|Year : 2018 | Volume
| Issue : 3 | Page : 166-169
Supraventricular tachycardia associated with umbilical venous catheterization in neonates
Ayman Sheta, Essa Hamdan Al-Awad, Amuchou Singh Soraisham
Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
|Date of Web Publication||2-Aug-2018|
Dr. Amuchou Singh Soraisham
Department of Pediatrics, University of Calgary, Alberta
Source of Support: None, Conflict of Interest: None
Umbilical venous catheters (UVCs) are commonly used central venous access in the Neonatal Intensive Care Unit, especially in very low birth weight infants. Chest and abdominal radiograph, taken soon after catheter insertion, is the most common method for confirming catheter tip position. UVC-related complications commonly result from catheter malposition; hence, it is important to determine the catheter tip position accurately. However, complacency when a UVC is initially normal positioned can lead to late detection of subsequent UVC-related complications. We describe two cases of supraventricular tachycardia related to UVC, despite the initial UVC was in optimum position. The use of point-of-care echocardiography helped in the diagnosis of catheter malposition and minimized further medical intervention. We suggest point-of-care ultrasound assessment at regular intervals in all infants with UVC to ensure that the catheter is maintained in the optimum position.
Keywords: Arrhythmia, echocardiography, neonates, supraventricular tachycardia, umbilical venous catheter
|How to cite this article:|
Sheta A, Al-Awad EH, Soraisham AS. Supraventricular tachycardia associated with umbilical venous catheterization in neonates. J Clin Neonatol 2018;7:166-9
|How to cite this URL:|
Sheta A, Al-Awad EH, Soraisham AS. Supraventricular tachycardia associated with umbilical venous catheterization in neonates. J Clin Neonatol [serial online] 2018 [cited 2019 Dec 15];7:166-9. Available from: http://www.jcnonweb.com/text.asp?2018/7/3/166/238395
Umbilical venous catheters (UVCs) are commonly used in the Neonatal Intensive Care Units (NICUs) for intravenous administration of parenteral nutrition, hypertonic solutions, blood products, and medications. The ideal position of UVC tip to minimize complications is just outside the heart at the junction of inferior vena cava and right atrium. Chest—abdomen radiograph is the most commonly used method for catheter tip localization in most NICUs worldwide. Previous studies showed that X-ray is really suboptimal in determining the UVC tip position., Bedside ultrasound detected a significant number of catheters predicted to be in an appropriate location by standard radiograph — to actually be inappropriately placed. For example, only 38% catheter tips that were identified as good position on radiograph were actually at optimum position on ultrasound.
UVC complications commonly result from catheter malposition; hence, it is important to determine the catheter tip position accurately. The complications of UVC include pericardial effusion, cardiac tamponade, pleural effusion, thrombosis, endocarditis, infections, diffuse liver injury, portal hypertension, and cardiac arrhythmias.,,,,,,, We report two cases of supraventricular tachycardia (SVT) associated with UVC migration and malposition in neonates that were diagnosed using point-of-care ultrasound and prevented further medical interventions.
A 950-g male infant was born at 26 weeks to a 36-year-old healthy mother by normal vaginal delivery. Apgar score was 4 and 7 at 1 and 5 min, respectively. He was intubated and given surfactant for respiratory distress syndrome. Umbilical catheters were inserted in the NICU, and chest and abdomen radiograph showed respiratory distress syndrome along with UVC and arterial catheter tip at the seventh thoracic vertebra [Figure 1]. UVC was pulled back by 1 cm following initial radiograph. He was extubated to nasal continuous positive airway pressure on day 3 and UAC was removed.
|Figure 1: Chest and abdomen radiograph showing umbilical venous and arterial catheter tip at the level of seventh thoracic vertebra at the time of insertion before manipulation|
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On day 5, sudden-onset tachycardia with heart rate of >260 beats/min was noted. His perfusion was good and the blood pressure was stable (63/45). An electrocardiogram (ECG) showed a narrow QRS complex tachycardia with a rate of 270 beats/min with absent P waves and no flutter waves, suggestive of SVT. Vagal maneuvers were tried initially through ice application over the face. Adenosine was administered at 0.1 mg/kg through UVC followed by a rapid normal saline flush, but the response was not sustained. Repeated doses of adenosine in increasing dosage were given, but there was no sustained response. Chest radiograph was ordered, and bedside point-of-care ultrasound was performed by the attending neonatologist while waiting for radiograph which revealed that the UVC tip was in the right heart. A chest radiograph also showed malposition of UVC inside the right atrium [Figure 2]. UVC was immediately pulled back by 4 cm and the 8th dose of adenosine was given and heart rate returned to normal sinus rhythm permanently. The baby remained well perfused with stable blood pressure. Complete echocardiogram showed structurally normal heart. There was no recurrence of arrhythmia during hospital stay, and he was discharged home at 37 weeks 4 days.
