Comparison of ultrasound and X-ray in determining the position of umbilical venous catheters

Association between Portal Vein Thrombosis after Umbilical Vein Catheterization and Neonatal Asphyxia

INTRODUCTION

Neonatal portal vein thrombosis (PVT) is frequently related to umbilical venous catheterization (UVC), but risk factors remain unclear. This study aims to analyze the variables associated to PVT in near- to full-term newborns with UVC, with a focus on newborns exposed to controlled therapeutic hypothermia (CTH) for hypoxic ischemic encephalopathy (HIE).

METHODS

This is retrospective cohort study of infants delivered at or after 36 weeks and with a birthweight over 1,500 g. All infants were assessed for UVC location and PVT using ultrasonography performed between day 5 and day 10 after catheterization.

RESULTS

Among 213 eligible patients, PVT was diagnosed in 57 (27%); among them, 54 (95%) were localized in the left portal vein branch. With all significant factors in univariate analysis considered, higher gestational age at birth (adjusted OR 1.35; 95% CI: 1.12-1.64, p = 0.002) and duration of UVC placement (adjusted OR 1.36; 95% CI: 1.11-1.67, p = 0.004) were the main risk factors of PVT. Among 87 infants who were cooled for HIE, 31 (36%) had PVT compared to 26 (21%) in infants without CTH. Using a multivariate model including variables linked to treatment procedures only, an increased PVT incidence was statistically associated with UVC duration (adjusted OR 1.33; 95% CI: 1.08; 1.63, p = 0.01) and CTH (adjusted OR 1.94; 95% CI: 1.04-3.65, p = 0.04).

CONCLUSION

Left PVT was frequently observed in near- to full-term neonates with UVC. Among factors linked to treatment procedures, both duration of UVC and CTH exposure for HIE were found to be independent risk factors of PVT.

Umbilical Vein Calcification Associated with Double-Lumen Catheter Malpositioning in an Extremely Low-Birth-Weight Infant

Umbilical venous (UV) catheters (UVCs) are commonly used in severely ill neonates. Complications associated with UVC often result from an inappropriate UVC position. Calcification of the UV, a rare complication, was observed in an extremely low-birth-weight infant born at 23 weeks of gestation. After birth, the infant experienced respiratory and circulatory dysfunction, followed by disseminated intravascular coagulation (DIC). A UVC was inserted, and circulatory agonists and blood transfusions were administered, as well as a calcium gluconate infusion for hypocalcemia and hyperkalemia. Ten days after birth, calcification was detected in the UV, likely due to a tunica intima injury caused by UVC, a hypercoagulable state due to DIC, and a high-dose calcium gluconate infusion. Additionally, proximal port malpositioning of the double-lumen catheter might have contributed to calcification within the UV. To prevent such complications, real-time ultrasound confirmation with agitated saline contrast during UVC placement is recommended; in the absence of the facility or skills for ultrasonography, X-rays should be performed in the lateral and anteroposterior views. Furthermore, when using multi-lumen catheters, physicians should not only verify the tip position but also ensure proper placement of proximal ports and carefully select medications administered through the ports.

Central Lines and Their Complications in Neonates: A Case Report and Literature Review

Central lines are essential devices in NICUs, used primarily in preterm neonates and critically ill term neonates. They are typically divided into non-tunnelled, tunnelled and totally implanted. In light of the increasing use of central lines in the NICU setting, monitoring of the risk factors associated with complications has to be an important part of neonatal care quality management. Presented here is a case of a preterm neonate with cardiac tamponade caused by UVC tip migration. Among complications of central lines are CLABSI, with an incidence of 3 to 21 per 1000 catheter days, and portal vein thrombosis, which is common but probably under-recognised, whereas other mechanical complications such as pericardial and pleural effusions are rare, with an incidence of less than 1%. Complications can cause injury to the neonates, as well as increase the costs of health services because of increases in the length of stay in the NICU. It is recommended that the catheter tip location is confirmed either by X-ray or ultrasonography. In order to minimise the risk of CLABSI, the use of bundles is recommended. Certain recommendations need to be followed when using different types of catheters. Future research is aimed at novel ways of central line securement to minimise mechanical complications and the use of antimicrobial catheters to reduce the rate of CLABSI.

Accuracy of chest radiography compared to ultrasound for positioning the umbilical venous catheter in neonates: A meta-analysis and systematic review

This study was aimed to investigate the accuracy of anteroposterior chest radiography for tip position verification for the umbilical venous catheters in neonates compared to ultrasound. A search in the PubMed, Embase, the Cochrane Library, and EBSCO was conducted to evaluate all the related articles on umbilical venous catheter (UVC), ultrasound AND neonates updated to August, 2020. Study selection, data extraction, and quality assessment were performed independently by two investigators. Random effects model was used to estimate the pooled sensitivity, specificity, and diagnostic odds ratio (DOR). The summary receiver operator characteristic (SROC) curve was constructed, and the area under the SROC curve (AUC) was calculated. Fourteen related studies were finally included for meta-analysis. The overall diagnostic sensitivity and specificity of X-ray on tip verification of UVC were 0.90 (95% CI 0.71-0.97) and 0.82 (95% CI 0.53-0.95), respectively. The pooled DOR was 3.69 (95% CI 1.64-5.71). The AUC was 0.93 (95% CI 0.90-0.95). The meta-regression analysis suggested that study sample size, study design, different US confirming method, and different gold standard in original design might be potential sources of heterogeneity. Our conclusion is that the commonly used anteroposterior X-ray is not reliable in identifying the exact anatomical location of UVC tip in neonates. Studies suggested ultrasound or echocardiography with saline contrast injection could be the gold standard for verification of catheter location and should be considered whenever possible, especially in premature patients. More studies are needed to expand the use of ultrasound or echocardiography in tip position confirming of UVCs.

Securement of Umbilical Venous Catheter Using Cyanoacrylate Glue: A Randomized Controlled Trial

OBJECTIVE

To evaluate the role of cyanoacrylate glue in reducing dislodgement of umbilical venous catheters (UVCs).

STUDY DESIGN

This was a single-center, randomized, controlled, nonblinded trial. All infants requiring an UVC according to our local policy were included in the study. Infants with a UVC with a centrally located tip as verified by real-time ultrasound examination were eligible for the study. Primary outcome was the safety and efficacy of securement by cyanoacrylate glue plus cord-anchored suture (SG group) vs securement by suture alone (S group), as measured by reduction in dislodgment of the external tract of the catheter. Secondary outcomes were tip migration, catheter-related bloodstream infection, and catheter-related thrombosis.

