Pleural effusion due to intra-abdominal extravasation of parenteral nutrition

Embryological, anatomical and clinical considerations on pleuroperitoneal communication

The pleural and peritoneal cavity share many related features due to their common celomic origin. Normally these two spaces are completely separated with the development of the diaphragm. Defects in diaphragm morphogenesis may result in congenital diaphragmatic hernias, which is the most known form of communication between the pleural and peritoneal cavity. However, in several cases, findings of pleuroperitoneal communication (PPC) have been described in adults through an apparently intact diaphragm. In this comprehensive review we systematically evaluate clinical scenarios of this form of "unexpected" PPC as reported in the literature and focus on the possible mechanisms involved.

Percutaneously Inserted Central Catheter-Related Pleural Effusion in a Level III Neonatal Intensive Care Unit: A 5-Year Review (2008-2012)

BACKGROUND

Although peripherally inserted central catheters (PICCs) provide vascular access in newborns who require parenteral nutrition and medications, they can be associated with complications that lead to significant morbidity and mortality.

OBJECTIVES

To describe the characteristics of pleural effusion (PLE) associated with PICC use in a large level III neonatal intensive care unit.

DESIGN/METHODS

A retrospective review of PICC-related PLE in newborns was conducted over a 5-year period, from 2008-2012.

RESULTS

A total of 926 PICCs were inserted, accounting for 17,606 catheter days. PICC-related PLE was identified in 7 infants, with an incidence of 0.4 per 1000 catheter days. Infants who developed PLE had a median gestational age of 28 weeks (range, 24-38 weeks) and birth weight of 735 g (range, 500-2975 g). PICCs were inserted at a median age of 4 days (range, 3-11 days). The median time from catheter insertion to the development of PLE was 16 days (range, 7-75 days). In all cases, the catheter tips were centrally located at the time of insertion but migrated to the subclavian veins or tributaries at the time of the events.

CONCLUSION

PICC-related PLE can be associated with the migration of PICC tips to noncentral locations, despite optimal positioning of the tip at the time of insertion. Attention should be paid to migration of catheter tips on subsequent x-ray films. For PICCs inserted via upper limb or scalp, serial follow-up x-rays, beginning 1 week after insertion, may be helpful to detect migration of catheter tips and identify patients at risk.

Heparin infusion to prevent umbilical venous catheter related thrombosis in neonates

OBJECTIVE

To investigate umbilical venous catheter (UVC) related thrombosis by Doppler echocardiographic evaluation of neonates infused with heparin or placebo.

METHODS

We conducted a prospective study to determine UVC-related thrombosis in term and nearterm neonates. Heparin or placebo (0.5 IU/mL) was infused at a rate of 1 mL/hr to the study and control group. Doppler echocardiography was performed at 1, 3, and 5 days after UVC insertion.

RESULTS

Forty-six neonates (63% males) with a mean gestational age of 38.2 ± 1.8 weeks, and a mean birth-weight of 2993 ± 563 grams were included. No UVC-related thrombosis was observed in the study group, which included 19 neonates. Among the 27 neonates in the control group, one neonate developed UVC-related thrombosis. There were no statistical differences between the groups for gestational age, birth weight, postnatal age, UVC duration, mortality, mechanical ventilation, and inotrope requirement, and hemagram or coagulation profile. The complications were as follows, mild pulmonary hemorrhage, 6.5% (3); leak-out, 4.3% (2); peritoneal leakage, 2.2% (1); occlusion, 2.2% (1); gastrointestinal findings, 6.5% (3); sepsis, 10.9% (5); and catheter-related thrombosis, 2.2% (1).

CONCLUSION

This study demonstrated that heparin infusion of 0.5 IU/mL through the UVC had no effect on catheter-related thrombosis in term and near-term neonates. Randomized controlled trials are necessary to conclusively evaluate the effect of heparin on UVC-related thrombosis.

Common etiologies of neonatal pleural effusion

BACKGROUND

Pleural effusion is rare and includes several disease entities in the neonatal period. The aim of this study was to investigate the etiology, management, and outcome of neonatal pleural effusions.

METHODS

We retrospectively collected all neonates who were admitted to the neonatal intensive care unit of Chung Shan Medical University Hospital, Taichung, Taiwan, with discharge diagnosis of pleural effusion, chylothorax, hydrothorax, hemothorax, and empyema, from January 1999 to December 2009. The characteristics, etiology, management, and outcome were analyzed.

RESULTS

There were 21 patients identified, 16 males (76%) and 5 females (24%). Eight patients (38%) had primary and 13 patients (62%) had secondary etiologies. The etiologies included four parapneumonic effusions or empyema (19%); nine chylothorax (42.8%) with four congenital and five iatrogenic after thoracic surgery; three percutaneously inserted central venous catheter extravasation (14%); one umbilical venous catheter extravasation (4.7%); three hydrops fetalis (14%); and one congestive heart failure (4.7%). Fifteen patients (71%) needed chest tube placement. Conservative management with complete cessation of enteral feedings and use of total parenteral nutrition followed with infant formula containing medium-chain triglyceride was successful in six of the patients (67%) with chylothorax. There were two patients (22%) with chylothorax who received somatostatin administration; one was successful and the other one failed. Thoracic duct ligation was performed uneventfully in two patients with acquired chylothorax. There were three mortalities (14.3%) in this study, which were related to causes other than pleural effusion.

CONCLUSIONS

Pleural effusions in the neonatal stage may result from chylothorax, hydrops fetalis, extravasation of percutaneously inserted central venous catheter, parapneumonic effusion, congestive heart failure, or other less frequently occurring conditions. Diagnostic chest tap is required for subsequent management. Good outcome is the rule except in hydrops fetalis, which carries high mortality rate.

Pleural effusion in a neonate

A premature neonate who developed respiratory distress in the first few days of life was found to have a pleural effusion, which reaccumulated following drainage. The effusion was demonstrated to be a chylothorax. He required multiple chest drains and was started on a medium chain triglyceride formula feed. This brought about a full resolution of the effusions and he made a complete recovery.