P2A357: Extensive Pleural Effusion – a Rare Complication of Peripheral Intravenous Catheter Infiltration in a Pediatric Patient – a Case Report

Introduction: Peripheral intravenous (IV) catheterization is a commonly performed procedure in hospitalized pediatric patients for the administration of intravenous fluids, drugs, nutrients and blood products. Complications associated with IV catheterization can occur including infiltration, occlusion and infections. The vast majority of IV complications are minor and require minimal intervention, however, we present a rare case in which severe IV infiltration led to bilateral pleural effusions, a pericardial effusion and respiratory failure requiring urgent tube thoracostomy.

Case Description: A 9-month-old female presented to the emergency department with 10 days of fevers and 5 days of worsening right sided neck swelling. She was diagnosed with lymphadenitis secondary to methicillin-resistant Staphylococcus aureus and treated with incision and drainage and IV clindamycin. Maintaining reliable IV access was persistently challenging, so an ultrasound guided IV was placed in the left upper arm. About 24 hours later, patient was noted to be in progressive hypoxic respiratory failure with oxygen saturations of 85% on room air. On examination, she had extensive left arm and anterior chest wall edema with significantly diminished breath sounds over the left thorax in addition to signs of respiratory distress: tachypnea, nasal flaring and costal retractions. Chest X-ray showed a bilateral pleural effusion (figure 1) and a small pericardial effusion present on echocardiogram. The patient was transferred to the pediatric intensive care unit, where a tube thoracostomy was performed, resulting in drainage of over 400 mLs of serous fluid. Laboratory analysis of fluid (table 1) was consistent with the patient’s maintenance fluids of dextrose and normal saline. Following unilateral drainage and IV diuresis, patient’s respiratory status improved, and residual effusions resolved.

Discussion: Bilateral pleural and pericardial effusions as a result of peripheral IV infiltration are not yet a reported complication of peripheral IV use in pediatric patients. The most common cause of pleural effusions in pediatrics is an infectious etiology although other causes include malignancy, trauma and heart failure. Given this patients discovery of pleural effusions as well as the results of the pleural fluid analysis, we hypothesize that an imbalance of Starling forces and possible remnants of embryologic connections account for the etiology. Abnormal connections between these spaces have been reported in the literature. Prevention and early recognition are essential to limit serious complications. Many hospitals have established protocols to prevent these injuries from occurring including frequent nursing examination of sites. Treatment includes immediate discontinuation of any infusions, aspiration of any remaining medication and administration of local antidote if indicated.

Conclusion: Pleural effusion secondary to peripheral IV infiltration is a rare occurrence but potentially life threatening. It is thus important to thoroughly assess all sites of vascular access in order to prevent and promptly recognize IV infiltrates and therefore avoid serious complications.