RESULTS

In the first 48 hours after UVC insertion, dislodgement was significantly higher in the S group than in the SG group (23.1% vs 1.5%; P < .001). The overall dislodgement rate was 24.6% in the S group vs 7.7% in the SG group (P = .016). No differences were found in catheter-related bloodstream infection and catheter-related thrombosis. The incidence of tip migration was similar in both groups (S group 12.2% vs SG group 11.7%).

CONCLUSIONS

In our single-center study, cyanoacrylate glue was safe and effective for securement of UVCs, and particularly effective in decreasing early catheter dislodgments.

TRIAL REGISTRATION

UMIN-CTR Clinical Trial; Registration number: R000045844.

Point-of-care ultrasound aided diagnosis and management of peritoneal parenteral nutrition extravasation in a preterm baby: A case report

POCUS could identify some of UVC complications at the bedside. It complements the clinical picture and helps narrowing the deferential diagnosis when there is a clinical deterioration.

Imaging of Umbilical Venous Catheter-Related Hepatic Complications in Neonates

An umbilical venous catheter (UVC) is commonly placed for central venous access in preterm or critically ill full-term neonates to provide total parenteral nutrition (TPN) and medication. However, UVCs can result in complications, including infection, portal vein thrombosis, and hepatic tissue injury. The inadvertent administration of hypertonic fluid through a malpositioned UVC can also cause hepatic parenchymal damage with mass-like fluid collection that simulates a tumorous condition during imaging. Ultrasonography and radiographic examinations play an essential role in detecting UVC-related complications. This pictorial essay aims to present the imaging findings of UVC-related hepatic complications in neonates.

Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes

Point-of-care ultrasonography (POCUS) refers to the use of portable imaging performed by the provider clinician at the bedside for diagnostic, therapeutic, and procedural purposes. POCUS could be considered an extension of the physical examination but not a substitute for diagnostic imaging. Use of POCUS in emergency situations can be lifesaving in the NICU if performed in a timely fashion for cardiac tamponade, pleural effusions, pneumothorax, etc, with potential for enhancing quality of care and improving outcomes.

In the past 2 decades, POCUS has gained significant acceptance in clinical medicine in many parts of the world and in many subspecialties. Formal accredited training and certification programs are available for neonatology trainees as well as for many other subspecialties in Canada, Australia, and New Zealand. Although no formal training program or certification is available to neonatologists in Europe, POCUS is widely available to providers in NICUs. A formal institutional POCUS fellowship is now available in Canada. In the United States, many clinicians have the skills to perform POCUS and have incorporated it in their daily clinical practice. However, appropriate equipment remains limited, and many barriers exist to POCUS program implementation.

Recently, the first international evidence-based POCUS guidelines for use in neonatology and pediatric critical care were published. Considering the potential benefits, a recent national survey of neonatologists confirmed that the majority of clinicians were inclined to adopt POCUS in their clinical practice if the barriers could be resolved.

This technical report describes many potential POCUS applications in the NICU for diagnostic and procedural purposes.

Ultrasound-Guided Umbilical Venous Catheter Insertion to Reduce Rate of Catheter Tip Malposition in Neonates: A Randomized, Controlled Trial

OBJECTIVE

To investigate whether ultrasound-guided umbilical venous catheter (UVC) insertion (US group) reduced the rate of malpositioning of the catheter tip compared to the standard method of insertion (SD group).

METHODS

In this open-label, randomized, controlled trial, neonates admitted to NICU within the first week of life were randomly assigned to the US group (n = 26) or SD group (n = 27). Neonates with major congenital anomalies of the thorax and abdomen were excluded. The primary outcome was the rate of malpositioning of the catheter tip.

RESULTS

The rate of malpositioning of the catheter tip was observed in a significantly lower number of neonates in the US group as compared to the SD group (11/26, 42.3% vs. 20/27, 74%; RR = 0.57, 95% CI: 0.34 to 0.94, p = 0.019). As more of the UVCs were positioned optimally in the first attempt in the US group than SD group, the need for repeated attempts at catheter repositioning was reduced, resulting in reduced procedure time (minutes) [mean (SD), 23.96 (6.42) vs. 30 (1.83); mean difference 6.04 (95% CI: 3.46 to 8.62), p = 0.005]. This also led to a reduction in the additional X-ray exposure in the US group (n = 11) compared to the SD group (n = 20) [95% CI: 3.12 to 44.26; p = 0.020].

CONCLUSION

Ultrasound-guided UVC insertion significantly reduced the rate of catheter tip malposition. It also reduced the number of attempts at catheter manipulation, procedure time, and X-ray exposures. With adequate training, it could be incorporated into routine bedside practice during UVC insertion for optimum placement.

TRIAL REGISTRATION

Clinical Trial Registry of India ( www.ctri.nic.in ) CTRI/2021/03/031894.

Real-Time Ultrasound Guidance for Umbilical Venous Cannulation in Neonates With Congenital Heart Disease

OBJECTIVES

Umbilical venous cannulation is the favored approach to perinatal central access worldwide but has a failure rate of 25-50% and the insertion technique has not evolved in decades. Improving the success of this procedure would have broad implications, particularly where peripherally inserted central catheters are not easily obtained and in neonates with congenital heart disease, in whom umbilical access facilitates administration of inotropes and blood products while sparing vessels essential for later cardiac interventions. We sought to use real-time, point-of-care ultrasound to achieve central umbilical venous access in patients for whom conventional, blind placement techniques had failed.

DESIGN

Multicenter case series, March 2019-May 2021.

SETTING

Cardiac and neonatal ICUs at three tertiary care children's hospitals.

PATIENTS

We identified 32 neonates with congenital heart disease, who had failed umbilical venous cannulation using traditional, blind techniques.

INTERVENTIONS

Real-time ultrasound guidance and liver pressure were used to replace malpositioned catheters and achieve successful placement at the inferior cavoatrial junction.

MEASUREMENTS AND MAIN RESULTS

In 32 patients with failed prior umbilical venous catheter placement, real-time ultrasound guidance was used to successfully "rescue" the line and achieve central position in 23 (72%). Twenty of 25 attempts (80%) performed in the first 48 hours of life were successful, and three of seven attempts (43%) performed later. Twenty-four patients (75%) were on prostaglandin infusion at the time of the procedure. We did not identify an association between patient weight or gestational age and successful placement.

CONCLUSIONS

Ultrasound guidance has become standard of care for percutaneous central venous access but is a new and emerging technique for umbilical vessel catheterization. In this early experience, we report that point-of-care ultrasound, together with liver pressure, can be used to markedly improve success of placement. This represents a significant advance in this core neonatal procedure.

Fifteen-minute consultation: Is this umbilical venous catheter safe to use?

