A46-46 When Dinner Hits the Pleura: Acute Respiratory Failure From Total Parenteral Nutrition Extravasation

Introduction Peripherally inserted central catheters (PICCs) are routinely utilized for total parenteral nutrition (TPN), and long-term intravenous therapy. Often preferred over traditional central venous catheters for ease of placement and perceived safety, complications such as infection, occlusion and misplacement can still occur. Venous perforation and subsequent TPN extravasation is a rare but life-threatening complication. Here we describe an unusual case of bilateral pseudochylous pleural effusions and acute hypoxic respiratory failure (AHRF) from TPN extravasation following PICC placement resulting in venous perforation. Case Report An 84-year-old female with history of stage II invasive transverse colonic adenocarcinoma status post en bloc resection of the stomach and end colostomy placement presented to the emergency room for intractable nausea and vomiting. CT abdomen demonstrated a markedly distended stomach suspicious for gastric outlet obstruction (GOO), as well as stable, left greater than right small to moderate sized bilateral pleural effusions. Following several days of high volume, bilious nasogastric output, the decision was made to proceed with gastrojejunostomy (GJ) tube placement. In the interim, a PICC was placed for TPN. A chest x-ray (CXR) confirmed the catheter tip within the left brachiocephalic vein. Before surgery, the patient became hypoxic requiring supplemental oxygenation with nasal cannula. Repeat CXR showed larger bilateral pleural effusions with interstitial prominence as well as interval development of mediastinal widening. Bilateral thoracentesis was performed with removal of a large amount chylous-appearing pleural aspirates with immediate improvement in subjective dyspnea. TPN was stopped and a CT chest with contrast was obtained showing the PICC tip extraluminally, medial to the left brachiocephalic vein, with small, mediastinal gas bubbles. A venogram showed the PICC line within a subintimal tract with some communication with the true lumen. After bilateral thoracentesis and PICC line removal, the right pleural effusion resolved, the left improved substantially, and oxygenation requirements resolved. Discussion To our knowledge, this is the first documented case of bilateral, pseudochylous effusions from TPN extravasation secondary to PICC migration and venous perforation. The hyperosmolar, lipid-rich TPN solution likely promoted erosion of endothelium, leading to leakage into the mediastinum and pleural spaces. This case highlights a rare, but clinically significant iatrogenic cause of AHRF mimicking more common etiologies such as heart failure, infection or malignancy. Providers should maintain vigilance for abrupt effusion enlargement or unexplained/worsening hypoxia in patients after PICC placement, as early recognition and catheter removal can prevent worsening morbidity and mortality.