|Year : 2014 | Volume
| Issue : 6 | Page : 793-796
Hepatic necrosis due to the umbilical vein catheter malposition: A case report with review of literature
Sanjay Mhalasakant Khaladkar, Aditi Gujarathi, Vilas Moreshwar Kulkarni, Amarjeet Singh
Department of Radio-diagnosis, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, India
|Date of Web Publication||18-Nov-2014|
Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune
Source of Support: None, Conflict of Interest: None
A preterm infant was admitted to the neonatal intensive care unit because of prematurity and respiratory distress syndrome. An umbilical venous catheter (UVC) was inserted for central line access and for giving total parenteral nutrition and antibiotic therapy to the patient. UVC tip location was confirmed with X-ray and was removed after 10 days. She was referred for ultrasonography abdomen for persistent fever. Ultrasound showed anechoic fluid collection in the center with peripheral mixed echoic solid lesion in left hepatic lobe along course ductus venosus suggestive of extravasated fluid with hepatic necrosis. Superadded infection could not be ruled out. Possibility of displacement of catheter during nursing care due to poor fixation was likely. The purpose of this case report is to create awareness of hepatic findings due to the umbilical vein catheter malposition.
Keywords: Hepatic necrosis, neonatal, total parenteral nutrition, umbilical vein catheter
|How to cite this article:|
Khaladkar SM, Gujarathi A, Kulkarni VM, Singh A. Hepatic necrosis due to the umbilical vein catheter malposition: A case report with review of literature. Med J DY Patil Univ 2014;7:793-6
|How to cite this URL:|
Khaladkar SM, Gujarathi A, Kulkarni VM, Singh A. Hepatic necrosis due to the umbilical vein catheter malposition: A case report with review of literature. Med J DY Patil Univ [serial online] 2014 [cited 2021 May 15];7:793-6. Available from: https://www.mjdrdypu.org/text.asp?2014/7/6/793/144888
| Introduction|| |
Umbilical venous catheterization (UVC) is a standard component of neonatal intensive care and fastest way of gaining access to a central line. Few complications have been described in the literature. Its advantages are provision of total parenteral nutrition (TPN), safe administration of drugs, elimination of stress, and pain connected with repeated puncture of peripheral veins. The reported rate of misplaced UVCs is in the range of 20-37%.  Hepatic complications are rare and life-threatening in preterm newborns.  Hepatic abscess in newborns is a rare disorder with <100 cases reported worldwide until date and a high fatality rate. 
| Case Report|| |
A preterm female was born to a primigravida at 32 weeks of gestation by normal vaginal delivery due to premature rupture of membranes with leak.
She was referred to the neonatal intensive care unit immediately because of prematurity and respiratory distress syndrome. The birth weight of the baby was 1200 g. The patient was subjected to nasal continuous positive airway pressure after receiving porcine surfactant. On day 1, the patient had hypoglycemia, fever, and respiratory distress with respiratory rate of 62/min and heart rate of 142 beats/min. The total leukocyte counts were raised (13,000 cm 3 ) and platelet counts were reduced. Umbilical vein catheterization was done for central line access and for giving TPN and antibiotic therapy to the patient. The position of the umbilical vein catheter tip was determined to be just above right diaphragm by a plain abdominal radiograph [Figure 1]. TPN and antibiotic were given 10 days. UVC was removed on 10 th day. On the following days, the fever was still present. Antibiotics were changed. Patient was sent for ultrasound of the abdomen for sepsis.
|Figure 1: Radiograph chest and abdomen showing normal position of UVC just above right diaphragm|
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Ultrasonography (USG) revealed a well-defined mixed echoic, predominantly hypoechoic lesion of size approximately 22 mm × 8 mm in the left lobe medial segment (segment IVa) along the course of ductus venosus. Its central portion appeared anechoic measuring approximately 6 mm × 1 mm [Figure 2]. Main portal vein, right and left portal veins and hepatic veins appeared patent with the normal flow pattern [Figure 3]. Rest of liver appeared normal. No ascites noted. A diagnosis of extravasation of fluid with hepatic necrosis was given. Superadded infection could not be entirely ruled out. Follow-up USG done after 3 weeks of antibiotic treatment showed near complete resolution of hepatic lesion [Figure 4].
|Figure 2: Longitudinal oblique (a) and transverse sections (b) of left hepatic lobe showing mixed echoic lesion measuring approx. 22.7 X 8.4 mm along course of ductus venosus and showing central anechoic|
component measuring 6.2 X 1.5 mm (c)
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|Figure 3: Colour Doppler image showing normal main portal vein, right and left portal vein (a) and normal hepatic veins and IVC (b)|
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|Figure 4: Follow up USG- transverse section of liver showing near complete resolution of necrosis in left hepatic lobe|
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There was no information on whether the catheter was mis-introduced during cannulation or displaced during nursing care due to poor fixation. The present case shows how dangerous may be the incorrect placement of the catheter tip.
Our case confirms the need of controlling a proper location of the central catheter right after its insertion and during hospitalization.
| Discussion|| |
UVC is done on the 1 st day of life. The procedure is short and simple and does not require general anesthesia. The tip of the cannula should be in the inferior vena cava (IVC), over the diaphragm. After catheterization, the position of the cannula should be confirmed with radiograph of the abdomen and chest. 
The UVC is passed through the umbilicus, umbilical vein, medial part of left portal vein, ductus venosus, left hepatic vein, IVC and into the right atrium. Ideal position of UVC is in the right atrium. On anteroposterior view the catheter curves slightly to the right within the liver, extends just above the diaphragm at the level of D9-D10. On lateral view, catheter is seen anteriorly traversing the liver assumes an 'S' shaped position before reaching the heart. 