Umbilical venous catheters are widely used in neonatal practice, therefore promoting safe use of such catheters to reduce complications remains a healthcare priority. This report will equip the reader with essential knowledge for successful catheter insertion and maintenance, which is key to better outcomes. Recent advances in safe localisation of catheter tip and the development of a red flag system will enhance the clinician's ability to predict potential complications related to these catheters as they remain in situ.

Incidence of umbilical vein catheter-associated thrombosis of the portal system: A systematic review and meta-analysis

BACKGROUND

The use of umbilical venous catheters (UVCs) in the perinatal period may be associated with severe complications, including the occurrence of portal vein thrombosis (PVT).

AIM

To assess the incidence of UVC-related PVT in infants with postnatal age up to three months.

METHODS

A systematic and comprehensive database searching (PubMed, Cochrane Library, Scopus, Web of Science) was performed for studies from 1980 to 2020 (the search was last updated on November 28, 2020). We included in the final analyses all peer-reviewed prospective cohort studies, retrospective cohort studies and case-control studies. The reference lists of included articles were hand-searched to identify additional studies of interest. Studies were considered eligible when they included infants with postnatal age up to three months with UVC-associated PVT. Incidence estimates were pooled by using random effects meta-analyses. The quality of included studies was assessed using the Newcastle-Ottawa scale. The systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

Overall, 16 studies were considered eligible and included in the final analyses. The data confirmed the relevant risk of UVC-related thrombosis. The mean pooled incidence of such condition was 12%, although it varied across studies (0%-49%). In 15/16 studies (94%), diagnosis of thrombosis was made accidentally during routine screening controls, whilst in 1/16 study (6%) targeted imaging assessments were carried out in neonates with clinical concerns for a thrombus. Tip position was investigated by abdominal ultrasound (US) alone in 1/16 (6%) studies, by a combination of radiography and abdominal US in 14/16 (88%) studies and by a combination of radiography, abdominal US and echocardiography in 1/16 (6%) studies.

CONCLUSION

To the best of our knowledge, this is the first systematic review specifically investigating the incidence of UVC-related PVT. The use of UVCs requires a high index of suspicion, because its use is significantly associated with PVT. Well-designed prospective studies are required to assess the optimal approach to prevent UVC-related thrombosis of the portal system.

The Use of a Disposable Umbilical Clamp to Secure an Umbilical Venous Catheter in Neonatal Emergencies—An Experimental Feasibility Study

Recent guidelines recommend the umbilical venous catheter (UVC) as the optimal vascular access method during neonatal resuscitation. In emergencies the UVC securement may be challenging and time-consuming. This experimental study was designed to test the feasibility of new concepts for the UVC securement. Umbilical cord remnants were catheterized with peripheral catheters and secured with disposable umbilical clamps. Three different securement techniques were investigated. Secure 1: the disposable umbilical clamp was closed at the level of the inserted catheter. Secure 2: the clamp was closed at the junction of the catheter and plastic wings. Secure 3: the setting of Secure 2 was combined with an umbilical tape. The main outcomes were the feasibility of fluid administration and the maximum force to release the securement. This study shows that inserting peripheral catheters into the umbilical vein and securing them with disposable umbilical clamps is feasible. Rates of lumen obstruction and the effectiveness of the securement were superior with Secure 2 and 3 compared to Secure 1. This new approach may be a rewarding option for umbilical venous catheterization and securement particularly in low-resource settings and for staff with limited experience in neonatal emergencies. However, although promising, these results need to be confirmed in clinical trials before being introduced into clinical practice.

Adverse events associated with umbilical catheters: a systematic review and meta-analysis

OBJECTIVE

To determine the incidence of adverse events (AEs) associated with umbilical catheters in the neonatal population.

STUDY DESIGN

Systematic review and meta-analysis of observational studies and randomized controlled trials published between 2010 and 2020.

RESULTS

In total 14,226 umbilical venous catheters (UVCs) and 4228 umbilical arterial catheters (UACs) were included. Overall, 13.4% of UVCs were associated with an AE (95% CI: 10.1-17.0) or 2.4 per 1000 catheter days (95% CI: 1.8-3.0). UACs had an AE rate of 9% (95% CI: 5.9-12.8) or 0.87 per 1000 catheter days (95% CI: 0.4-1.3). UVC malposition was the most common (41.7% [95% CI: 27.6-56.5]). Local injury from UAC taping was the most common AE in one study.

CONCLUSIONS

Umbilical catheters have a high incidence of AEs. Research into accurate methods of tip verification, tip surveillance, and securement is required.

Peripherally inserted central cathether migration in neonates: Incidence, timing and risk factors

BACKGROUND

PICC line use is a common practice in neonatal units, but it is associated with various complications. Catheter migration is the most common complication in neonates. Periodic imaging is recommended to monitor the tip position of the PICCs, but the optimal frequency is undetermined. The incidence, timing and risk factors that are associated with PICC migration have not been fully investigated beyond 24 hrs in neonates. The aim of the study was to determine the incidence, timing and risk factors that are associated with peripherally inserted central venous catheter (PICC) migration in neonates.

METHODS

This was a single center, retrospective study of 168 PICCs placed in 141 neonates in the neonatal intensive care unit (NICU) between 2015 and 2016. The incidence of catheter migration was determined radiographically at 12-24 hrs and every third day after insertion until it was removed.

RESULTS

Overall incidence of PICC migration was 28%and most commonly was detected within the first three days after PICC placement (83%). The incidence of PICC migration was higher in males. The PICC migration was associated with difficulty advancing the PICC at the time of insertion and PICC dressing change.

CONCLUSION

Serial evaluation of PICC placement in neonates is required to maintain proper position. Based on our experience in our unit, we recommend periodic imaging at 12-24 hrs and on the third day after PICC placement as most migration occurred within three days after insertion.

Structured Neonatal Point-of-Care Ultrasound Training Program

OBJECTIVE

Point-of-care ultrasound (POC US) has been increasingly used by intensive care physicians. Growing use of POC US necessitates defining distinct clinical indications for its application, as well as structured POC US training programs. Homogeneous approach to POC US education combined with rigorous quality assurance should further enable POC US to become standard-of-care clinical tool. This study aimed to present the first, innovative, and structured POC US program in neonatal-perinatal medicine field. In addition, we reviewed the availability of the POC US training programs across different medical specialties.

STUDY DESIGN

Available English-language publications on POC US training programs in general and neonatal-perinatal medicine were reviewed in this study.

DISCUSSION

Mounting body of evidence suggests improved procedural completion rates, as well as clinical decision making with the use of POC US. However, limited research supported the existence of structured, comprehensive POC US programs. It was recognized that medical institutions need to develop syllabuses, teach, and credential increasing number of health care professionals in the use of POC US. We defined intuitive educational strategy that encompasses POC US clinical indications, educational curriculum, scanning protocols, competence evaluation, and finally credentialing process. In addition, we offered description of the imaging quality assurance, as well as POC US coding, and reimbursement.

