or help early identification) of UVC extravasation. 3 This was emphasized in a recent study, where a 4-day-old newborn at 24 weeks' gestation developed solitary ascites. POCUS shows that the UVC is not positioned properly. Removing the UVC can quickly resolve the symptoms and prevent any complications. 12

A baby boy was delivered vaginally at home after 28 weeks and 6 days of natural premature, weighing 1510 g. Pregnancy with gestational diabetes. Based on the history of unattended family births, the baby's Apgar scores at 1 minute and 5 minutes are 9 and 9, respectively. He was transferred to the neonatal ward by ambulance when he was 1 hour old; his pulse oximetry was 99% and his core temperature was 35.9°C. Due to respiratory distress, nasal continuous positive airway pressure (CPAP) was started with room air through the Hudson fork (Teleflex Medical, Wellington, New Zealand) under 7 cm H2O. He also received caffeine, probiotics and short-term antibiotic treatment according to the unit guidelines.

The tip of the dual-chamber UVC (Argyle 5Fr, Covidien Auckland, New Zealand) was inserted below the diaphragm at the level of the T9 thoracic spine, and this position was accepted after discussion with radiology (Figure 1). Started to use standard TPN solution and Vitalipid (Biomed, Auckland, New Zealand), and graded to 160 mL/kg/d, and intravenously injected 3 g of lipids. Enteral feeding (expressed breast milk) starts on the 2nd day and is graded to 48 mL/kg/d on the 7th day, and the TPN is reduced accordingly. Figure 1 (A and B) anteroposterior and lateral radiographs show that the initial umbilical vein catheter is positioned at the level of the 9th thoracic vertebra. Adjusted the position of the umbilical artery line.

Figure 1 (A and B) anteroposterior and lateral radiographs show that the initial umbilical vein catheter is positioned at the level of the 9th thoracic vertebra. Adjusted the position of the umbilical artery line.

On the 6th day, the infant developed respiratory distress and decreased saturation and needed to restart CPAP treatment (which had been stopped the day before), and the condition deteriorated. In the next 4-6 hours, his clinical symptoms worsened, his paleness worsened, hypotension (blood pressure 26/12 mmHg, average 20 mmHg), obvious abdominal distension, and metabolic acidosis (pH 7.07, PaCO2 6.6 kPa, Alkaline excess-17), hyperglycemia (23.2 mmol/L) and hyponatremia (124 mmol/L). Stop feeding and get an abdominal X-ray. The differential diagnosis at this time includes necrotizing enterocolitis, sepsis, or other acute abdomen such as volvulus. The X-ray showed the same picture as the abdominal effusion, abdominal distension, insufficient intestinal gas, and the tip of the catheter in the shadow of the liver (Figure 2). Ultrasound of the abdomen at the bedside confirmed the presence of ascites, and the overall condition was consistent with TPN extravasation/ascites. Figure 2 Supine abdominal radiograph showing abdominal distension and lack of abdominal gas (note that the umbilical vein catheter is now misplaced, between T9 and T10).

Figure 2 Supine abdominal radiograph showing abdominal distension and lack of abdominal gas (note that the umbilical vein catheter is now misplaced, between T9 and T10).

As the patient was in critical condition and there was no pediatric surgery support on site, emergency bedside treatment was performed. Remove the UVC and use the No. 17 cannula to perform ascites puncture in the right iliac fossa after the local anesthetic infiltration; take out 105 mL salmon pink liquid, and the abdominal distension is significantly reduced. Starting antibiotics requires active resuscitation, including elective intubation, mechanical ventilation, and cardiovascular support. A bolus of epinephrine was given for hypotension, followed by a fluid bolus, epinephrine and dopamine infusion, and red blood cell infusion (15 mL/kg; hemoglobin 108 g/L). The coagulation screening showed that the activated partial thromboplastin time was normal, the prothrombin ratio was 1.7, and the fibrinogen level was normal. These measures improved blood pressure, blood gas and urine output. Inotropic drugs were gradually discontinued over the next 48 hours, and the infant was extubated to CPAP. The glucose concentration of the abdominal aspirate was 56 mmol/L, the protein was <10 g/L, the red blood cells were 53×109/L, and the white blood cells were 2.1×109/L.

