Superiority of targeted neonatal echocardiography for umbilical venous catheter tip localization: accuracy of a clinician performance model

Impact of targeted neonatal echocardiography consultations for critically sick preterm neonates

RATIONALE

Preterm neonates needing rescue treatments with inotropes and/or inhaled nitric oxide (iNO) (acute critical illnesses, ACIs) in neonatal intensive care units (NICUs) are at high risk of mortality. While targeted neonatal echocardiography consultations (TNE) are increasingly used to guide management, its clinical impact need evaluation.

OBJECTIVES

To investigate clinical outcomes in relation to TNE utilisation during episodes of ACIs among preterm neonates.

METHODS

This retrospective cohort study, conducted at two tertiary NICUs over 10 years, included neonates<37 weeks gestational age (GA) who developed ACIs. Patients receiving TNE-guided care (TNE within 24 hours of treatment initiation) were compared with non-TNE management. Outcomes included predischarge mortality, episode-related mortality (<7 days) and a new diagnosis of intraventricular haemorrhage≥grade 3 (IVH-3). Inverse probability of treatment weighting (IPTW) using propensity score was used to account for confounders, including site, birth years and baseline illness severity.

MEASUREMENTS AND MAIN RESULTS

Of 622 included patients, 297 (48%) had TNE; median (IQR) GA at ACI was 26.4 (25.0-28.4) weeks. TNE group demonstrated higher baseline mean airway pressure, oxygen requirement and heart rate and frequently received both inotrope and iNO during ACI. IPTW analysis revealed TNE was associated with lower mortality (adjusted OR (95% CI) 0.75 (0.59 to 0.95)), episode-related mortality (0.54 (0.40 to 0.72)) and death or IVH-3 (0.78 (0.62 to 0.99)). TNE group received more varied inotropic agents, demonstrated earlier improvements in blood pressures, without increasing overall inotrpoic burden.

CONCLUSIONS

Among preterm neonates requiring rescue treatments with inotropes/iNO, TNE utilisation to guide clinical management may be associated with improved survival.

A narrative review on tip navigation and tip location of central venous access devices in the neonate: Intracavitary ECG or real time ultrasound?

The proper location of the tip of a central venous access device plays a crucial role in minimizing the risks potentially associated with its use. Recent guidelines strongly recommend preferring real-time, intra-procedural methods of tip location since they are more accurate, more reliable and more cost-effective than post-procedural methods. Intracavitary electrocardiography and real time ultrasound can both be applied in the neonatal setting, but they offer different advantages or disadvantages depending on the type of central venous access device. Reviewing the evidence currently available about the use of these two methods in neonates, in terms of applicability, feasibility and accuracy, it can be concluded that (a) real time ultrasound is the only acceptable methodology for tip navigation for any central venous access device in neonates, (b) intracavitary electrocardiography is the preferred method of tip location for central catheters inserted by ultrasound-guided cannulation of the internal jugular vein or the brachiocephalic vein, and (c) real time ultrasound is the preferred method of tip location for umbilical venous catheters, epicutaneo-cava catheters, and central catheters inserted by ultrasound-guided cannulation of the common femoral vein.

Educational Impact of Targeted Neonatal Echocardiography and Hemodynamics Programs on Neonatal-Perinatal Medicine Fellows

OBJECTIVE

Targeted neonatal echocardiography (TNE) is a real-time cardiac imaging modality used by a hemodynamics program to aid in diagnosis, treatment, and monitoring of neonatal cardiovascular illness. This study aimed to describe trainees' perspectives on existing hemodynamics education and perceived impacts of TNE and hemodynamics services on their education.

STUDY DESIGN

This was a mixed quantitative and qualitative study that surveyed neonatal-perinatal medicine (NPM) fellow trainees in Canada and the United States, at programs both with and without a hemodynamics service.

RESULTS

Ninety-two fellows responded to the survey, of whom 24 (26%) were enrolled in a program with an active hemodynamics service, 64 (70%) were training at a program without a hemodynamics service, and 4 (4%) were unsure. Trainees at centers with a hemodynamics service were more satisfied with their cardiovascular physiology education (91 vs. 69%, p = 0.040). Twenty-five percent of all trainees felt they do not have sufficient hemodynamics training to prepare them for independent practice. Areas of knowledge gaps were identified. Bedside teaching combined with didactic teaching was identified as useful means of teaching.

CONCLUSION

Most trainees believed that TNE and a hemodynamics service are valuable educational assets. Thoughtful curriculum design for real-time and consolidation learning, with specific emphasis on content gaps, should be considered.