CONCLUSION

Future efforts need to be dedicated to the ongoing development of neonatal POC US as a clinical instrument. It should allow for eventual paradigm change and improved effectiveness in management of critically ill neonates.

Agitated saline contrast to delineate central venous catheter position in neonates

OBJECTIVE

Central venous catheter (CVC) insertion is required for the management of sick neonates. Ultrasonography/targeted neonatal echocardiography (TNE) with/without normal saline (NS) flush is used to identify CVC position. The present study compared the visibility and safety of agitated saline (AS) with normal saline (NS) flush.

STUDY DESIGN

This prospective interventional study included 110 CVC insertions, both umbilical venous catheterization (UVC) and peripherally inserted central catheterization (PICC). Catheter position was monitored by real-time TNE.

RESULTS

Overall visibility of catheter tip (combined UVC and PICC) was significantly better in AS (n = 55) compared with NS group (n = 55) [48/55 (87.2%) vs. 28/55 (50.9%); p < 0.0001]. Time to detect catheter tip by AS push was significantly less than that of NS push. There was no difference in the amount of saline flush required with either method. No major adverse effect was observed.

CONCLUSIONS

AS push can be used as a safe method to delineate CVC position in neonates.

Risk factors for umbilical vascular catheter-related adverse events: A scoping review

INTRODUCTION

Adverse events associated with umbilical catheters include malposition, bloodstream infections, thrombosis, tip migration, and extravasation, resulting in loss of vascular access and increased risk of morbidity and mortality. There is a need for greater understanding of risk factors associated with adverse events to inform safe practice.

OBJECTIVES

The aim of the study was to summarise the existing evidence regarding risk factors for umbilical catheter-related adverse events to inform the undertaking of future research.

REVIEW METHOD USED

A scoping review of peer-reviewed original research and theses was performed.

DATA SOURCES

The US National Library of Medicine National Institutes of Health, Embase, EMcare, and ProQuest Dissertations and Theses were the data sources.

REVIEW METHODS

Informed by the Joanna Briggs Institute Reviewer's Manual, all types of original research studies reporting adverse events published in English from 2009 to 2020 were eligible for inclusion. Studies where umbilical artery catheter and umbilical venous catheter data could not be extracted separately were excluded.

RESULTS

Searching identified 1954 publications and theses, 1533 were excluded at screening, and 418 were assessed for eligibility at full text. A total of 89 studies met the inclusion criteria. A range of potential risk factors for umbilical arterial and venous catheters were identified. Longer dwell time and prematurity were associated with increased risk of bloodstream infection and thrombosis in cohort studies. Case studies detailed analogous factors such as insertion techniques and lack of catheter surveillance during dwell warrant further investigation.

CONCLUSIONS

We identified a vast range of patient, device, and provider risk factors that warrant further investigation. There was a lack of large cohort studies and randomised controlled trials to demonstrate the significance of these risk factors. Improvement in methods to ensure correct catheter tip location and to detect adverse events early is essential. In addition, policy needs to be developed to guide clinicians in catheter surveillance measures to reduce the risk of adverse events.

Neo-ECHOTIP: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in neonates

Central venous access devices are often needed in neonates admitted to Neonatal Intensive Care Unit. The location of the tip of the central catheter is usually assessed by post-procedural X-ray. However, this strategy is inaccurate and time consuming. Recent guidelines strongly recommend intra-procedural methods of tip location, to increase the cost-effectiveness of the maneuver and to shorten the time between device placement and utilization. In this regard, real-time ultrasound represents the most promising tool for tip navigation and location in neonates. The aim of this paper is (a) to review all the evidence available about ultrasound-based tip navigation and tip location of central catheters in the neonatal population (b) to propose a novel protocol for tip navigation and location (Neo-ECHOTIP) based on such evidence.

Implementing point of care ultrasound in the neonatal intensive care unit: a safety study

OBJECTIVE

Point of care ultrasound (POCUS) use is increasing in pediatrics and has been demonstrated to be superior in identifying central catheter tip location in neonatal intensive care units. However, limited data exist regarding cardiorespiratory changes secondary to POCUS in neonates.

STUDY DESIGN

A prospective observational equivalence study was performed on 50 POCUS assessments of central catheter tip location in 46 patients ≥23 weeks gestation. Heart rate (HR), respiratory rate (RR), and percent oxygen saturation (SpO2) levels were collected before and after POCUS. Limits of equivalence were set in advance.

RESULT

Equivalence was demonstrated in HR, RR, and SpO2 before and after POCUS. HR decreased by 3.24 beats per minute (90% CI: -5.36, -1.14). RR increased by 0.71 breath/min (90% CI: -1.84, +3.27). SpO2 increased by 0.54 percentage points (90% CI: -0.23, +1.31).

CONCLUSION

Identifying central catheter tip location using POCUS in neonates appears safe without affecting cardiorespiratory stability.

Real-time ultrasound for tip location of umbilical venous catheter in neonates: a pre/post intervention study

BACKGROUND

Recent guidelines advocate the use of real-time ultrasound to locate umbilical venous catheter tip. So far, training programs are not well established.

METHODS

A pre/post interventional study was carried out in our tertiary neonatal intensive care unit centre to evaluate the efficacy of a training protocol in the use of real-time ultrasound. Primary outcome was the percentage in the use of real-time ultrasound.

RESULTS

Fifty-four patients were enrolled. The use of real-time ultrasound for tip location significantly increased after the training program (15.3% vs 89.2%, p <  0.0001). After the training the tip of the catheters was more frequently placed at the junction of the inferior vena cava and right atrium (75% vs 30.7%, p = 0.0023). Twenty-two catheters were also evaluated with serial scans during the intervention phase to assess migration rate which was 50%.

CONCLUSION

a multimodal, targeted training on the use of real-time ultrasound for umbilical venous catheter placement is feasible. Real-time ultrasound is easily teachable, increases the number of umbilical venous catheters placed in a correct position, reduces the number of line manipulations and the need of chest-x-rays.

Bedside sonography performed by neonatology residents to confirm central vascular catheter position in neonates - A Prospective Diagnostic Evaluation study

OBJECTIVE

To evaluate the diagnostic accuracy and utility of bedside ultrasound (US) by neonatology residents to confirm position of umbilical venous catheter (UVC), umbilical arterial catheter (UAC), and peripherally inserted central catheter (PICC).

METHODS

In this prospective study, we included neonates who required UVC, UAC or PICC insertion. Two neonatology residents performed all bedside US examinations after a short period of training. Plain radiograph was taken as gold standard. Time taken for confirmation of catheter position by US and radiograph was recorded.

