Pedro Jose Cruz Guzman, MD¹; Karen Lidsky, MD¹; William Hanna, MD¹*

(1)  Department of Pediatric Critical Care, Cleveland Clinic Children’s, Cleveland, Ohio, USA

*Corresponding Author:  Dr. William Hanna (email: hannaw@ccf.org)

Download article PDF – POCUS Journal 2025;10(2):21-23.

DOI: https://doi.org/10.24908/pocusj.v10i02.18439

Supplementary Material: S1, S2

Abstract

Peripherally inserted central catheters (PICCs) are commonly used in pediatric patients, but rare complications such as cardiac tamponade can occur. This case report describes a 5-month-old ex-premature infant who developed cardiac tamponade associated with PICC line malposition. Point of care ultrasound (POCUS) was used to diagnose and effectively manage the condition peri-arrest via emergent pericardiocentesis. The report highlights the role of POCUS in the prompt identification and treatment of hemodynamic deteriorations and posits potential utilization of POCUS as a tool in preventative surveillance.

Introduction

Peripherally inserted central catheters (PICCs) are extensively utilized in pediatrics for long-term therapies including nutrition, chemotherapy, and antibiotics due to their ease of insertion, low insertion related complications, and lower costs [1,2]. Despite their advantages and safety, PICCs still remain prone to occlusion, thrombosis, infections, migrations, and—rarely— pleural or pericardial effusions [3]. Cardiac tamponade related to PICC line malposition is a rare yet serious complication, with neonatal studies suggesting an incidence ranging from 0.049% to 1.5% and a mortality as high as 50%. Despite its rarity, the consequences can be devastating and require prompt diagnosis and management [3-5].

Within acute care pediatric settings, the use of point of care ultrasound (POCUS) continues to expand beyond standard procedural applications such as central venous access. More recent applications in the literature are extensive, including effective placement and surveillance of PICC line tip position and as a diagnostic tool in better characterizing and managing undifferentiated shock states [6-10].

This case report describes a pediatric case of cardiac tamponade related to PICC line malposition and highlights the unique role of POCUS for both acute diagnosis and management, and potentially as a mode of surveillance in early diagnosis of these complications.

Case presentation

A 5-month-old ex-34-week, infant girl was initially admitted to an outside hospital with new onset acute liver failure. Her initial clinical course following transfer involved supportive care including mechanical ventilation and nutritional support along with an extensive diagnostic evaluation, being managed in the pediatric intensive care unit by a multidisciplinary team including pediatric gastroenterology, hematology, nephrology, and palliative care.

On day 3 of admission, a decision was made to place a PICC line given the need for ongoing antibiotics and total parenteral nutrition. Access was obtained via the right basilic vein using fluoroscopic guidance, placing a 4 French double-lumen catheter that was cut at the 15 cm mark. The tip of the PICC was confirmed with fluoroscopy and post-PICC chest x-ray to be in an appropriate position (SVC/RA junction), with the patient transferred back to the pediatric intensive care unit in stable condition.

Her respiratory status improved within the next 4 days following PICC placement, leading to her extubation. Within the subsequent 24 hours, she developed tachycardia, tachypnea, hypoxemia and decreased perfusion with no improvement, despite using non-invasive ventilation (HFNC, BiPAP). This necessitated re-intubation that resulted in a very brief period of improved perfusion and vital signs. Within the next 10 minutes, however, she became acutely hypotensive of unclear etiology, degenerating into pulseless electrical activity (PEA) arrest requiring cardiopulmonary resuscitation (CPR). During a scheduled compression pause within the first 10 minutes, POCUS was performed by an experienced pediatric intensivist utilizing the GE Venue Ultrasound system (Chicago, Illinois, USA)  with 6S phased array transducer over the subxiphoid area. This generated a cardiac subcostal window that exhibited a massive circumferential pericardial effusion with right ventricle collapse throughout the cardiac cycle and pseudo-PEA. A 21 g 7 cm needle was used with syringe and direct image guidance to evacuate 50 mL of cloudy fluid from the pericardial space. This caused the immediate return of spontaneous circulation with minimal residual pericardial effusion. A temporary 20 g 1 ¾ inch catheter was then placed with a subsequent brief period of clinical stabilization. Shortly after establishing additional arterial and venous access via intraosseous line, she was noted again to show signs of severely low output state. POCUS imaging confirmed the re-accumulation of a large circumferential pericardial effusion that was evacuated in similar fashion with stabilization of hemodynamics. With concern for PICC line malfunction being actively raised, a bedside cardiac bubble study was then performed through the PICC line. This revealed bubbles extravasating from the right atrium directly into the pericardial space (see video 1). Visualization of the PICC line with the catheter in the low right atrium and projecting in the direction of the tricuspid valve (see video 2) suggested the malpositioned PICC line as the cause of a likely intracardiac perforation. She developed a second PEA arrest lasting one minute, which occurred immediately after placement of the definitive pericardial drain. Surveillance POCUS confirmed that the event was unrelated to pericardial fluid reaccumulation. The PICC line was removed and post-cardiac arrest protocols were followed.

