Variation in identifying neonatal percutaneous central venous line position

Role of a radiopaque agent and surveillance radiographs for peripherally inserted central catheters in newborn infants

BACKGROUND

Controversy exists regarding the use of a radiopaque agent to identify peripherally inserted central catheter (PICC) tip positions in newborn infants and of serial radiography to monitor PICC tip migration.

OBJECTIVE

To investigate the roles of (1) the injection of a radiopaque agent to identify PICC tip position and (2) the performance of weekly radiography to monitor PICC migration.

MATERIALS AND METHODS

This retrospective single-centre cohort study included newborn infants who received a PICC between 1 January 2016 and 31 December 2020. A radiopaque agent was injected to identify PICC tip position and radiographs were performed weekly to detect PICC migration.

RESULTS

We identified 676 PICC episodes in 601 infants. A radiopaque agent was used for 590 of these episodes. There was no difference in the proportion of central PICC tip positions based on radiopaque agent use status (490/590, 83% for the radiopaque agent used group versus 73/85, 85.8% for the radiopaque agent not used group, P=0.51). Irrespective of the site of PICC insertion, outward migration was observed for most centrally placed PICCs over their entire in situ duration. Inward migration was identified in 23 out of 643 PICC episodes (3.6%) only on radiographs obtained on or before day 7. Based on serial radiographs, the odds for PICC tips remaining in a central position were lower the longer the PICC remained in situ (adjusted odds ratio-OR 0.93; 95% confidence interval 0.92-0.95). There was no difference in PICC migration between side and limb of insertion.

CONCLUSION

PICC tips can be identified without injection of a radiopaque agent. Serial radiographs identified PICC migration over the in situ duration. This study has implications for reducing exposure to a radiopaque agent and ongoing migration surveillance practices.

High-resolution feature based central venous catheter tip detection network in X-ray images

Hospital patients can have catheters and lines inserted during the course of their admission to give medicines for the treatment of medical issues, especially the central venous catheter (CVC). However, malposition of CVC will lead to many complications, even death. Clinicians always detect the malposition based on position detection of CVC tip via X-ray images. To reduce the workload of the clinicians and the percentage of malposition occurrence, we propose an automatic catheter tip detection framework based on a convolutional neural network (CNN). The proposed framework contains three essential components which are modified HRNet, segmentation supervision module, and deconvolution module. The modified HRNet can retain high-resolution features from start to end, ensuring the maintenance of precise information from the X-ray images. The segmentation supervision module can alleviate the presence of other line-like structures such as the skeleton as well as other tubes and catheters used for treatment. In addition, the deconvolution module can further increase the feature resolution on the top of the highest-resolution feature maps in the modified HRNet to get a higher-resolution heatmap of the catheter tip. A public CVC Dataset is utilized to evaluate the performance of the proposed framework. The results show that the proposed algorithm offering a mean Pixel Error of 4.11 outperforms three comparative methods (Ma's method, SRPE method, and LCM method). It is demonstrated to be a promising solution to precisely detect the tip position of the catheter in X-ray images.

Radiologist variability in assessing the position of the cavoatrial junction on chest radiographs

OBJECTIVE

To assess the variability in identifying the cavoatrial junction (CAJ) on chest X-rays (CXRs) amongst radiologists.

METHODS

23 radiologists (13 consultants and 10 trainees) assessed 25 posteroanterior erect CXRs (including 8 duplicates) and marked the positions of the CAJ. Differences in the CAJ position both within and between observers were evaluated and reported as limits of agreement (LOA), repeatability coefficients (RCs) and intraclass correlation coefficients and were displayed graphically with Bland-Altman plots.

RESULTS

The mean difference for within-observer assessments was -0.2 cm (95% LOA, -1.5 to +1.1 cm) and between observers, it was -0.3 cm (95% LOA, -2.5 to +1.8 cm). Intraobserver RCs were marginally lower for consultants than for trainees (1.1 vs 1.5). RCs between observers were comparable (2.1 vs 2.2) for consultants and trainees, respectively.

CONCLUSION

This study detected a large interobserver variability of the CAJ position (up to 4.3 cm). This is a significant finding considering that the length of the superior vena cava is reported to be approximately 7 cm. We conclude that there is poor consensus regarding the CAJ position amongst radiologists.

ADVANCES IN KNOWLEDGE

No comparisons exist between radiologists in determining CAJ position from CXRs. This report provides evidence of the large observer variability amongst radiologists and adds to the discussion regarding the use of CXRs in validating catheter tip location systems.

