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 the heart by a 2F central venous catheter used to administer parenteral nutrition. Abnormal orientation of the catheter tip preceded 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.