Discussion

Our case represents one of the rarest and most severe complications associated with PICC line placement and highlights the unique role that POCUS may play in diagnosing, managing, and potentially preventing PICC line-associated cardiac tamponade. 

Recent pediatric and neonatal evidence-based guidelines recognize the value and role of POCUS in further characterizing low cardiac output states, including assessment of ventricular function, intravascular volume status, and life-threatening conditions such as pulmonary hypertensive crises and pericardial tamponade [9]. Within pediatrics, focused cardiac ultrasound has been shown to influence the practitioner’s characterization of hemodynamics, although robust clinical outcome data remains lacking. However, recent adult literature suggests that appropriate utilization of POCUS in shock may positively impact mortality, lactate clearance, and the duration of vasoactive needs, among other parameters [11].  This case highlights a clear proof-of-concept instance of POCUS use in pediatrics as a time sensitive, question-focused adjunct that directly affected patient outcome. POCUS utilization helped with characterizing and treating tamponade, isolating the specific etiology of the tamponade, and reassessing for recurrence during repeated episodes of clinical deterioration. This instance and others within the literature may serve to further strengthen the claim that POCUS, when used by the right person, for the right indication, and at the right time, can function as a powerful and necessary tool in critically ill pediatric patients  [12,13].

Besides recognizing and managing acute clinical changes, POCUS may have an equally important role in surveillance and prevention of PICC-related complications. Prospective studies, such as those by Lin and Katheria, suggest pediatric POCUS use during PICC line placement optimizes PICC tip position and reduces both time for successful placement and need for repeated radiography when compared to standard approaches to placement [14]. Despite optimal placement, it is thought that up to 24% of PICC lines migrate within the first 24 hours following insertion in neonates and small infants. Moreover, while full consensus may not exist regarding optimal catheter tip position, vascular perforation has still been described for catheters with tips outside of the cardiac silhouette. Potential proposed mechanisms include chronic friction, which can result in vascular wall compromise, especially in neonates and small infants whose thin vascular walls and fast heart rates may further predispose them to such events [2,15]. Studies like Trinh HT et al. advocate for the use of emergent bedside POCUS for unexplained clinical deterioration post-PICC placement and to surveil tip position or other subclinical findings twice weekly. While standard recommendations regarding POCUS surveillance are lacking, given the high mortality of such complications and minimal risk and time associated with POCUS surveillance, we would agree with regular proposed surveillance checks as a preventative measure in high-risk neonates and infants [5].

Conclusion

This case serves as a reminder of the potential hazards associated with PICC lines in pediatric patients and the potential that POCUS offers as a lifesaving diagnostic and therapeutic tool for PICC line-associated cardiac tamponade. The adoption of POCUS both during clinical deteriorations and potentially in routine clinical surveillance for higher risk patients may improve patient safety and healthcare outcomes.

Ethics Statement

This case report was carried out in full compliance with ethical research guidelines. Informed consent to publish was obtained by the legal guardians prior to publication, and measures were taken to safeguard the privacy and maintain confidentiality of the data presented.

Disclosure

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors declare they have no financial interests.

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