Ideal catheter tip position is at the junction of the ductus venosus and the IVC just above or at the level of the diaphragm and outside the heart approximately D9-D10. 
Ideally, the tip of the UVC should lie at the junction of the IVC and the right atrium or just above the diaphragm. Optimal positioning of the UVC may not be possible all the time. In an emergency situation, it is easiest and safest to cannulate the umbilical vein, placing the end of the cannula just within the abdominal wall. For longer term use, it is best to place the end of the umbilical vein cannula in the vena cava above the liver. 
Central venous access in neonates is needed in first 14 days of life for administration of medication, parenteral nutrition and intravenous fluids, exchange or partial exchange transfusion, central venous pressure monitoring, frequent blood sampling in unstable patients without arterial access. The UVC catheter should be carefully secured on the skin, in order to avoid displacement or it's coming out. It is necessary to check on the location of the catheter tip after its insertion prior to administration of TPN and drugs. 
Contraindications are abdominal surgery requiring an incision above the umbilicus, infection (omphalitis, necrotizing enterocolitis, and peritonitis), abdominal wall defect (omphalocele gastroschisis umbilical fistula).
Umbilical venous catheterization is also associated with complications, which increases with an incorrect placement of the tip of the cannula. They are infection, thromboembolism, and thrombophlebitis.
Blood loss from umbilical stump and accidental disconnection of UVC, malposition in heart and great vessels (perforation through the heart muscle, pericardial effusion/cardiac temponade, cardiac arrhythmia, thrombotic endocarditis, hemorrhagic infarction of lung, hydrothorax), UVC malposition in the portal system (necrotizing enterocolitis, perforation of colon, hepatic necrosis, hepatic cysts, portal hypertension, vascular perforation, UVC rupture, transaction or fragmentation and migration of fragmented UVC. ,
Hepatic fluid collection is reported as a rare, serious complication of UVC malposition. Catheter type, tip of the catheter and osmolarity of infused solutions are suggested as etiologic factors for hepatic fluid collection.
Infusion of hypertonic fluids into the liver tissue may lead to a substantial damage of the liver parenchyma or its necrosis. When being introduced, the catheter frequently moves toward the liver, through the portal vein. It should be removed immediately. If left in a hepatic vessel (usually due to ignorance of its incorrect location) results in many serious complications that may put the newborn's life at risk. Thromboembolic complications are the most common which may lead to portal hypertension. Direct administration of concentrated infusion fluids, drugs or parenteral nutrition to liver parenchyma may in turn result in a damage of liver parenchyma due to a direct chemical irritation of the parenchyma and to a lower extent, in compression of normal tissues by extravasated fluid. In case of abdominal manifestations, thromboembolic incidence the catheter should be removed immediately. 
Radiologists should be familiar with the clinical and imaging features of the hepatic lesions seen with UVC erosion for prompt treatment to avoid catastrophic complications.
Because of hypertonic and alkaline nature of TPN formulations hepatic necrosis can occur due to contact of the catheter tip with the hepatic parenchyma.
Intraparenchymal liver lesions are seen in the expected course of the umbilical vein and ductus venosus. They are well marginated with hyperechoic rims and had heterogeneously hypoechoic centers with cystic components. This appearance was likely caused by separation of the TPN infuscate into a layer of fat peripherally and a central core of aqueous material. Varying appearance of hepatic lesions is related to the age of the lesion. Recent lesions appear cystic and hypoechoic, progressing to become hyperechoic on follow-up sonograms. Few may develop calcifications.
In late stages of hepatic necrosis due to extravasation of hyper alimentation with disruption of the liver capsule and spilling of the TPN into the peritoneal cavity can occur. TPN ascites initially may be simple without debris and septations.
In late stages, it is complex showing septations and debris and mimic ascites caused by bowel perforation secondary to necrotizing enterocolitis or intraperitoneal hemorrhage associated with hepatic erosion from UVC perforation. 
Hepatic abscess due to UVC malposition has a high mortality of 50-70%. UVC malposition rate at the first insertion attempt is reported as nearly 51%. There is increased risk of malposition to the portal vein when catheter tip is placed in sub diaphragmatic region. Even after confirmation of the catheter tip in an ideal position at first application, caregivers should be cautious about any signs of UVC complications during follow-up in NICU. UVC should be removed as soon as possible when there is no need of the catheter to prevent related complications. Liver abscess is uncommon but life-threatening event in the neonatal period. Endothelium of hepatic vessels can be damaged during infusion of parenteral nutrition or other hypertonic solutions if UVC is positioned improperly. Abscess formation is easier in culture medium provided by necrotic tissue and parenteral nutrition. ,,
The differential diagnosis includes abscesses, hemangioendotheliomas, hematomas from birth trauma, and hamartomas. Clinical history correlation can exclude the possibility of a hematoma from birth trauma and an abscess from history of necrotizing enterocolitis. Lack of peripheral hypervascularity on sonography can exclude the possibility of a hemangioendotheliomas. 
| Conclusion|| |
The UVC catheter should be carefully secured on the skin to avoid displacement. Location of the catheter tip should be checked after its insertion prior to administration of TPN and drugs. The purpose of this case report is to create awareness of hepatic findings due to the umbilical vein catheter malposition. Serial USG is suggested to rule out malposition of UVC during nursing care, even if its position is in the right place immediately after its placement.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]