KEY POINTS

· NPM Fellows perceive TNE & Neonatal Hemodynamics service as a valuable educational opportunity.. · Incorporation of TNE/Hemodynamics teaching into NPM curriculum can enrich trainee experience.. · Combining bedside and classroom teaching is key to successful cardiovascular training..

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.

Fingertip ultrasound evaluation of umbilical catheter position in the neonatal intensive care unit compared to conventional ultrasound radiography: a preliminary investigation

OBJECTIVE

The purpose of the study is to compare conventional linear and fingertip ultrasound transducers, for the evaluation of umbilical catheters, with radiography. Fingertip ultrasound transducers have the potential to simplify sonographic examination due to their small size and ability to fit on a finger.

STUDY DESIGN

A prospective, IRB approved comparative study was performed. Linear and fingertip sonographic images were obtained around the same time as a radiograph in neonates with umbilical catheters by two board certified pediatric radiologists and a radiology resident. The positions of catheters were then compared across all three modalities.

RESULT

A total of 41 catheters were evaluated, which included 14 arterial and 27 venous catheters. Two venous catheters were not identified by the linear transducer and one arterial catheter tip was not identified by the fingertip transducer.

CONCLUSION

A fingertip ultrasound probe can be used to evaluate umbilical catheter positioning for potentially faster sonographic examination and decrease the need for repeated radiation.

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.

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.

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.

Learning Curves for Training in Ultrasonography-Based Examination of Umbilical Catheter Placement: A Piglet Study

BACKGROUND

The training required for accurate assessment of umbilical catheter placement by ultrasonography (US) is unknown.

OBJECTIVE

To describe the learning curve and provide an estimate of the accuracy of physicians' US examinations (US skills) and self-confidence when examining umbilical catheter tip placement.

METHODS

Twenty-one physicians with minimal experience in US completed a 1.5-hour eLearning module. Ten piglets with catheters inserted in the umbilical vessels were used as training objects. Following eLearning each physician performed up to twelve 10-min US examinations of the piglets. Expert examinations were reference standards. Sensitivity and specificity of physicians' skills in detecting catheter tip placement by US was used to describe the learning curve. Self-confidence was reported by Likert scale after each examination.

RESULTS

Physicians' detection of a correctly placed and misplaced umbilical artery catheter tip increased by an odds ratio of 1.6 (95% CI: 1.1, 2.3) and 3.6 (95% CI: 1.7, 7.8) per examination performed. A sensitivity of 0.97 (95% CI: 0.80, 0.99) and specificity of 0.95 (95% CI: 0.84, 0.99) was reached after 6 examinations. For the venous catheter, US skills in detecting a misplaced catheter tip increased with an odds ratio of 2.4 (95% CI: 1.2, 4.8) per US examination. Overall, performance and self-confidence plateaus were reached after 6 examinations.

CONCLUSION

We found steep learning curves for targeted US examination of umbilical catheter placement. eLearning followed by 6 examinations was found to be adequate training to perform with a sufficiently high accuracy and self-confidence to allow for point-of-care use.

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.

Epicutaneo-caval catheters in neonates: New insights and new suggestions from the recent literature

Epicutaneo-caval catheters have been widely used in neonatal intensive care units since Shaw has described them in 1973. These central venous access devices are usually placed at bedside and they have the purpose of delivering parenteral nutrition and/or drugs that are not compatible with the peripheral route. Even though in the last decade there was a fast advancement in the world of vascular access devices, such changes have only marginally affected the field of neonatal venous access. The aim of this editorial is to give 10 recommendations that correspond to 10 novelties in the field of epicutaneo-caval catheter: some are already evidence-based and should be introduced in our daily practice now, while others are particularly interesting and deserve further clinical studies.

Point-of-care ultrasound for peripherally inserted central catheter monitoring: a pilot study

Objective To assess the feasibility and accuracy of point-of-care ultrasound (POCUS) in monitoring peripherally inserted central catheter (PICC) location in neonates by non-radiologist physicians. Methods A prospective cohort study compared PICC localization by ultrasound in neonates with a recent radiograph. The ultrasound exam was performed using a standardized protocol with 13-6 MHz linear and 8-4 MHz phased array transducers by a neonatal-perinatal fellow who was blinded to PICC location on the radiograph. Results Of the 30 neonates included, 96.6% (n = 29) were preterm, with 63.3% (n = 19) weighing <1500 g. Nighty-four percent (n = 94) of ultrasound scans matched the radiograph report. The protocol had a sensitivity of 0.97, specificity of 0.66 and positive predictive value of 0.98. Conclusion Limited ultrasound exams to monitor PICC position in neonates using a standardized protocol by non-radiologist physicians are feasible and accurate in a single ultrasound user. Further study in multiple providers is needed before widespread use.

