Rationale: Vascular access is a critical component of care in the neonatal intensive care unit, especially for nutritional support and medication administration. While umbilical vein catheters are commonly used during the first few days of life, peripherally inserted central catheters (PICCs) become the preferred method of central venous access thereafter. However, malpositioning of PICCs, particularly when the tip lies within or in close proximity to the right atrium, may lead to severe complications such as pericardial effusion and cardiac tamponade, especially in extremely low birth weight infants.

Patient concerns: Two extremely low birth weight preterm infants experienced sudden clinical deterioration following PICC insertion, raising concerns about catheter-related complications.

Diagnoses: Both infants were diagnosed with cardiac tamponade secondary to pericardial effusion caused by PICC malposition, with the catheter tip located in or near the right atrium.

Interventions: In both cases, emergency pericardiocentesis was attempted after echocardiographic confirmation of pericardial effusion and clinical signs of tamponade. Despite resuscitative efforts, both infants succumbed to the complication.

Outcomes: The outcome was fatal in both cases and confirmed catheter malposition as the underlying cause of pericardial effusion and cardiac tamponade.

Lessons: To prevent fatal complications such as cardiac tamponade, PICCs should be positioned in safe area. Proper placement in the superior vena cava should be confirmed and maintained. Regular verification of catheter tip position and minimizing unnecessary repositioning are essential for preventing catheter-related adverse events in vulnerable preterm infants.

Shin J, Kim SY, Youn YA. Two fatal case reports of cardiac tamponade caused by pericardial effusion due to misplaced peripherally inserted central catheters in extremely low birth weight infants. Medicine (Baltimore). 2025 Jun 20;104(25):e42822. doi: 10.1097/MD.0000000000042822. PMID: 40550091.