Sonography-guided positioning of intravenous long lines in neonates

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Abstract

Objective

In neonates, proper positioning of the tip of intravenous long lines (LL) is essential in order to prevent potential life-threatening complications. The gold standard for the evaluation of LL position in neonates is the chest X-ray with or without contrast.

We performed a prospective study to assess the use of transthoracic ultrasonography (US) for the positioning of LL in neonates and to compare it to plain radiography.

Materials and method

Thirty-six consecutive neonates requiring percutaneous LL over a period of 3 months were included in the study. Immediately after LL insertion, the position of its tip was verified using transthoracic US, followed by plain radiography. The two techniques were compared in terms of adequate placement and length of time between insertion and radiographic evaluation of the correct position.

Results

The correlation between positioning by US and plain radiography was very good (r = 0.97, r2 = 0.94, p < 0.0001). The time needed to verify LL placement by US was shorter by a mean 15 min compared to plain radiography.

Conclusion

US can accurately guide LL tip positioning. We believe that because of the potential gain of time it offers and its lack of ionising radiation, it to be considered as an interesting tool for the positioning of LL in neonates. Yet more accurate results could be obtained with a better-trained staff.

Introduction

Percutaneous long lines (LL) are commonly used in neonates for parenteral nutrition. Great care must be paid to the proper positioning of the tip of the LL in order to avoid potentially fatal complications (direct tissue injury, intravascular thrombosis, embolism, parenteral nutrition risks, infection, delayed effusion, pericardial effusion with cardiac tamponade). Chest X-ray, with or without contrast is the actual gold standard for LL positioning in neonates. Though ultrasonographic (US) detection of LL has already been reported in neonates [1], [2], this technique, to our knowledge, has not yet been used to guide positioning of the tip during insertion. We prospectively studied the feasibility and accuracy of sonography-guided LL tip positioning in neonates.

Section snippets

Materials and methods

Between March 2005 and June 2005, all neonates admitted to our tertiary care unit and requiring an intravenous percutaneous LL were included in a prospective study. Percutaneous 24G–30 cm “Epicutaneo-cava Katheters” (Vygon®, Germany) were inserted by various paediatricians, each using the same standard procedure. In each case, we estimated, prior to the insertion, the required length of catheter. To do so, we measured on the skin, the distance between the estimated point of insertion (hand,

Results

Thirty-six consecutive neonates were included in the study. Gestational age was 30.6 ± 3.7 weeks (range 26–40; median 30) and birth weight was 1559 ± 769 g (range 620–3550; median 1305). The age at insertion of the LL was 10 ± 12 post-natal days (range 1–43; median 4). After positioning by US, the catheter tip was in a proper position in 62% of cases (23/36 neonates) in comparison with chest X-ray. It was repositioned in 25% of cases (9/36). The tip of the LL was undetectable by US in 13% of cases

Discussion

Percutaneous LL are usually necessary for parenteral nutrition in neonatology especially in very low birth-weight neonates [4]. Though the tip's proper position is considered to be at the junction of the superior or inferior vena cava and the right atrium, the primordial point is that it must be outside the cardiac chamber [1], [5], [6], [7], [8], [9]. Correct position of the tip of the LL is mandatory because if the tip is in the cardiac chamber (Fig. 3), potentially life-threatening

Conclusion

This prospective study indicates that US is adequate and fares well in comparison with plain radiography for the detection of LL tips during their insertion in neonates. Further studies are necessary in order to evaluate its use as first-line exploration in this setting. Nevertheless, we believe that in the current setting of quality care, the appreciable gain of time, and the fact that US does not expose to ionising radiations or the complications of contrast injection pleads strongly in

Conflict of interest

No conflicts of interest have to be declared for this work.

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