[Tamponade and total parenteral nutrition by central venous catheter]

Various complications are associated with the use of central venous catheters for total parenteral nutrition; cardiac tamponade is one of the most severe. Four cases are reported of cardiac tamponade during total parenteral nutrition: three of them were related to cardiac perforation by the tip of the catheter, placed in the right atrium; the fourth case may have been due to cardiac perforation or to an extraintestinal complication of inflammatory bowel disease. Hydropericardium may manifest itself soon after the catheter is inserted or, more usually, some days or weeks later. Immediate diagnosis is mandatory: a sudden and unexpected deterioration in a patient receiving total parenteral nutrition through a central venous catheter, with shock, heart failure, cyanosis, congestion of neck veins should arouse suspicion of hydropericardium. Long term undernutrition, a small atrophic heart, steroid treatment may also contribute to cardiac perforation. Immediate aspiration of the hydropericardium may be life-saving: if possible, the fluid is evacuated through the catheter while still in place; otherwise, pericardiocentesis must be immediately performed. Such complications can be prevented by: the use of flexible silicone or polyurethane catheters instead of rigid polyethylene catheters, especially for long term use; a correct positioning of the catheter tip in the superior vena cava in its extrapericardial sector, as it can be checked by chest X-ray. This examination, with opacification of the catheter with contrast medium, must be repeated because of the possibility of secondary displacement of the catheter.