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An unusual complication of a central venous catheter in a neonate

The use of central venous catheters in neonates is associated with early and late complications. It is recognized that catheter tip migration and perforation of a viscus can occur at any time with a potentially fatal outcome. We present a case in which the successful placement of a central line was followed 2 weeks later by a sudden respiratory deterioration necessitating intubation and ventilation. The catheter tip had eroded through the wall of a pulmonary artery and a bronchus into the bronchial tree. The report highlights the serious morbidity arising from the use of central venous lines in neonates and stresses the importance of X‐rays in establishing the correct position of all catheters. A sudden change in the condition of a patient should raise the suspicion of a catheter‐related problem.