Normal and abnormal position of the umbilical artery and venous catheter on the roentgenogram and review of complications

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.

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.

Ultrasound assessment of umbilical venous catheter migration in preterm infants: a prospective study

OBJECTIVES

To evaluate the umbilical venous catheter (UVC) tip position by ultrasound and compare it with standard radiograph findings and to examine the catheter tip migration rates during the first week of life.

DESIGN

Prospective observational study of inborn preterm infants who had an UVC placed and its position radiographically confirmed. The first ultrasound was done on UVC placement at median (IQR) age of 2 hours (1-4) and follow-up scans at a median (IQR) age of 34 hours (27-44 hours), 77 hours (70-94 hours) and 6 days (5-7 days) after insertion. Catheter tip was considered in optimum position if tip was lying in the inferior vena cava up to the right atrium opening.

RESULTS

We studied 65 infants at a mean (±SD) gestational age and birth weight of 26.4 (±2.1) weeks and 808 (±289) g, respectively. Ultrasound confirmed optimum position of UVC tip in 25/65 (38.5%) infants. Majority (38/40) of the malpositioned catheters were located inside the heart with 15 reaching the left atrium. Catheter tip migration occurred in 29 of 58 infants (50%) at any time during the first week. The proportions of UVC migration were found to be 17%, 31% and 29% on subsequent ultrasound with a trend to outward movement over time.

CONCLUSION

UVC tip localisation by standard radiography is very imprecise, and catheter tip migration occurs in a significant proportion of infants during first weeks of age. We suggest ultrasound as the best modality to assist localisation and follow-up of UVC tip in preterm infants.

Umbilical venous catheters placement evaluation on frontal radiogram: application of a simplified flow-chart for radiology residents

BACKGROUND

Umbilical Venous Catheter (UVC) are commonly used in neonatal period; they can be not correctly positioned and could be associated with complications. The purpose of this article is to suggest a flow-chart to evaluate the placement of UVC, testing it in young radiologists-in-training.

METHOD

We developed a simple flow-chart to asses, steps by step, UVC placement considering its course and tip location (ideally placed in the atriocaval junction). We tested the flow-chart impact asking to 20 residents to evaluate the placement of 10 UVC before and after they familiarized with the flow-chart and the anatomical findings of a newborn. The agreement among the 20 students was evaluated too.

RESULTS

The number of correct characterizations was different due to the administration of the flow-chart. One hundred and six correct UVC assessments at the beginning switched to 196 after the administration of the flow-chart (p = 0.0001). The observed agreement among the twenty radiology residents was statistically significant, both before (kappa = 0.41, p < 0.001) and after (kappa = 0.37, p < 0.001) the flow-chart administration.

CONCLUSION

The developed flow-chart demonstrated to be useful in increasing residents performance in UVC placement assessment.

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.

Rates of intracardiac umbilical venous catheter placement in neonates

OBJECTIVES

To review umbilical venous catheter (UVC) placement in neonates who underwent targeted neonatal echocardiography (TNE) and to correlate catheter tip placement on TNE and anteroposterior thoracoabdominal radiography.

METHODS

We conducted a retrospective analysis of 51 neonates who had UVC positions assessed by TNE and radiography in a neonatal intensive care unit (NICU). A single operator performed all TNE examinations. The final radiographic catheter placement was taken from the image closest to the time of echocardiography. Fisher exact, χ(2), and t tests were used as appropriate.

RESULTS

Among the 51 neonates who had catheters placed for 24 hours or more, TNE was performed on 48 in the first 48 hours, 2 at day 6, and 1 at day 9. Thirty-six neonates were extremely low birth weight (ELBW; <1000 g). Twenty-nine had good catheter tip positions, and 22 had catheters inside the heart (10 in the right atrium [RA], 3 at the foramen ovale, and 9 in the left atrium [LA]). Twenty neonates with catheter tips in the heart were ELBW, including 8 with catheters in the LA. The ELBW neonates were more likely to have catheters in the heart than non-ELBW neonates (20 of 36 versus 2 of 15; P= .01; odds ratio [OR], 8.1; confidence interval [CI], 1.59-41.3). Good placement on TNE varied widely in relation to thoracic vertebral landmarks on radiography: from the T7-8 interspace to T11. When radiography showed a catheter tip at T9-T10, there was no difference in the proportion of neonates with a good catheter position versus malposition (8 of 22 versus 8 of 29; P = .55; OR, 0.67; CI, 0.20-2.19).

CONCLUSIONS

A high proportion of ELBW neonates in a busy NICU had UVCs placed with the tips in the RA or LA despite common placement practices. We recommend adding TNE to radiography to position UVCs, especially in ELBW neonates.

Determination of umbilical venous catheter tip position with radiograph

OBJECTIVES

To compare the cardiac silhouette method with the vertebral body method in predicting the umbilical venous catheter tip position on ultrasound; to measure the length of the target zone for the umbilical venous catheter tip; and to determine the time taken for a neonatologist to ascertain position of the umbilical venous catheter tip with ultrasound.

DESIGN

Prospective cohort study.

SETTING

Neonatal ICU.

PATIENTS

Newborn infants with an umbilical venous catheter.

INTERVENTIONS

Ultrasound scans to determine the umbilical venous catheter tip position were performed within an hour of corresponding anteroposterior chest-abdominal radiograph.

