Picc Line Associated Brachiocephalic Vein Rupture with Consequent Mediastinal Placement Causing Pneumomediastinum and Large Total Parenteral Nutrition Bilateral Effusion

We present a rare case of large bilateral pleural effusion, pericardial effusion and pneumomediastinum caused by a peripherally inserted central catheter (PICC) line rupturing the left brachiocephalic vein, causing severe respiratory failure. The PICC line had been inserted with the aim of providing total parenteral nutrition (TPN). The patient developed symptoms within a day with effusions diagnosed on computer tomography pulmonary angiogram (CTPA). Bilateral pleural drains were inserted with a white milk-like substance drained consistent with TPN, prompting a further review of the CTPA revealing the mediastinal-positioned PICC line. The patient was transferred to the thoracic unit and was successfully managed with conservative measures. We propose some ideas such as the use of intracavitary electrocardiogram (IC-ECG) guidance as an adjuvant to obtain a correct and safe position. LEARNING POINTS: PICC lines, although seen as safer, have potential for catastrophic adverse effects. The use of intracavitary electrocardiogram may be a safe adjunct and even an alternative to the use of a chest X-ray. Aspirating blood from all lumens with particular emphasis on the distal most lumen is very important.