RESULTS

We recruited 71 neonates for UVC and UAC, and 40 neonates for PICC. Sensitivity and specificity of US in identifying a malpositioned catheter was good for UVC (94% and 66.7% respectively) and UAC (86.7% and 94.5%). Agreement between radiograph and US was good for UVC [0.718 (0.512, 0.861); p < 0.001] and UAC [0.857 (0.682, 0.953); p < 0.001]. Sensitivity (47.8%) of US in identifying a malpositioned PICC was low, though specificity (82.4%) was good. Agreement between radiograph and US in identifying PICC position was poor [0.25 (-0.084, 0.545); p 0.024]. This was due to incorrect interpretation of catheter position on radiograph in some infants, which was confirmed by the radiologist. The median time taken for US was significantly less than time taken for radiograph in confirming the position of UVC (50 vs. 155 minutes; p < 0.001)), UAC (45 vs. 128 minutes; p < 0.001), and PICC (60 vs. 136 minutes; p < 0.001).

CONCLUSION

US examination byneonatology residents has good diagnostic accuracy in confirming the position of UAC and UVC, and possibly PICC in neonates. The time taken to confirm catheter position by US is significantly less than radiograph.

Umbilical Venous Catheter Update: A Narrative Review Including Ultrasound and Training

The umbilical venous catheter (UVC) is one of the most commonly used central lines in neonates. It can be easily inserted soon after birth providing stable intravenous access in infants requiring advanced resuscitation in the delivery room or needing medications, fluids, and parenteral nutrition during the 1st days of life. Resident training is crucial for UVC placement. The use of simulators allows trainees to gain practical experience and confidence in performing the procedure without risks for patients. UVCs are easy to insert, however when the procedure is performed without the use of ultrasound, there is a quite high risk, up to 40%, of non-central position. Ultrasound-guided UVC tip location is a simple and learnable technique and therefore should be widespread among all physicians. The feasibility of targeted training on the use of point-of-care ultrasound (POCUS) for UVC placement in the neonatal intensive care unit (NICU) among neonatal medical staff has been demonstrated. Conversely, UVC-related complications are very common and can sometimes be life-threatening. Despite UVCs being used by neonatologists for over 60 years, there are still no standard guidelines for assessment or monitoring of tip location, securement, management, or dwell time. This review article is an overview of the current knowledge and evidence available in the literature about UVCs. Our aim is to provide precise and updated recommendations on the use of this central line.

Ultrasound Monitoring of Umbilical Catheters in the Neonatal Intensive Care Unit-A Prospective Observational Study

Introduction: Umbilical catheterization provides a quick yet demanding central line that can lead to complications seen nowhere else. The aim of our study was to determine whether the repeated ultrasound scanning can influence the catheterization time, prevent some of the catheter-related complications, support the decision-making process and allow prolonged catheterization in patients without an alternative central access route. Methods: A prospective observational study was performed in a tertiary neonatal intensive care unit. A total of 129 patients and 194 umbilical catheters (119 venous and 75 arterial) were analyzed with a total of 954 scans. Ultrasound screening consisted of 1) assessing the catheter tip, location, movability, and surface and 2) analyzing the catheter trajectory. The outcome variables were defined as 1) catheter dislocation and 2) associated thrombosis. Results: Dislocation of catheter throughout the whole catheterization period was observed in 68% (81/119) of UVCs and 23% (17/75) of UACs. Thrombotic complications were observed in 34.5% (41/119) of UVCs and 12% (9/75) of UACs. 1/3 of UAC-associated thrombi were visible only after catheter removal. 51% (61/119) of UVC patients and 8% (6/75) of UAC patients made a clinical decision regarding the obtained catheter image. Conclusion: Bedside ultrasound imaging of catheters supports the decision-making process related to the catheterization duration, shortening the time if abnormalities are detected and allowing a safer prolonged UC stay when an alternative central line cannot be inserted.

Neonatal Nurse Practitioner Use of Ultrasonography to Verify Umbilical Venous Catheter Placement in the Neonatal Intensive Care Unit

BACKGROUND

Literature dating back to 1982 supports the use of ultrasound to confirm UVC position as a more reliable method compared to x-ray. The use of ultrasound to confirm UVC position remains infrequent in the NICU.

PURPOSE

To determine the feasibility of training an NNP in the acquisition and interpretation of a parasternal short-axis (PSAX) image of the heart to confirm UVC position.

METHODS

A retrospective review of 48 charts evaluated descriptive data using standard technique of an x-ray to confirm UVC placement. An NNP was trained to acquire and interpret a parasternal short-axis (PSAX) cardiac view by a pediatric cardiologist. The NNP independently and prospectively evaluated 21 neonates and determined whether the UVC was in satisfactory or unsatisfactory position. The same image was blindly over-read by the pediatric cardiologist. Agreement between the NNP and pediatric cardiologist interpretations as well as the pediatric cardiologist and radiologist interpretations was evaluated using the κ-test.

RESULTS

Initial pediatric cardiology interpretation of UVC position showed the UVC to be malpositioned in 66% of neonates (n = 14). NNP and pediatric cardiology interpretations in UVC position had 86% agreement (κ-0.667). Pediatric cardiology (ultrasound) and radiology interpretations (x-ray) in UVC position had 86% agreement (κ-0.69).

IMPLICATIONS FOR PRACTICE

It is feasible to train NNPs to perform and accurately interpret a single PSAX ultrasound image to determine satisfactory UVC position.

IMPLICATIONS FOR RESEARCH

Increasing the use of ultrasound to determine satisfactory position of UVCs in the NICU can reduce unnecessary exposure to ionizing radiation in neonates.

Application of a modified electrocardiogram-guided technique for umbilical venous catheterisation in neonates: A retrospective trial

AIM

To investigate the effectiveness and safety of modified electrocardiogram (ECG)-guided technique in umbilical venous catheterisation in neonates.

METHODS

Sixty-six critically ill neonates underwent umbilical venous catheterisation with (ECG group) or without (control group) ECG guidance from January 2017 to March 2019. We retrospectively analysed and compared the rate of correct tip placement on first try, unplanned extubation rate and incidence of catheter-related complications between the two groups.

RESULTS

There were 33 patients in each group. The ECG group showed significantly higher rate of correct tip placement on first try (P < 0.001), lower unplanned extubation rate (P < 0.001), but identical incidence of catheter-related complications (P = 0.492) comparing with the control group.

CONCLUSION

The ECG-guided technique is an effective and safe method for umbilical venous catheterisation. The connecting method we modified made this technique more practical and can be promoted to areas without access to specific ECG adaptors.

