Legal Briefs: Venous Catheter Tips Need to Stay Out of the Heart

EDITOR’S NOTE

The Legal Briefs feature is based on actual malpractice cases with opinions of the plaintiff and defense physician experts interspersed throughout the case. The format of this feature does not provide evidence that supports or refutes each of these opinions.

Case 1

A 1,190-g male infant who was one of triplets was born at 27 3/7 weeks’ gestation to a 35-year-old gravida 3, para 3 woman. The pregnancy was notable for conception by in vitro fertilization, hospitalization for premature rupture of membranes, and administration of a complete course of antenatal steroids. Because of a prolapsed cord, the triplets were delivered by emergent cesarean section with rupture of membranes 31 hours before birth. The infant had Apgar scores of 6 and 8 at 1 and 5 minutes, respectively. He needed positive pressure ventilation briefly, and was placed on continuous positive airway pressure (CPAP) for mild respiratory distress. Evaluation after birth included a complete blood cell (CBC) count, which was unremarkable, and a blood culture that was negative. The neonatology team placed umbilical arterial and venous catheters. Antibiotic treatment was not started. On day 2, gavage feedings were initiated; on day 3, cranial ultrasonography was performed, the result of which was unremarkable; on day 4, the umbilical arterial catheter was removed; and on day 10, the umbilical venous catheter (UVC) was discontinued.

Over the course of the following 6 weeks, the infant had intermittent abdominal distention with occasional emesis; abdominal radiography was inconclusive for necrotizing enterocolitis (NEC) or bowel obstruction. Because of feeding intolerance, parenteral nutrition was started at 5 weeks via a percutaneous intravascular central catheter (PICC) placed in the right femoral vein. Radiography showed that the tip of the PICC was deep in the right atrium and it remained there. The plaintiff neonatologist was critical of the catheter not being …