TPN Peritoneal Extravasation

Umbilical venous catheters (UVC) in newborns provide intravascular access for administration of intravenous fluids, parenteral nutrition (TPN), drugs, transfusions and central venous monitoring especially for management of low birth weight infants. Improper placement of umbilical catheters  is associated with complications that may lead to morbidity and mortality. The tip of the umbilical venous catheter should be positioned at the junction of the inferior vena cava and right atrium just at or above the level of the diaphragm (T7 to T9). Also, adequate blood return must ne obtained before use. A normal positioned UVC between T7 and T9 can stay in use up to 14 days if intravenous access is in need, otherwise is advised to discontinue the UVC by day 10 and replace it with a percutaneously place intravenous central catheter. Improper placement of UVC can lead to intraperitoneal extravasation of TPN. This may also lead to vessel perforation or liver capsule disruption due to hepatic necrosis. The complication of intraperitoneal spillage has an insidious onset. The infant will develop abdominal distension, tenderness associated with acute pain, ascites, dehydration, hemoconcentration, characteristic induration of the abdominal wall due to infiltration of the soft tissue and acute renal failure from hypovolemia and hypertonicity of TPN. Abdominal ultrasound will demonstrate ascites. Paracentesis if performed reveals a cloudy fluid high in glucose, triglycerides and protein consistent with TPN. The differential diagnosis is chylous ascites with high chylomicrons and lymphocytes in a peripheral smear of fluid sample. Intraperitoneal TPN extravasation has also been reported after placement of femoral central a venous catheter. Management of TPN peritoneal extravasation should consist of catheter removal, paracentesis or peritoneal exploration to accomplished peritoneal lavage of the offending fluid. Prognosis is usually good if not associated with serious liver laceration with uncontrollable hemorrhage.

References:
1- Egyepong J, Jain A, Chow P, Godambe S: Parenteral nutrition--ascites with acute renal failure as a complication from an umbilical venous catheter in an extremely low birth weight infant. BMJ Case Rep. 2011 Apr 26;2011. pii: bcr0220113813. doi:10.1136/bcr.02.2011.3813.
2- Sztajnbok J, Troster EJ: Acute abdomen due to late retroperitoneal extravasation from a femoral venous catheter in a newborn. Sao Paulo Med J. 120(2):59-61, 2002
3- Adesanya O, Naqvi M: Term Neonate With Liver Laceration, Obstructive Uropathy, and Ascites-Secondary to Extravasation of Total Parenteral Nutrition: A Complication of Malpositioned
Umbilical Venous Catheter. Glob Pediatr Health. 2016 Oct 12;3:2333794X16670494. eCollection 2016.
4- Shareena I, Khu YS, Cheah FC: Intraperitoneal extravasation of total parental nutrition infusate from an umbilical venous catheter. Singapore Med J. 49(2):e35-6, 2008
5- Guzoglu N, Erdeve O, Yilmaz Y, Dilmen U: Intraperitoneal extravasation from umbilical venous catheter in differential diagnosis of neonatal chylous ascites. Acta Paediatr. 99(9):1284, 2010
6- Selvam S, Humphrey T, Woodley H, English S, Kraft JK: Sonographic features of umbilical catheter-related complications. Pediatr Radiol. 48(13):1964-1970, 2018



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