Point-of-care ultrasound use in umbilical line placement: a review

Point-of-care ultrasound (POCUS) has become a novel tool for assessing umbilical catheter tip location in the neonate. This review analyzes the current evidence on the efficacy and utility of POCUS for identifying umbilical catheter positioning. Medline, EMBASE, and Cochrane searches were performed until October 2018. Eight studies were identified comparing POCUS to x-ray in assessing umbilical catheter tip location in the last 10 years. POCUS was shown to be feasible and appears to be a superior imagining modality to x-rays in assessing umbilical line tip location. POCUS is more accurate in determining umbilical catheter positioning, allows for more rapid line umbilical catheter placement, and reduces the time to treatment as well as radiation exposure to the neonate when compared with x-ray. The available studies support further education in training neonatal providers to become proficient in POCUS for assessing umbilical lines.

Point-of-care ultrasound in the neonatal ICU

PURPOSE OF REVIEW

Point-of-care ultrasound (POCUS) is an emerging clinical tool in the neonatal intensive care unit (NICU). Recent literature describing the use of POCUS for various applications in the NICU has garnered increased interest among neonatologists.

RECENT FINDINGS

Diagnostic applications for POCUS in the NICU include the evaluation and serial monitoring of common pulmonary diseases, hemodynamic instability, patent ductus arteriosus (PDA), persistent pulmonary hypertension of the newborn (PPHN), necrotizing enterocolitis (NEC), and intraventricular hemorrhage (IVH), among others. Procedural applications include vascular access, endotracheal intubation, lumbar puncture, and fluid drainage.

SUMMARY

Experience with POCUS in the NICU is growing. Current evidence supports the use of POCUS for a number of diagnostic and procedural applications. As use of this tool increases, there is an urgent need to develop formal training requirements specific to neonatology, as well as evidence-based guidelines to standardize use across centers.

Umbilical venous catheter insertion depth estimation using birth weight versus surface measurement formula: a randomized controlled trial

OBJECTIVE

To determine if umbilical venous catheter (UVC) insertion depth estimated by surface measurement (SM) results in optimal catheter tip position on ultrasound as compared with formula using birth weight (BW).

METHODS

In this randomized controlled trial, eligible infants were randomized to UVC insertion depth estimated by SM or BW method. We compared proportion of optimum UVC position on ultrasound read by neonatologist masked with group assignment.

RESULTS

UVC was inserted to estimated depth in 164 of 200 enroled infants. There was no difference in the proportion of correctly positioned UVCs between the groups (SM 33/82 (40.2%) vs BW 27/82 (32.9%), p = 0.33). Among BW < 1000 g, SM method had higher correctly positioned UVC (43.7% vs 22.5%, p = 0.07).

CONCLUSION

There was no difference in the rate of optimally positioned UVC tip between the two methods for estimating UVC insertion depth. However, SM method results in more optimal positioning of UVC tip among BW < 1000 g infants.

Use of clinician-performed ultrasound in the assessment of safe umbilical venous catheter tip placement

AIM

Safe tip placement of umbilical venous catheters (UVCs) in sick neonates is critical in minimising risk. We aimed to demonstrate the utility of clinician-performed ultrasound (CPU) in identifying UVCs that are placed within small intrahepatic portal vessels or within the heart despite the appearance of being well placed on X-ray.

METHODS

This was a retrospective observational study of preterm and term neonates who had a UVC placed and the position assessed by X-ray and/or CPU according to the Royal Prince Alfred Hospital level 3 neonatal intensive care unit (NICU) guideline. Cases were identified by exporting the records of all admissions between 1 April 2015 and 30 June 2016 from the NICU's data collection database. Paper-based medical records, NICU's data collection database records and the ultrasound reporting system were reviewed to determine X-ray and CPU findings.

RESULTS

A total of 157 neonates had 169 UVCs placed. CPU was performed in 77% (111). In 15 cases (14%), UVC placement on X-ray appeared appropriate based on estimated vertebral level; however, CPU demonstrated the line to be in an unsafe position (small intrahepatic portal vessel (3); right atrium (9); left atrium (3)).

CONCLUSIONS

Assessment of safe UVC placement by estimations according to vertebral level on X-ray alone is inadequate. CPU offers confident localisation of the UVC tip and enables corrective manipulation of intracardiac or intrahepatic UVCs in real time. We recommend CPU as an adjunct to X-ray to ensure safe UVC placement.

Ionizing Radiation Exposure in NICU

The authors prospectively studied ionizing radiation exposure in consecutive 107 very low birth weight (VLBW) neonates, admitted to their Level III neonatal intensive care unit (NICU). Number of X-rays, their indications and calculated dose of radiation were documented. Their mean birth weight (+SD) and gestational age (+SD) were 1077 (±219.8) g and 29.7 (+2.57) wk respectively. Extremely low birth weight (ELBW) neonates underwent significantly higher radiographs when compared with VLBW neonates; 7.5(5-13.25) vs. 2(1-6); p < 0.0001. ELBW neonates received 3 times higher dose of radiation, when compared with VLBW neonates; 139.4 μsv (81.6-256.15) vs. 46.6 μsv (14.4-115.7); p < 0.0001. Seven percent of ELBW neonates received >1msv radiation. Lifetime risk associated with high radiation exposure during neonatal period is unknown. Every effort should be taken to reduce number of radiographs. Imaging modalities without radiation exposure such as, point of care ultrasound should be used wherever possible.

Hepatic extravasation complicated by umbilical venous catheterization in neonates: A 5-year, single-center experience

BACKGROUND

Care of newborns in the neonatal intensive care unit generally involves umbilical venous catheterization (UVC) for central vein access to enable medical needs. The study aimed to evaluate the sonographic appearance, risk factors, and outcomes of UVC-related hepatic extravasation (HE) in neonates.

METHODS

A 5-year retrospective study where 33 neonates were enrolled with a diagnosis age ranging from 2 to 25 days. 78.8% of the subjects had UVC malpositioning shown on initial radiography. All neonates sonographically diagnosed with HE, and follow-up ultrasound (US) was performed.

RESULTS

The main findings of HE on US were hyperechoic or heterogeneous lesions of a lobulated (51.7%) or wedge shape (48.3%), located mainly in the left lobe (72.7%). The mean time to resolution of HE was 2.25 months. Seven (21.2%) patients showed hepatic vascular thrombosis at follow-up. Two (6%) patients had abnormal liver function, which subsequently normalized.

CONCLUSION

Malposition of the UV catheter was the predisposing factor for UVC-related HE in neonates. US facilitates detection of UVC malpositioning and diagnosis of HE, as well as delayed complications. A shorter duration of UVC placement is associated with favorable outcomes of UVC-related HE in neonates.