|Figure 2: Chest and abdomen radiograph at the time of cardiac arrhythmia showing umbilical catheter tip inside the right atrium|
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A term male infant weighing 2205 g was born to a healthy 23-year-old gravida 5 para 1 mother by emergency cesarean section for fetal distress. Antenatal ultrasound showed intrauterine growth restricted fetus with suspected vascular ring and suggested for postnatal echocardiogram. The baby had Apgar score of 6 and 9 at 1 and 5 min, respectively. Due to difficulty in establishing peripheral intravenous access, UVC was inserted to 9.5 cm and chest abdomen radiograph showed 13 pairs of ribs with UVC tip located at the level of seventh thoracic vertebra. UVC was pulled back by 1 cm and secured at 8.5 cm.
At 3 h of age, he developed tachycardia up to 280 beats/min. Vagal maneuver was applied and responded well. Adenosine was prepared ready at bedside if there was any recurrence. At 5 h of age, he had second episodes of tachyarrhythmia with heart rate of 270 beats/min briefly and resolved spontaneously. A third episode of tachyarrhythmia was noted briefly for 30 s. ECG done in between episodes showed sinus tachycardia with heart rate of 157 beats/min and right ventricular hypertrophy with nonspecific T wave abnormality. Bedside point-of-care ultrasound of the heart showed that UVC tip was in the right atrium almost reaching foramen ovale. UVC was withdrawn and no further episodes of arrhythmia occurred. The baby had complete echocardiogram and showed right-sided aortic arch with an aberrant left subclavian artery with good biventricular function. He was transfer to level II NICU on day 4 and subsequently discharged home on 10 days of age.
Cardiac arrhythmias are rare, life-threatening complications of UVCs in neonates. To the best of our knowledge, this is the first reported cases of cardiac arrhythmias associated with UVC migration that was diagnosed by bedside ultrasound performed by a neonatologist. The two most common arrhythmias associated with central lines include SVT and atrial flutter. More than 10 cases of cardiac arrhythmias associated with UVCs have been reported [Table 1].,,,,,, The proposed mechanism for central line-associated arrhythmia includes intracardiac central line disposition or atrial triggering to develop a re-entrant pathway.,, The presence of a catheter deep inside the heart with direct contact to the endocardium may predispose the patient to have premature atrial beats which may lead to SVT in the presence of an accessory pathway. da Silva et al. suggested direct mechanical distortion of the atria, predisposing to the development of reentry pathway.
|Table 1: Reported cases of Cardiac arrhythmia associated with Umbilical Venous Catheters*|
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Bedside point-of-care ultrasound has become an important diagnostic tool for the critically ill patients around the world. Until recently, most neonatal units relied on the chest radiograph for assessing the catheter tip position. However, ultrasound is far more accurate than radiograph for the detection of UVC position., Migration of catheter tip after initial insertion is common and reported in 17%—23% at 24—48 h, and up to 50% during the 1st week following insertion. It is possible that our first case had migration of catheter tip that resulted in the development of SVT and completely recovered after pulling out the catheter. The potential reasons for catheter migration include contraction of umbilical stump, changes in abdominal circumference, recurrent movement of affected limbs, and routine flushing and handling of catheter by nursing/medical staff. Therefore, correct initial positioning of the catheter tip on insertion does not preclude the central line as a cause for a subsequent arrhythmia, and serial imaging should be considered as a way of confirming catheter tip location. Understanding the potential for catheter migration and subsequent arrhythmia is also important as time to onset varies. While the majority of arrhythmias occur at the time of insertion, arrhythmia can occur hours or even days after insertion, as demonstrated by our first case which occurred on day 5.
Confirmation of arrhythmia types and determining catheter tip position are critical aspects of acute management. The catheter should be pulled back if it was discovered inside the heart. Vagal stimulation should be the first line of management for SVT, especially when the medical drugs for SVT are not ready for intravenous administration. This is followed by adenosine therapy. Synchronized cardioversion should be used to treat SVT in the presence of circulatory collapse. For infants with atrial flutter, synchronized cardioversion with or without transesophageal overdrive pacing are the only therapeutic options for infants with atrial flutter. We report these cases to highlight that UVC can migrate following initial placement and consideration should be given to serial imaging as a program to reduce catheter-related complications. High index of suspicion should be anticipated for early diagnosis and proper management of cardiac arrhythmias associated with central lines. Bedside point-of-care ultrasound is an invaluable tool for fast and accurate diagnosis of UVC-associated complications, especially tachyarrhythmia.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]