Hepatic Laceration due to Umbilical Venous Catheter Malpositioning

An umbilical venous catheter (UVC) was introduced in a 1853-g, preterm neonate suffering from hemolytic icterus, and its position was checked radiologically (Figure 1A). At 60 hours of life, a blood transfusion was administered because of a drop in hematocrit from 42%, at birth, to 25%. The baby was in good condition; however, a slight oliguria was noted on Day 6, suddenly followed by apnea, bradycardia, and marked hypotension. Hematocrit dropped to 14%, and cardiopulmonary resuscitation was performed without any recovery. The postmortem radiological examination, performed by ultrasound, computed tomography, and magnetic resonance imaging, indicated the presence of a 51 mm×11 mm subcapsular hematoma extending along the upper-anterior edge of the liver, where there was a small capsular laceration. An intraparenchymal 2.5 mm nodular-like area with irregular edges was observed next to the vascular pedicle, shown as hyperechogenic by ultrasound, dishomogeneously hypodense by computed tomography, and dishomogeneous isointense by magnetic resonance imaging in both the T1- and T2-weighted sequences, with some hyperintense gaps. Postmortem examination revealed 21 mL of free abdominal blood and a hepatic subcapsular hematoma on both the hepatic lobes (Figure 1B and C) that broadened deeply into the parenchyma (Figure 1D). The tip of the UVC was inside the liver (Figure 1E). Histological examination confirmed a subcapsular hematoma with capsular laceration (Figure 1F) and an intraparenchymal hemorragic collection with interruption of the wall of an intrahepatic vein. The use of UVC is essential in neonatal care.1Anderson J. Leonard D. Braner D.A. Lai S. Tegtmeyer K. Videos in clinical medicine. Umbilical vascular catheterization.N Engl J Med. 2008; 359: e18Crossref PubMed Scopus (46) Google Scholar, 2Yiğiter M. Arda I.S. Hiçsönmez A. Hepatic laceration because of malpositioning of the umbilical vein catheter: case report and literature review.J Pediatr Surg. 2008; 43: E39-E41Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Because of the risk of ominous complications due to inappropriate placement, knowledge of proper pathway and tip localization is imperative.1Anderson J. Leonard D. Braner D.A. Lai S. Tegtmeyer K. Videos in clinical medicine. Umbilical vascular catheterization.N Engl J Med. 2008; 359: e18Crossref PubMed Scopus (46) Google Scholar, 2Yiğiter M. Arda I.S. Hiçsönmez A. Hepatic laceration because of malpositioning of the umbilical vein catheter: case report and literature review.J Pediatr Surg. 2008; 43: E39-E41Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 3Oestreich A.E. Umbilical vein catheterization – appropriate and inappropriate placement.Pediatr Radiol. 2010; 40: 1941-1949Crossref PubMed Scopus (32) Google Scholar The inferior vena cava/right atrium confluence is a preferred position for the tip of the catheter. A fairly common but inappropriate position is in the umbilical vein recess from which half or more of the injected fluid is likely to enter the portal system and the catheter may migrate into the liver.3Oestreich A.E. Umbilical vein catheterization – appropriate and inappropriate placement.Pediatr Radiol. 2010; 40: 1941-1949Crossref PubMed Scopus (32) Google Scholar A UVC near midline and straight on a frontal radiograph is not reassuring. A lateral radiograph is imperative in this common, and even dramatic, error.3Oestreich A.E. Umbilical vein catheterization – appropriate and inappropriate placement.Pediatr Radiol. 2010; 40: 1941-1949Crossref PubMed Scopus (32) Google Scholar The authors declare no conflict of interest.