Parenteral Nutrition Ascites: Calamity from an Umbilical Vein Cannula

Umbilical vein catheterization is considered a critical requirement in preterm neonates for the administration of fluids and parenteral nutrition. However, inadvertent migration and malposition are known to cause complications that are often life-threatening. We describe a neonate with parenteral nutrition-associated lipid ascites owing to extravasation from an umbilical vein cannula. Fatality was averted due to prompt recognition and paracentesis that was therapeutic and confirmed the diagnosis as well.

[Ultrasound-guided umbilical venous catheterisation: A cost-effectiveness analysis]

INTRODUCTION

Although the use of ultrasound for the insertion of central catheters has proven to be cost-effective in adults, it is not known if this is the case in the neonatal population. This study compared the cost-effectiveness of ultrasound-guided umbilical venous catheterisation with conventional catheterisation in a neonatal intensive care unit of a Public University Hospital.

PATIENTS AND METHODS

A retrospective observational study was conducted on newborns that required an umbilical venous catheter before completing their first 24hours of extra-uterine life. Two retrospective cohorts were formed, including one with ultrasound-guided catheterisation and the other with conventional catheterisation. The effectiveness was measured using 2 variables: placement of ideal position and insertion without complications. The cost of human and material resources (consumable and non-consumable), the cost-effectiveness ratio, and the incremental cost-effectiveness ratio were estimated, as well as carrying out a sensitivity analysis.

RESULTS

Catheter obstruction was more frequent in guided catheterisation than in conventional catheterisation (7.7% vs. 0%, p=.04) and catheter dysfunction was higher in the latter (79% vs. 3.8%, p<.0001). The cost-effectiveness ratio of the guided catheterisation was €153.9, and €484.6 for the conventional one. The incremental cost-effectiveness ratio was €45.5. The sensitivity analysis showed a €2.6 increase in the cost-effectiveness ratio of the guided catheterisation and €47 in the conventional one.

CONCLUSIONS

The use of ultrasound to guide umbilical catheterisation is more efficient than conventional catheterisation since, despite using more economic resources, it offers greater effectiveness.

Accuracy of five formulae to determine the insertion length of umbilical venous catheters

INTRODUCTION

Umbilical venous catheter (UVC) placement is a common neonatal procedure. It is important to position the UVC tip accurately at the first attempt to prevent complications and minimise handling. Catheters positioned too low need to be removed, but catheters positioned too high may be withdrawn in a sterile fashion to a safe position. We aimed to determine the precision and accuracy of five published formulae developed to guide UVC placement.

METHODS

This was a prospective observational study. Following UVC insertion, anteroposterior and lateral X-rays were performed to identify catheter tip position. Parameters required to apply the five formulae were recorded. Insertion lengths were then calculated and compared with the gold standard (UVC tip at the level of the diaphragm on the lateral X-ray). They were also used to classify predicted UVC tip position as either correct (UVC tip at or up to 1 cm above the diaphragm), too high or too low.

RESULTS

Of 118 eligible infants, 70 had the UVC tip in a position where measurements could be used. Their median (IQR) gestational age and weight were 28.5 (26-36) weeks and 1035 (745-2788) g, respectively. The predicted success rate for each formula ranged from 44.9% to 55.7%. A formula based on birth weight had the highest rate of either correct or high position (95.8%).

CONCLUSIONS

Inserting a UVC into a safe position on first attempt is difficult and low tip placement is common. Around half of UVCs need to be manipulated to achieve the desired position.

The superiority of point of care ultrasound in localizing central venous line tip position over time

The primary objective was to study agreement between X-rays and point of care ultrasound (POC-US) in determining central venous line (CVL) tip position. The secondary objective was to examine malposition rates over time using POC-US. Fifty-six neonates were enrolled who had a CVL placed. Initial X-rays and POC-US were obtained. POC-US was performed daily thereafter for the total of 6 days. US video clips were acquired in four standard echocardiographic views: subcostal, four-chamber, and short- and long-axis parasternal views. Gwet's agreement coefficient (AC1) for agreement measured inter-rater reliability of X-rays and POC-US (correct position/malposition). A generalized linear mixed model for binary clustered data estimated malposition rate over time. All analyses were conducted using SAS version 9.4 and Agree Stat. The study included 108 "pairs" of X-rays and POC-US images. Agreement coefficient (AC1), with respect to correct position/malposition of CVL tip, was high AC1 = 0.872 (UVC-AC1 = 0.814, PICC-AC1 = 0.94). Among birth weight (BW) < 1000 g, 1000-1499 g, and BW > 1500 g, AC1 values were 0.922, 0.774, and 0.873, respectively. CVL tip malposition rate decreased over time.Conclusions: Agreement between POC-US and X-rays for CVL tip position was high, with the highest in BW < 1000 g. The data suggest that POC-US can be used for initial confirmation and follow up of CVL tip position. What is Known • X-ray is currently the gold standard for localizing central venous line (CVL) tip position. • Malposition of CVL tip can lead to life-threatening complications. What is New • POC-US is superior to X-ray as it can follow CVL tip position over time, detecting malpositioned lines, adjusting them in a timely manner thus preventing complications. • Standardizing CVL placement, X-ray acquisition, POC-US acquisition with four views with video clips and ultrasound operator training increases accuracy and thus agreement between X-ray and POC-US. • UVC tip is more likely to be malpositoned than PICC tip. Malposition of UVC tip using POC-US decreased over time due to shrinking of the umbilical cord in the first 48 of life.

Inadvertent Migration of Umbilical Venous Catheters Often Leads to Malposition

BACKGROUND

Migration of umbilical venous catheters (UVCs) has been described anecdotally.

OBJECTIVES

The aim of this paper was to investigate migration of UVCs using ultrasonography (US).

METHODS

In a prospective observational study, the position of UVCs was determined using serial US within 24 h, at midweek, and at the end of the week after umbilical catheterization. Migration was recorded in distance and direction. Malposition was defined as a position of the UVC in the heart (right atrium or more distal along the UVC-route), umbilicoportal confluence, or in the umbilical vein. UVC position determined by US was compared with chest X-rays (CXRs) when these were performed for standard care within the same period of 1 h.

RESULTS

Migration of UVCs was detected with US in 25/40 infants (63%) in 32 occasions, leading to malposition in 17/25 (68%) infants. UVCs migrated inwards in 18/32 (56%), leading to a position within the heart in 17/18 occasions. Most migrations occurred before Day 3 (21/32 [66%]). When a CXR was taken at the same time as US was performed (30 occasions), the assessment of the catheter-tip position differed in 23% of the occasions. When malposition was detected by US, this was detected on routinely performed CXRs in 11% of the occasions.