Limited Ultrasound Protocol for Upper Extremity Peripherally Inserted Central Catheter Monitoring: A Pilot Study in the Neonatal Intensive Care Unit

OBJECTIVES

To assess whether a limited ultrasound (US) scanning protocol to monitor the upper extremity peripherally inserted central catheter (PICC) location in neonates is feasible for experienced US operators.

METHODS

A radiologist, who was blinded to the PICC location on chest radiography, performed 14 US scans on 11 neonates with upper extremity PICCs. A US machine with 13-6-MHz linear and 8-4-MHz phased array transducers was used for the examinations.

RESULTS

The study population included 54% (n = 6) preterm infants, with 72% (n = 8) weighing less than 1500 g. The US location of the PICC was the same as the chest radiographic report in all 14 scans. A subclavicular long-axis view of the anterior chest visualized all PICCs in the subclavian or brachiocephalic veins. A parasternal long-axis right ventricular inflow view was able to visualize PICCs in the superior vena cava (SVC), and a subcostal long-axis view evaluated PICCs in the lower SVC and heart. The scanning time was location dependent: less than 5 minutes for PICCs in the brachiocephalic or subclavian vein and 5 to 10 minutes for PICCs in the SVC or heart. There were no desaturations below 90%, increases in the fraction of inspired oxygen need, or hypotension episodes during scanning.

CONCLUSIONS

A limited US scanning protocol to determine the upper extremity PICC location is feasible. Our protocol needs to be tested in neonatal providers before further dissemination.

Merits and perils of targeted neonatal echocardiography-based hemodynamic research: a position statement

In the neonatal setting, point-of-care ultrasound is increasingly being used to help clinicians with the evaluation of heart function. Practices in neonatology, particularly with regard to acute and chronic hemodynamic managements, were traditionally more driven on dogma and predefined thresholds and not always supported by demonstrable physiology. For the first time, targeted neonatal echocardiography (TNE) provided neonatal intensivists with a bedside tool that made real-time assessment of neonatal hemodynamics status feasible in even the tiniest of babies. This opened the door towards more targeted physiological driven practices, allowing us to test historical approaches to clinical problems in a more precise way. Despite the standardization of TNE training and the creation of a formalized curriculum, little attention has been paid to the establishment of an empirical framework to adjudicate scientific investigation. In this position statement, we reflect on the evolution of TNE in Canadian neonatal intensive care units, appraise its strengths and limitations, and suggest guiding principles for clinicians and researchers to consider as they take this field forward.

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.

Lung ultrasonography score versus chest X-ray score to predict surfactant administration in newborns with respiratory distress syndrome

OBJECTIVES

We aim to verify the diagnostic accuracy of a lung ultrasonography (LUS) score to early predict the need for surfactant therapy in newborns with respiratory distress syndrome (RDS), and to compare it with a chest X-ray score.

METHODS

In this prospective diagnostic accuracy study we included all newborns admitted for respiratory distress and initially treated with nasal CPAP. LUS was performed within 2 h from nasal CPAP positioning and in any case before surfactant administration. A chest X-ray was also performed. A LUS score and an X-ray score were used and compared. Ability of the scores to predict surfactant administration was evaluated through ROC analysis.

RESULTS

In our population of 56 newborns with mean gestational age of 31 weeks (SD 3) and mean birth weight of 1442 g (SD 520), LUS score showed higher AUC than X-ray score in early recognition of infants with respiratory distress syndrome requiring surfactant treatment (0.94; 95%CI, 0.89-0.98; P < 0.001 vs 0.80; 95%CI, 0.74-0.86; P < 0.001). It showed also higher sensitivity (86% vs 82%), higher specificity (88% vs 76%), better positive (83% vs 69%), and negative (91% vs 87%) predictive values.

CONCLUSIONS

LUS is a non-invasive, bedside and reproducible method that could improve the management of neonatal respiratory distress. It is accurate and reliable to early identify patients who will need treatment with surfactant allowing both an early treatment and a reduction of radiation exposure.

