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ARTICLE: Todd T. Nowlen, Geoffrey L. Rosenthal, Gregory L. Johnson, Deborah J. Tom, and Thomas A. Vargo Pericardial Effusion and Tamponade in Infants With Central Catheters Pediatrics 2002; 110: 137-142 [Abstract] [Full text] [PDF]

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Successful treatment and prevention of acute neonatal cardiac tamponade due to feeding via a central

Ishaq Abu-Arafeh, Imran Ahmed and Katherine Lenton   (2 September 2002)

Pericardiocentesis with Pericardial Effusion

Todd T Nowlen   (9 October 2002)

Successful treatment and prevention of acute neonatal cardiac tamponade due to feeding via a central 2 September 2002
Ishaq Abu-Arafeh, Consultant Paediatrician Stirling Royal Infirmary, Striling, UK, Imran Ahmed and Katherine Lenton Send letter to journal: Re: Successful treatment and prevention of acute neonatal cardiac tamponade due to feeding via a central Iabuarafeh{at}sri.scot.nhs.uk Ishaq Abu-Arafeh, et al.	Nowlen et al. have rightly suggested that increased mortality rate in babies with pericardial effusion (PEC) may be related to late diagnosis in serverly ill child with cardiac decompensation. They have also shown that heightened awareness and education regarding the potential complications of central venous catheters (CVC) may help to reduce overall mortality. In our unit we treated to babies 6 months apart with similar problems but with different outcomes as a result of high index of suspicion of PEC. The first baby (girl) was born at 27 week of gestation with birth weight of 850 grams by emergency caesarean section for maternal hypertension. The mother was given pre-delivery dexamethasone for prophylaxis against neonatal respiratory distress syndrome. Early management included intubation and ventilation, endotracheal surfactant, umbilical artery catheterisation and intravenous antibiotics. On the second day of life a percutaneous central venous line was inserted in the right arm and its tip was visualised by plan X-ray at the lateral aspect of the right second rib. General condition and respiratory distress improved gradually. She was extubated 5 days later. On day 8, she was started on small feeds via a nasogastric tube. However during the same day she started to have frequent episodes of apnoea, hyperglycaemia and poor perfusion. She was screened for sepsis and was started on iv vancomycin as her earlier cultures of the tracheal secretions grew staphylococcus epidermidis. Her general condition continued to deteriorate and she was intubated and ventilated. Two hours later, she died suddenly following an unexplained collapse, profound bradycardia and failure to respond to active resuscitation. Post mortem examination showed massive (18 ml) pericardial effusion consisting of creamy fluid suggestive of parentral nutrition. There was no evidence of macroscopic cardiac rupture or perforation. The second baby (boy) was born at 26 weeks gestation with a birth weight of 880 grams. He was ventilated from birth for 16 days. On day 17, a long venous line was inserted in his left arm for the administration of parentral nutrition (TPN). An X-ray examination (without contrast) showed the long line tip at the medial end of the left clavicle. TPN and lipid infusions were commenced. His general condition was good and he only required supplemental oxygen via a nasal prong. On day 19 suffered a sudden unprovoked episode of profound apnoea and bradycardia. He was immediately resuscitated with bag and mask ventilation and external cardiac massage. He showed no improvement, as his heart rate remained at 40-60 per minute, his pulses were very weak and his oxygen saturation was between 50-60%. Within 3 minutes, he was intubated, ventilated and continued on external cardiac massage. Weak circulation was maintained, but with no significant overall improvement. Air entry was normal and chest transillumination did not show evidence of pneumothorax. Adrenaline 1:10000 was administered via tracheal tube followed by a second dose of 1:1000 after 3 minutes. He was given an infusion of Normal Saline (20mls/kg). His heart remained at 60-70 per minute with no clinical improvement. After 20 minutes of active resuscitation and poor response, pericardial effusion and temponade was suspected as the cause of the circulatory failure. Echocardiographic confirmation was not immediately available. Because of the deteriorating clinical condition, subxiphoid pericardial aspiration was performed using a butterfly needle and a 3-way tap. Six millilitres of creamy fluid was aspirated followed by an intracardiac injection of Adrenaline 1:10000 using the same needle with very good immediate response. He became stable within a few minutes and achieved normal perfusion, heart rate and oxygen saturation. Chest X-ray immediately afterwards with contrast revealed long line tip lodged deep inside the right ventricle. Long line was immediately removed. Chemical analysis of the aspirated fluid was confirmed as TPN with high triglyceride content. Echocardiography confirmed the normal cardiac anatomy, left ventricular function and the complete resolution of the pericardial effusion. The baby recovered completely and was extubated 5 days later. Follow up at age of 1 year showed no obvious adverse effect. The experience with these two cases confirms the importance of using radio-opaque catheters if at all possible. The position of the catheter tip should be confirmed before use and every 2-3 days afterwards. Pericardial effusion should be suspected, confirmed if possible, and aspirated immediately in any baby receiving parentral nutrition via a centrally placed venous catheter, and presenting with acute circulatory collapse that is not responding to normal resuscitation measures.
Pericardiocentesis with Pericardial Effusion 9 October 2002
Todd T Nowlen, Pediatric Cardiologist Arizona Pediatric Cardiology Consultants Send letter to journal: Re: Pericardiocentesis with Pericardial Effusion todddeb{at}msn.com Todd T Nowlen	I congratulate Dr. Abu-Arafeh, et al. for presenting yet more evidence that central line associated pericardial effusions are not an unusual or institution-specific phenomena. Dr. Abu-Arafeh demonstrates in case #2 that pericardiocentesis is life saving and should be considered in any patient with a central catheter with sudden decompensation. I also certainly agree with the importance of using radio-opaque catheters and routine surveilance radiograpy highlighted by Dr. Abu-Arafeh.