CONCLUSIONS

UVCs often migrate following insertion, often leading to malposition. Awareness for this is needed, and US is a feasible alternative for detecting malposition compared to CXRs and avoids additional radiation. Re-evaluation of the position of UVCs at least once, but within 24 h after placement, is recommended.

A National Survey of Neonatologists: Barriers and Prerequisites to Introduce Point-of-Care Ultrasound in Neonatal ICUs

Point-of-care (POC) ultrasound refers to the use of portable imaging. Although POC ultrasound is widely available to the neonatologists in Australia and Europe, neonatologists in the United States report limited availability. Our objective was to seek the US neonatologists' perception of barriers and prerequisites in adopting POC ultrasound in neonatal intensive care units. An online survey link was sent via e-mail to 3000 neonatologists included in the database maintained by the American Academy of Pediatrics. Survey results (n = 574) were reported as percentage of total responses. Personal experience requiring an urgent sonography in managing cardiac tamponade or pleural effusion was reported by 78% respondents. However, emergent ultrasound (≤10 min) was not available in 80% of the neonatal intensive care units. We compared the responses based on years of clinical experience (>20 vs <20 years), with 272 (48%) neonatologist reporting more than 20 years of experience. Similarly, results from neonatal fellowship programs were compared with nonteaching/teaching hospitals, with 288 (50%) replies from neonatology fellowship programs. Compared with senior neonatologists, respondents with less than 20 years of clinical experience consider POC ultrasound enhances safety and accuracy of clinical procedures (87% vs 82%) and favor adopting POC ultrasound in clinical practice (92% vs 84%). There were no differences in opinion from neonatology fellowship programs compared with the nonteaching/teaching hospitals. Lack of training guidelines, inadequate support from local radiology department, and legal concerns were reported as the top 3 primary barriers in adopting POC ultrasound. If these barriers could be resolved, 89% respondents were inclined to adopt POC ultrasound in clinical practice.

Sonographic features of umbilical catheter-related complications

Umbilical catheters are commonly used in the neonatal period for blood sampling or for administering medication or parenteral nutrition. The position of the catheter is usually confirmed with radiography. However, many complications associated with the use of umbilical catheters, such as liver collections from extravasation or vascular thrombosis, are not apparent on radiographs but can be easily diagnosed with ultrasound. This pictorial review illustrates the sonographic findings of complications that should be excluded in the sick neonate with an indwelling catheter.

Diagnostic Bedside Ultrasound Program Development in Pediatric Critical Care Medicine: Results of a National Survey

OBJECTIVES

To assess current diagnostic bedside ultrasound program core element (training, credentialing, image storage, documentation, and quality assurance) implementation across pediatric critical care medicine divisions in the United States.

DESIGN

Cross-sectional questionnaire-based needs assessment survey.

SETTING

Pediatric critical care medicine divisions with an Accreditation Council of Graduate Medical Education-accredited fellowship.

RESPONDENTS

Divisional leaders in education and/or bedside ultrasound training.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Fifty-five of 67 pediatric critical care medicine divisions (82%) with an Accreditation Council of Graduate Medical Education-accredited fellowship provided responses. Overall, 63% of responding divisions (34/54) were clinically performing diagnostic bedside ultrasound studies with no difference between divisions with large versus small units. Diagnostic bedside ultrasound training is available for pediatric critical care medicine fellows within 67% of divisions (35/52) with no difference in availability between divisions with large versus small units. Other core elements were present in less than 25% of all divisions performing clinical studies, with a statistically significant increase in credentialing and documentation among divisions with large units (p = 0.048 and 0.01, respectively). All core elements were perceived to have not only high impact in program development but also high effort in implementation. Assuming that all structural elements could be effectively implemented within their division, 83% of respondents (43/52) agreed that diagnostic bedside ultrasound should be a core curricular component of fellowship education.

CONCLUSIONS

Diagnostic bedside ultrasound is increasingly prevalent in training and clinical use across the pediatric critical care medicine landscape despite frequently absent core programmatic infrastructural elements. These core elements are perceived as important to program development, regardless of division unit size. Shared standardized resources may assist in reducing the effort in core element implementation and allow us to measure important educational and clinical outcomes.

Hepatic Complications of Umbilical Venous Catheters in the Neonatal Period: The Ultrasound Spectrum

OBJECTIVES

Umbilical venous catheterization is commonly used in the neonatal period; however, it has some complications. In this study, we evaluated neonates who underwent umbilical venous catheterization and developed hepatic complications. Furthermore, we aimed to define all of the possible lesions and to clarify the imaging findings of umbilical venous catheter-induced hepatic injury.

METHODS

Two hundred forty-four neonates who underwent umbilical venous catheterization between March 2013 and September 2015 in a single tertiary care referral center were included in this study. To determine whether they had any hepatic complications, all patients underwent abdominal grayscale and Doppler ultrasound examinations, and their clinical data were recorded.

RESULTS

The frequency of liver-related complications from umbilical venous catheterization was 33.6% (82 of 244). Air in the portal venous system was the most frequent complication (20.1% [49 of 244]). Left portal venous thrombosis was noted in 6.1% (15 of 244). Parenchymal lesions in the liver related to umbilical venous catheterization were seen in 7.4% of patients (18 of 244) as follows: single nodular echogenic lesions (4.1% [10 of 244]), branching small nodular echogenic lesions (2.1% [5 of 244]), and large irregular heterogeneous lesions with laceration and perihepatic fluid (1.2% [3 of 244]). There was no statistical significance for any type of complication according to the gestational age (P > .05).

CONCLUSIONS

Hepatic complications due to umbilical venous catheters are not uncommon in the neonatal period. Ultrasound is the best imaging modality for confirming the diagnosis and for follow-up.

Incidental Findings on Routine Targeted Neonatal Echocardiography Performed in Preterm Neonates Younger Than 29 Weeks' Gestation

OBJECTIVES

The aim of this study was to quantify the rate of incidental findings identified on elective research echocardiography performed on neonates younger than 29 weeks' gestation.

METHODS

We conducted a retrospective study of echocardiographic examinations performed within the first 24 hours of age on neonates younger than 29 weeks' gestation over a 3-year period for research purposes. Incidental echocardiographic findings and pertinent clinical data were recorded.

RESULTS

Echocardiographic examinations performed on 145 neonates were retrospectively reviewed. Forty-three neonates (30%) had a total of 54 unexpected findings (37%). Most comprised malpositioned umbilical venous catheters, where the tip was located in the left atrium. The remainder of the conditions identified included unsuspected congenital heart disease, liver hematomas, and unexpected pulmonary hypertension.

CONCLUSIONS

There is a high rate of incidental findings identified on screening echocardiograms. Routine targeted neonatal echocardiographic screening of preterm neonates may be warranted to identify the considerable likelihood of asymptomatic findings.