Pericardial parenteral nutrition infusion following acute angulation of a neonatal polyurethane central venous catheter tip

Life threatening cardiac tamponade developed in a premature infant due to perforation of theheart by a 2F central venous catheter used to administer parenteral nutrition. Abnormal orientation of the catheter tip preceeded the appearance of the pericardial effusion. Unusual angulation of the tip of central venous lines in premature infants may be an important warning sign of impending cardiac perforation and its potentially major sequelae and should therefore prompt immediate repositioning of the catheter.