[Aseptic meningitis after intrathecal infusion of a parenteral nutrition solution: examples of rare malpositions of central venous catheters in preterm neonates].
BACKGROUND
Central venous catheters are an indispensable part of intensive care. In the management of preterm neonates, these are introduced after puncture of a peripheral subcutaneous vein. The catheters are supposed to be pushed forward with the venous flow. A chest X-ray is usually performed for verification of the position of the catheter. Localization of the tip of the catheter is often very difficult because of its extremely small diameter.


METHODS
A malposition of a central venous catheter resulting in intrathecal infusion of parenteral nutrition and subsequent aseptic meningitis in a preterm neonate is presented. Further cases of catheter malpositions leading to arthrography, arteriography and incorrect position in various parts of the venous system are discussed.


CONCLUSIONS
The case reports demonstrate that wire-guided central venous catheters are not only advanced by the forward blood flow but can also inadvertently end up in undesired sites and may thus induce serious side effects.
Wirbelauer
J
J
Universitäts-Kinderklinik Würzburg. wirbelauer_j@klinik.uni-wuerzburg.de
Singer
D
D
Darge
K
K
Speer
C P
CP
D002406:Catheterization, Peripheral / Q000009:adverse effects*; D005119:Extravasation of Diagnostic and Therapeutic Materials / Q000150:complications* / Q000517:prevention & control; D006801:Humans; D007231:Infant, Newborn; D007234:Infant, Premature; D007263:Infusions, Parenteral / Q000009:adverse effects; D007278:Injections, Spinal / Q000009:adverse effects* / Q000379:methods*; D008582:Meningitis, Aseptic / Q000175:diagnosis / Q000209:etiology*; D010288:Parenteral Nutrition / Q000009:adverse effects*