Deuxième niveau de compétence pour l’échographie clinique en médecine d’urgence. Recommandations de la Société française de médecine d’urgence par consensus formalisé

La Société française de médecine d’urgence a élaboré en 2016 des recommandations formalisées d’experts définissant le premier niveau de compétence en échographie clinique en médecine d’urgence. Ce niveau est maintenant complété par un deuxième niveau correspondant à une pratique plus avancée utilisant des techniques non envisagées dans le premier niveau comme l’utilisation du Doppler et nécessitant aussi une pratique et une formation plus poussées. Des champs déjà présents dans le premier référentiel sont complétés, et de nouveaux champs sont envisagés. La méthodologie utilisée est issue de la méthode « Recommandations par consensus formalisé » publiée par la Haute Autorité de santé et de la méthode Delphi pour quantifier l’accord professionnel. Ce choix a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. Ce document présente les items jugés appropriés et inappropriés par les cotateurs. Ces recommandations définissent un deuxième niveau de compétence en ECMU.

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.

Role of ultrasound for central catheter tip localization in neonates: a review of the current evidence

Central catheters are known as "life lines" in intensive care units and are used frequently in neonatal intensive care unit (NICU) for multiple indications. The central catheters used in NICU includes umbilical venous catheter (UVC), umbilical arterial catheter (UAC) and peripherally inserted central catheter (PICC) lines. The tip of these central lines needs to be in a correct position as malpositioned central line tips lead to many neonatal complications. Radiograph either abdomen or chest is the most widely used modality for locating the tip of the central catheter. There are many disadvantages of radiographic confirmation of tip position and recently ultrasound (USG)/echocardiography has been used for localization of catheter tip. USG provides real-time assessment of the tip position with other added advantages like no radiation exposure, need for minimal training for performing USG, minimal handling of the neonate, identification of migration of central lines and making repositioning of central lines under USG guidance. The present evidence supports the use of USG/Echo for localization of central catheter tip and USG has shown to have good sensitivity, specificity, positive predictive value and negative predictive value when compared with a radiograph. In this review, we discuss about the role of USG/Echo in the identification of tip of central catheters in neonatal care.

Accuracy of chest radiography for positioning of the umbilical venous catheter

OBJECTIVES

To evaluate the accuracy of the simultaneous analysis of three radiographic anatomical landmarks - diaphragm, cardiac silhouette, and vertebral bodies - in determining the position of the umbilical venous catheter distal end using echocardiography as a reference standard.

METHODS

This was a cross-sectional, observational study, with the prospective inclusion of data from all neonates born in a public reference hospital, between April 2012 and September 2013, submitted to umbilical venous catheter insertion as part of their medical care. The position of the catheter distal end, determined by the simultaneous analysis of three radiographic anatomical landmarks, was compared with the anatomical position obtained by echocardiography; sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated.

RESULTS

Of the 162 newborns assessed by echocardiography, only 44 (27.16%) had the catheter in optimal position, in the thoracic portion of the inferior vena cava or at the junction of the inferior vena cava with the right atrium. The catheters were located in the left atrium and interatrial septum in 54 (33.33%) newborns, in the right atrium in 26 (16.05%), intra-hepatic in 37 (22.84%), and intra-aortic in-one newborn (0.62%). The sensitivity, specificity and accuracy of the radiography to detect the catheter in the target area were 56%, 71%, and 67.28%, respectively.

CONCLUSION

Anteroposterior radiography of the chest alone is not able to safely define the umbilical venous catheter position. Echocardiography allows direct visualization of the catheter tip in relation to vascular structures and, whenever possible, should be considered to identify the location of the umbilical venous catheter.

Optimal radiologic position of an umbilical venous catheter tip as determined by echocardiography in very low birth weight newborns

OBJECTIVE

To compare chest X-ray with echocardiogram (ECHO) in the localization of an umbilical venous catheter (UVC) tip in very low birth weight infants (VLBW). Secondary objectives determined the association between techniques for tip placement by the vertebral body level on X-ray, as well as the length of the thoracic inferior vena cava-right atrial (TIVC-RA) junction by ECHO.

STUDY DESIGN

Prospective, sequentially enrolled, masked, single regional perinatal center study. Shortly after birth, one or more anterior-posterior X-rays were ordered by the clinical team to verify that the UVC tip was fixed in the central right atrium (cRA) or at the TIVC-RA junction. An echocardiogram was performed as soon as possible after the last X-ray and UVC tip location was interpreted by a pediatric cardiologist. The pediatric radiologist and cardiologist were masked with regard to each other's reading.

RESULTS

The newborns (n = 51) were 27 (±3) weeks by gestational age with birth weights of 1029 (±288) grams (mean±SD). The radiologist read 50 UVC tips (98%) in the cRA or TIVC-RA junction and 1 (2%) in the LA. The cardiologist read 22 (43%) in the cRA or TIVC-RA, 21 (41%) in the LA and 8 (16%) tips could not be located in the heart. When the UVC tip was interpreted by X-ray as located in the TIVC-RA junction 8/29 (28%) were in the LA by echocardiogram. There was no agreement between vertebral level and tip position in the TIVC-RA junction, RA or LA. The TIVC-RA junction measured 6±1 mm and correlated with birth weight r = 0.54 (p < 0.001).

