Right-sided pleural, pericardial, and intra-abdominal effusion as a complication of an appropriately placed umbilical venous catheter: a case report

Abstract

Background

Umbilical venous catheters are frequently used when treating premature and sick newborns, to provide central access to medications, fluid, and nutrition. Pleural, pericardial, and intra-abdominal effusions are rare but can be fatal complications in newborns after umbilical catheterization. This is the first reported case of simultaneous pericardial, pleural, and intra-abdominal leakage of parenteral nutrition from a properly placed umbilical venous catheter.

Case presentation

We present a case of a preterm infant of Northern European descent, born at gestational age of 29 weeks, with a birth weight of 890 g. She received a properly placed umbilical venous catheter shortly after delivery. On day 4 she became critically ill with respiratory failure and required ventilator support for 5 days. She was also hypotensive and received vasopressor treatment for 2 days. Owing to kidney failure and hyperkalemia, she required dialysis treatment for 6 days. She was diagnosed with pleural effusion on the right side, pericardial effusion, and intra-abdominal effusion. The drained effusions were biochemically analyzed and were found to be consistent with parenteral nutrition. After the effusions were drained, she remained hemodynamically stable and was discharged from hospital at 2 months of age. At discharge, her creatinine level was ~100 µmol/L, requiring outpatient follow-up. A cerebral ultrasound and neurological examination at term were normal.

Conclusion

Although rare, clinicians should remain vigilant for effusions involving pleural, pericardial, and abdominal spaces, even when umbilical venous catheter placement appears correct. Early recognition and intervention are critical to improving neonatal outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-025-05690-5.

Introduction

Umbilical venous catheters (UVCs) are frequently used to treat premature and sick newborns to provide central access to medications, fluid, and nutrition. The recommended position of the UVC tip is at the junction of the inferior vena cava (IVC) and the right atrium [1, 2]. UVCs may cause a variety of complications (for example, infections, thrombosis, and perforations) [3, 4]. In rare cases, both properly and improperly placed catheters are associated with pericardial, pleural, or intra-abdominal effusions, all potentially life threatening conditions [5, 6]. Previous reports have discussed vessel puncture or endothelial damage caused by hyperosmolar fluid as possible mechanisms [7, 8]. This is the first reported case of simultaneous pericardial, pleural, and intra-abdominal leakage of parenteral nutrition (PN) from a properly placed UVC.

Case presentation

A preterm female infant of Northern European origin was born at 29 weeks’ gestation with a birth weight of 890 g. She was delivered by cesarean section owing to maternal preeclampsia. Apgar scores were 8-9-9, at 1, 5, and 10 minutes, respectively. She presented with respiratory distress and was placed on continuous positive nasal airway pressure (CPAP). At 1 hour of life, her fraction of inspired oxygen (F_iO₂) was 30%, and a dose of surfactant (200 mg/kg) was administered by less invasive surfactant administration (LISA). A 5-French dual-lumen silicone UVC (Utah Medical Products) was inserted 4 hours after birth (Fig. 1). The UVC was inserted without complications, demonstrating adequate blood return and no resistance upon flushing. The position of the catheter tip was confirmed at the tenth thoracic vertebra accordant with the junction of the IVC and the right atrium by chest radiography prior to initiating PN (Baxter Numeta G13%E Preterm for nutritional care) and medication.

Fig. 1.

Chest X-ray after insertion of the umbilical venous catheter: normal cardiac silhouette. No pneumothorax or pleural effusion. The lung fields have symmetric granular opacification, and the catheter tip is at the tenth thoracic vertebra accordant with the junction of the inferior vena cava and the right atrium

Enteral feeding was introduced on the first day of life and gradually increased. During the first 2 days of life, the serum glucose level was elevated to 21 mmol/L. The carbohydrate concentration in the PN was reduced and the serum glucose level normalized. On day 3, she appeared dehydrated, with decreased urine output; total fluid volume was increased accordingly. In addition (day 3), a greenish abdominal aspirate was observed from the abdomen, and the feeds were discontinued. A septic screen was performed, and empirical treatment with penicillin (50 mg/kg/12 hours) and gentamicin (5 mg/kg/48 hours) was initiated.

The patient was stable on CPAP pressure of 6 cm H₂O without supplemental oxygen for the first 3 days of life. On day 4, she had episodes of apnea and required increased oxygen supply. She was intubated and connected to a conventional ventilator, and a second dose of surfactant (100 mg/kg) was administered. Premedication before intubation was administered through the UVC. The ventilator settings were volume guarantee of 5 mL/kg, positive end-expiratory pressure (PEEP) of 5 cm H₂O, and positive inspiratory pressure in the range of 18–21 of cm H₂O. A chest radiograph after the intubation showed haziness of the lung fields, and the UVC was shown in the same position now as when it was initially placed. After a few hours, she became hemodynamically unstable, and her oxygen requirement increased to 50–70%. Inotropic drugs (dopamine and epinephrine) were initiated, and transfer to a regional university hospital was arranged. During the next hours, she developed abdominal distention and discoloration, and she required increased respiratory and cardiovascular support. Ultrasound examinations were performed and revealed intra-abdominal, pericardial (Fig. 2), and right-sided pleural effusions.