Subsequent abdominal ultrasound showed a complex accumulation of fluid centered on the right lobe of the liver (3×4×4 cm), with a hyperechoic avascular edge, which may reflect liver parenchymal damage (Figure 3). There are iso-echoic substances in the renal pelvis of both kidneys, accompanied by slight swelling, and hemorrhage is suspected. Liver function tests showed that the level of aspartate aminotransferase (AST) rose moderately to 512 U/L, but subsided within 4 days; similarly, alanine aminotransferase (ALT) and gamma glutamyl transpeptidase (γ GT) There was also a slight temporary increase in levels. Conjugated hyperbilirubinemia occurred, the highest level was 90 µmol/L at 5 weeks after the acute event, and the total bilirubin level was 109 µmol/L. By 3 months, the bilirubin level was normal. Except for the small, irregular, avascular area with increased echo in the right lobe, continuous ultrasound shows the resolution of the intrahepatic collection (Figure 3). One month after the initial scan, the renal ultrasound was normal, but there was still a small amount of free fluid in the abdominal cavity. Figure 3 (A) The lateral scan of the liver shows cavitation and hyperechoic edges. (B) Longitudinal liver scan shows the extent of lesions and separation (the distance between the markers is 42 mm). (C) A cross-sectional liver scan 2 months after the injury showed a small residual area (approximately 1 cm in size) in the right lobe of the liver.

Figure 3 (A) The lateral scan of the liver shows cavitation and hyperechoic edges. (B) Longitudinal liver scan shows the extent of lesions and separation (the distance between the markers is 42 mm). (C) A cross-sectional liver scan 2 months after the injury showed a small residual area (approximately 1 cm in size) in the right lobe of the liver.

Due to the extravasation of TPN fluid into the liver, and then obvious abdominal ascites, the premature baby's condition deteriorated sharply. Although treatment may involve laparotomy for diagnostic and therapeutic reasons, 4,10 urgent bedside treatment is required in this case. Many successful cases have been described,2,11 and therefore, in the case of possible diagnosis, abdominal paracentesis can be considered as a less invasive alternative to laparotomy. There is uncertainty as to whether UVC removal will increase the risk of bleeding. As far as we know, compared with laparotomy, there are no reports of this happening after bedside resection. In one case series, all 4 babies improved after being taken out at the bedside. 11

The invisibility of TPN accumulation is indicated by the fact that the amount of fluid removed will be infused within 24 hours or more, although there may be blood and exudate in the total amount.

The proper location for UVC is above or horizontally on the diaphragm (T7-T9) between the inferior vena cava and the right atrium after passing through the portal venous system and venous catheter. 7-10 There is a problem that UVC is in the liver when it is below the diaphragm (T10 or below). Although this position was critical in this case (T9), it was accepted based on radiological opinions. Repeated abdominal radiographs show that the tip has migrated to T11, but whether this is new or due to bloating is unclear. The confirmation of the UVC position is usually done by X-ray inspection of the front and back and side films. However, a recent study showed that the location of UVC in premature infants by X-rays is usually inaccurate, and ultrasound is increasingly used, 11 although this is not standard practice in many neonatal wards.

In terms of the nature of the injury, the tip of the catheter can directly damage the blood vessel wall (mechanical micro-injury), causing the TPN solution to leak directly to the peritoneum. 13 In addition to mechanical micro-injuries, hypertonic TPN fluid can also cause portal vein thrombosis and liver necrosis. TPN fluid leaks to necrotic foci, damaged sinusoids and subcapsular veins. 2 The fluid is likely to collect under the liver capsule, and then penetrate into the peritoneum, and may cause complex ascites with diaphragm and debris. 14 This mechanism of catheter misalignment leading to vascular damage and subsequent extravasation and ascites has also been reported. 2 Although the liver lesions and biochemical abnormalities were resolved in this case, the follow-up time so far is 6 months, which is the limitation of the report.

This case emphasizes the fact that as long as acute abdominal distension occurs in the presence of UVC, catheter-related complications must be considered. In the literature, dislocation is considered to be the most common UVC-related complication and the most important risk factor for extrahepatic extravasation. 15 Bedside ultrasound examination is a valuable auxiliary investigation to confirm the position of the UVC tip, especially when the information of standard X-rays is uncertain. The clinical scope of extravasation damage varies greatly, from occult ascites to unexplainable biochemical parameters The changes to the rapid depletion of blood vessel volume and potentially catastrophic renal failure. 3 Abdominal puncture with removal of the catheter and active supportive treatment may save lives and may avoid the need for laparotomy. The resolution of liver damage was noticed within a few months.

The child’s parents have provided informed consent and written approval for the publication of this case report. The publication of case details does not require agency approval.

The author has no conflicts of interest or financial disclosures to declare, nor has he obtained funding for the report.

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