CONCLUSION

In VLBW newborns, placement of the UVC tip into the cRA or TIVC-RA junction by X-ray does not avoid misplacement in the left atrium as demonstrated by echocardiography. For VLBW infants, it is suggested that echocardiography may be helpful in verifying that the original placement or migration of the UVC tip into the LA has not occurred.

Use of Targeted Neonatal Echocardiography and Focused Cardiac Sonography in Tertiary Neonatal Intensive Care Units: Time to Embrace It?

Focused cardiac sonography and targeted neonatal echocardiography refer to goal-directed cardiac imaging using ultrasound, typically by noncardiologic specialists. Although the former consists of a rapid qualitative assessment of cardiac function, which is usually performed by acute care practitioners, the latter refers to detailed functional echocardiography to obtain quantitative and qualitative indexes of pulmonary and systemic hemodynamics in sick neonates and is typically performed by neonatologists. Although the use of these modalities is increasing, they still remain unavailable in most North American centers providing acute care to neonates, partly because of limited data regarding their direct impact on patient care. Here we present a series of 5 cases from a large perinatal unit in which immediate availability of relevant expertise led to important and arguably life-saving clinical interventions. In 4 of these cases, focused cardiac sonography was sufficient to make the diagnosis, whereas in 1 case, clinical integration of detailed systemic hemodynamics measured on target neonatal echocardiography was required.

Advantages of being diligent: lessons learnt from umbilical venous catheterisation in neonates

Umbilical venous catheters (UVCs) are commonly used in neonatal units. Abdominal radiograph, taken soon after the insertion, is used to confirm the correct placement of the catheter. However, as demonstrated by our case series, complacency when an initial UVC is normally positioned can lead to detecting UVC-related complications very late. We describe cases of three neonates where, despite the initial UVC being confirmed to be well positioned, the patients developed life-threatening complications, including liver haematoma, left atrial thrombus and pericardial effusion causing cardiac tamponade. The routine use of point of care echocardiography helped in the early diagnosis of these complications. We suggest repeated echocardiographic screening at regular intervals in all newborn babies requiring UVCs, to ensure that the catheter is maintained in the proper position and for the early detection of catheter-related complications.

[Catheter tip position and risk of mechanical complications in a neonatal unit]

INTRODUCTION

The use of central catheters (CC) is associated with mechanical complications (MC).

OBJECTIVE

Our objetive was to determine the relationship between CC positions and associated MC in neonates.

MATERIAL

A descriptive analytical study was performed over a six year period in the NICU of the University Hospital Santa Lucía de Cartagena. Details were collected on the CC used, indication, reason for withdrawal, position in the imaging, MC, and treatment arising from them, as well as epidemiological data.

RESULTS

Of the total of 604 CC studied, the majority (347) were via the umbilical vein, followed by epicutaneous (193), and femoral vein (34). There were MC in 14.2% of catheters. Incorrect position of the tip was associated with greater MC (21.1 vs 8.2%; P<.001), including withdrawal due to MC (8.4 vs 3.1%; P<.01), extravasation (4.9 vs 1.9%; P<.05), pleural and pericardial effusions (1.4 vs 0.0%; P<.05), liver haematomas (4.6 vs 0.6%; P<.01), and ascites (2.8 vs 0.0%; P<.01). The midclavicular epicutaneous position of the tip was associated with greater MC (18.5 vs 6.8%; P<.05) than the brachiocephalic (0 vs 6.8%;NS). The low and ductal position of the umbilical vein catheter was also associated with higher rates of MC (24.5 vs 6%; P<.001 and 27 vs 6%; P<.001) due to the position of the tip. The most common complication was accidentally dislodged catheter.

CONCLUSIONS

The incorrect location of the tip was associated with more MC. The midclavicular epicutaneous had more risk than centrally or brachiocephalic locations. The low and ductal positions of the umbilical vein catheter were associated with higher rates of MC.

Pleural effusion caused by a malpositioned umbilical venous catheter in a neonate

Umbilical venous catheterisation (UVC) insertion is a common procedure performed in most neonatal units. We report a case of a neonate who developed pleural and pericardial effusions and ascites due to a malpositioned UVC causing diaphragmatic perforation. Timely diagnosis using bedside sonography and prompt removal of the catheter resulted in resolution of the effusions without undue complications.