Fig. 2.

Echocardiographic image demonstrating the presence of pericardial effusion

During the ultrasound examinations, the position of the catheter tip was confirmed at the junction of the IVC and the right atrium. We performed ultrasound-guided abdominal paracentesis (120 mL) and thoracentesis (20 mL), both yielding “milky” fluid (Fig. 3). The aspirated fluid appeared consistent with PN, and we therefore decided to remove the umbilical catheter. There were no indications of damage to the UVC. The cardiopulmonary status stabilized, and she was transferred to the University Hospital as previously arranged. Shortly after arrival, pericardiocentesis (13 mL) was performed, also yielding “milky” fluid.

Fig. 3.

“Milky” fluid from the abdomen

Biochemical analysis confirmed that the fluid originated from the PN solution (Table 1) [9]. The serum glucose level was around 9 mmol/L at the time the effusions were drained. Fluid with a milky appearance is usually suggestive of chylous effusion. However, in this case, biochemical analysis did not meet the chylus criteria. (Table 1) [9]. These findings confirmed that the fluid originated from the PN solution.

Table 1.

Biochemical analysis of the effusion and criteria for chylus. The content of the patient sample strongly differs from the composition of chylus

	Abdominal effusion from patient	Pleural effusion from patient	Pericardial effusion from patient	Criteria for chylus
Leukocytes (G/L)	0.046	0.033	< 0.1	> 1
Glucose (mmol/L)	50.7	51.5		2.7–11
Triglycerides (mmol/L)	15.6	12.5	5.6	> 1.1
Cholesterol (mmol/L)		0	< 0.1	1.7–5.7
Albumin (g/L)	3	3	< 2	12–41
Protein (g/L)	3	2.1		20–60
pH		7.4		7.4–7.8

The patient remained hemodynamically stable but developed signs of acute kidney injury. She received peritoneal dialysis for 6 days owing to hyperkalemia. She was hypotensive and received vasopressor treatment for 2 days and required ventilator support for 5 days. She was discharged from the hospital at 2 months of age with creatinine levels of ~100 µmol/L. Owing to kidney damage, she will continue follow-up at the pediatric outpatient clinic. Cerebral ultrasound and neurological examination at term were normal.

Discussion

Pleural, pericardial, or intra-abdominal effusions due to misplaced UVC have been previously described [3, 10, 11]. Single-space effusions as a complication of a properly placed UVC have also been described [5, 6, 12, 13]. Cardiac tamponade by UVC is rare but life-threatening and can occur even when the catheter is properly placed [3]. Perforation from the IVC to the pericardial cavity by the tip of the catheter is the most likely explanation [6, 7].

Kotinatot et al. report a case with properly placed UVC and pleural effusions [12]. They suggest line migration and hyperosmolar endothelial damage as two possible mechanisms, which may also be the causes in our case. The close anatomical relation of IVC and pleuropericardial cavities can explain the perforation of both cavities [5].

Hye et al. suggested two mechanisms of PN extravasation into the peritoneum from a misplaced UVC. Movement of the catheter tip combined with hyperosmolar PN can lead to vascular and liver erosion with extravasation of the PN. A low-positioned UVC tip inside the umbilical vein may also cause direct PN leakage via micropunctures of the vascular wall into the peritoneal cavity [14–16]. Leakage from the abdomen to the pleural space has also been reported [10].

To our knowledge, the combination of pleural, pericardial, and intrabdominal effusions has not previously been described, regardless of whether the UVC was correctly or incorrectly placed. Direct perforation at UVC insertion was less likely in our patient, owing to the high serum glucose levels in the first days. Erosion within the liver veins might be a possibility, but there was no ultrasound or biochemical evidence of liver damage. One possible mechanism is dissection and misposition of the catheter tip between the layers of the vessel wall and leakage along the vessel due to erosion. This may also explain the signs of dehydration 2 days before the patient became hemodynamically unstable.

This case highlights the critical importance of timely diagnosis of UVC complications. Clinicians should remain vigilant for signs of respiratory, circulatory, or gastrointestinal deterioration. In our patient, the routine use of point-of-care ultrasound could have enabled earlier detection [17].

Conclusion

The correct position of the UVC does not eliminate the risk of complications. The consequences can be fatal, and clinicians should be aware of the risk of intra-abdominal, pleural, and pericardial effusions even with correct UVC placement.

Author contributions

KVI and GW wrote the main manuscript text and prepared Figs. 1, 2, and 3. TØO prepared Table 1. JJ, TSO, PT, and TØO contributed to the conceptualization, supervision, and editing of the final manuscript.

Funding

Not applicable.

Data availability

No new data were generated or analyzed in this study.

Declarations

Ethical approval and consent to participate

Consent to participate was obtained from the patient’s parents.

Consent for publication

Written informed consent was obtained from the patient’s legal guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare no competing interests.