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Recurrent bilateral pleural effusions secondary to superior vena cava obstruction as a complication of central venous
Insights
Central venous catheters can cause pleural effusions in infants due to superior vena cava obstruction. Sterilization methods may contribute to catheter-related complications like thrombosis.
Area of Science:
- Neonatal Medicine
- Pediatric Surgery
- Medical Device Complications
Background:
- Central venous catheters (CVCs) are essential for neonatal care but associated with complications.
- Pleural effusions are a rare but serious complication of CVC use in neonates.
- The pathophysiology of CVC-induced pleural effusions requires further elucidation.
Purpose of the Study:
- To describe a series of neonates who developed bilateral pleural effusions secondary to CVC use.
- To investigate the potential mechanisms, including venous obstruction and catheter material, contributing to these effusions.
- To evaluate the impact of catheter sterilization methods on fibrin deposition and potential thrombosis.
Main Methods:
- Case series of five neonates with bilateral pleural effusions following CVC placement.
- Clinical data collection including fluid analysis, imaging (venograms), and autopsy findings.
- In vivo animal study using Silastic catheters (gas-sterilized vs. autoclaved) to assess fibrin deposition via electron microscopy.
Main Results:
- Pleural effusions developed 7-19 days post-CVC placement/change, requiring frequent thoracenteses.
- Fluid analysis revealed transudate that became chylous with feeding.
- Venograms and autopsies showed superior vena cava obstruction with collateral drainage.
- Electron microscopy demonstrated significant fibrin deposition on gas-sterilized catheters, minimal on autoclaved ones.
Conclusions:
- Pleural effusions in this cohort resulted from thoracic lymphatic flow obstruction into the venous system.
- Superior vena cava thrombosis, potentially exacerbated by sterilization residues (ethylene oxide), is implicated.
- Autoclaved catheters showed reduced fibrin deposition, suggesting a safer sterilization method.
Abstract:
Five babies (birth weight 730 to 1,120 g) who developed bilateral pleural effusions as a complication of the use of central venous catheters are described. The effusions occurred seven to 19 days after initial placement or change of a central venous catheter. All required repeated thoracenteses to remove fluid accumulation of up to 200 mL/kg/d. The fluid was a clear transudate, but it became chylous when feedings were given. Venograms and autopsies demonstrated obstruction of the superior vena cava with drainage occurring through collaterals to the azygous vein and inferior vena cava. Silastic gas-sterilized catheters implanted in animals for four and 24 hours showed fibrin deposition when scanned by electron microscopy. No deposition occurred on autoclaved catheters after four hours and there was minimal deposition after 24 hours. It may be concluded that the pleural effusions resulted from obstruction of thoracic lymph flow into the venous system. Vena caval thrombosis may have been enhanced by 2-chloroethanol or ethylene oxide residues from gas sterilization of Silastic catheters.