Evaluation of neonatal peripherally inserted central catheter tip movement in a consistent upper extremity position

OBJECTIVE

To compare the effect of standardized upper extremity position versus varied upper extremity positions on neonatal peripherally inserted central catheter (PICC) tip placement and movement. Secondary outcomes assessed were compliance with education, implementation, and complication rates.

STUDY DESIGN

Tip movement was analyzed between 136 post-PICC insertion x-ray pairs from 72 infants in the 6 months before and after standardization of upper extremity position. Tip movement was regressed over days between x-ray pairs, respiratory support, absolute weight change, and insertion vein.

RESULTS

There was no difference in PICC tip movement among varied analysis pairs or when standard position pairs were compared with pairs that were in a same nonstandard position. Days between x-rays, respiratory support, absolute weight change, and insertion vein did not predict tip movement. Attendance at education sessions was 100%. Compliance with the new standard was 73%. Complication rates were not significantly different.

CONCLUSION

Standardization of upper extremity position during neonatal PICC confirmation x-rays did not alter PICC tip movement.

A previously undescribed etiology for oliguria in a premature infant with a peripherally inserted central catheter

Peripherally inserted central catheter use has become widespread in the management of premature infants as a means to provide long-term intravenous therapy and nutritional support until enteral feedings can be established. Peripherally inserted central catheters are not without complications. This article describes the case of a premature infant with oliguria with the suspected etiology of a malpositioned catheter tip at a location where it was either occluding/blocking the renal vein(s) or causing damage to the kidney(s) from administration of hypertonic total parenteral nutrition solution directly into the renal vein(s). Peripherally inserted central catheter position should be verified radiographically and evaluated serially in any infant, even more so in an infant with symptoms of oliguria and possible sepsis.

Are supine chest and abdominal radiographs the best way to confirm PICC placement in neonates?

BACKGROUND

Peripherally inserted central catheters (PICCs) are commonly used in NICUs. Although they have many benefits, they also have many potential complications. Confirming catheter tip position is essential to decreasing complications, but the best method to achieve confirmation is unclear.

OBJECTIVES

Literature review for studies that address line position confirmation to assist health care providers in evaluating the available research and to identify gaps in the literature.

METHOD

A literature search of four major databases followed by an ancestry approach was performed. Articles reviewed specifically discuss PICC lines and PICC line placement confirmation.

RESULTS

Data on confirming PICC placement were lacking. Fluoroscopic placement is ideal, but cannot be done at the bedside and is costly. Supine chest radiograph is the most widely used method and is convenient, but when line tip position is unclear, contrast or ultrasound confirmation can be used. When PICC lines are placed in the saphenous vein, infants may benefit from supine and lateral abdominal radiographs to ensure placement in the inferior vena cava.

DISCUSSION

More studies are needed to generalize findings. PICC line tips should be located in the superior vena cava or inferior vena cava close to the junction with the right atrium (0.5-1 cm outside of the cardiac chambers in premature infants and 1-2 cm outside of the cardiac chambers in larger infants). Arm position is very important when performing radiographs for placement because movement of the arm can cause migration of the catheter. There is also significant inter-observer variability when identifying line tip position.

The reliability of 2D and colour Doppler ultrasound in localising longline position

BACKGROUND

The position of percutaneously inserted central venous catheters (longlines) in neonates is critical, as malpositioned longlines are associated with potentially fatal complications.

AIM

To determine if cardiac ultrasound (two-dimensional (2D) and colour Doppler) is useful in evaluating longline position, when compared with the position identified by contrast radiography.

SETTING

Single level 3 neonatal unit.

PARTICIPANTS

Forty-four neonates undergoing insertion of 24-gauge silastic longlines between July 2004 and September 2005.

METHODS

Infants who had a longline inserted underwent echocardiography by a novice and an experienced operator. Operators identified longline position using a 2D then colour Doppler echocardiography during a rapid bolus infusion of saline. The position was identified from contrast radiography by two independent observers.

RESULTS

Using 2D echocardiography, the novice and experienced operators could identify 41 and 59% of longlines, respectively. However, only 34% of longlines were identified by both operators. In 15 infants whose longline positions were identified by both operators, there was agreement in only eight infants (53%). Colour Doppler improved the experienced operator's success but did not assist the novice operator. For radiographs, there was 68% agreement on longline position between observers. The experienced echocardiographer located three (7%) longlines within the heart that from radiographs were thought to be in a proximal central vessel.

CONCLUSIONS

This technique is experience-dependent and complements rather than replaces the use of contrast radiography. However, some infants with an apparently acceptable longline position on contrast radiography have longlines located within the heart on echocardiography.