MEASUREMENTS AND MAIN RESULTS

Two hundred paired radiograph and ultrasound scans in 82 newborn infants were analyzed. Each radiograph was reviewed independently by an experienced neonatologist who recorded the position of the umbilical venous catheter tip by vertebral level and by the cardiac silhouette method. For each method, the sensitivity, specificity, and positive and negative predictive values were calculated for the prediction of the true position of the catheter tip on ultrasound. The umbilical venous catheter tip was well positioned in just 28 of 200 scans. The cardiac silhouette method was superior to the vertebral level method for all test variables, with a sensitivity and specificity of 86% and 94% compared with 61% and 74%. The length of the target zone approximates to a single T8 vertebral body height on radiograph.

CONCLUSIONS

For radiograph and ultrasound scans performed within an hour of each other, the cardiac silhouette method more accurately predicts umbilical venous catheter tip than vertebral body level and methods described in previous studies. Catheters are frequently malpositioned. The length of the target zone for optimal umbilical venous catheter tip position is short. Ultrasound assessment of umbilical venous catheter tip position is quick.

Critical skills and procedures in emergency medicine: vascular access skills and procedures

The venous and/or arterial vasculature may be accessed for fluid resuscitation, testing and monitoring, administration of blood product or medication, or procedural reasons, such as the implantation of cardiac pacemaker wires. Accessing the vascular system is a common and often critically important step in emergency patient care. This article reviews methods for peripheral, central venous, and arterial access and discusses adjunct skills for vascular access such as the use of ultrasound guidance, and other forms of vascular access such as intraosseus and umbilical cannulation, and peripheral venous cut-down. Mastery of these skills is critical for the emergency medicine provider.

The ductus venosus

The ductus venosus is a blood vessel functioning exclusively in the fetal circulation. According to many reports it was described for the first time by Giulio Cesare Arantius (Bologna 1530–1589) in his bookDe humano foetu libellus(1563) and it is often referred to as the ductus Arantii. Thorough research, however, has made it clear that Andreas Vesalius described this vessel in 1561 in his bookExamen observationium Falloppii, which was published three years later. Moreover, it has been pointed out that the first and second editions of Arantius’s book did not contain a description of the ductus venosus but that this appeared in the 1571 edition.

Complications of umbilical vein catheterization: neonatal total parenteral nutrition ascites after surgical repair of congenital diaphragmatic hernia

A 2-day-old girl was admitted to surgery for repair of a left-sided diaphragmatic hernia (CDH). Preoperatively, an umbilical vein catheter (UVC) was inserted with the tip in the left hypochondrium. The UVC tip position was unchanged radiographically peroperatively. At the fifth postopertive day abdominal distension and signs of gastric outlet obstruction appeared. Explorative laparotomy found liver necrosis at the site of the catheter tip and parenteral nutrition ascites.

Gallery of medical devices

This article provides an overview of the multitude of medical devices used in patients from head to toe. Simple line drawings show a wide assortment of medical devices. These drawings and the accompanying short descriptions are to be used for quick reference to identify some of the more common medical devices that are certain to appear on everyday radiographs. There is an extensive bibliography for the reader to obtain more detailed information about a particular device or medical apparatus. Knowing the specific name of a device is nearly impossible and is really not necessary, in particular, the eponyms attached to all manner of orthopedic apparatus. Many device names have evolved from their original meaning. What is important is the device's function and the recognition of its presence, as well as an understanding of its use and potential complications.

Central venous silastic catheters in newborns: localization by sonography and radiology

The positioning of various central venous catheters in newborns including very thin silastic catheters has been checked by sonography. Even the very thin silastic catheters are easily detectable owing to their strong echoes. Diverse malpositions are presented, including non-central positioning detected by sonography. The frequency of control radiographs could be reduced.

Umbilical vascular catheters: localization by two-dimensional echocardio/aortography

Umbilical vascular catheters are often necessary in the care of critically ill neonates. Position of the catheter tip is usually determined by roentgenography. Location of the umbilical arterial or venous catheter was determined by 2-dimensional echocardio/aortography in 55 consecutive infants and was compared to localization by thoraco-abdominal roentgenography. Most of the infants (76%) had respiratory distress syndrome or congenital heart disease. Echocaortographic localization of the umbilical arterial catheter correlated very closely (N = 50, sr = .90) with roentgenographic determination. For localization of the tip of the umbilical venous catheters, echocardiography was more accurate than roentgenography (employing contrast echocardiography for confirmation of cardiac chamber position). Two-dimensional echocardio/aortographic localization of the tip of indwelling umbilical vascular catheters is as accurate as roentgenography in the arterial system and more accurate than x-ray for umbilical venous catheters. Echocardio/aortography is superior to roentgenography (in localizing the catheter tip) because it 1) avoids ionizing radiation, 2) makes positioning of the patient unnecessary, 3) allows visualization of the catheter in relation to cardiovascular structures, and 4) may allow demonstration of intraarterial thrombo-emboli.

Tubes wires and the neonate

The structure and function of the various tubes and wires that may be seen on radiography of neonates undergoing intensive care are described. The desired position for these and some examples of the consequences of malposition are considered and illustrated; practical conclusions are made.

Role of catheter surface morphology on intravascular thrombosis of plastic catheters

The role of catheter surface roughness in initiation and propagation of intravascular catheter thrombosis was studied in dogs, utilizing the scanning electron microscope. Catheters were inserted in major arteries and veins for 200 min and the animals then sacrificed. Catheter segments, both with and without associated thrombi, were scrutinized with the scanning electron microscope. No correlation was found between catheter surface roughness and thrombus formation, suggesting that the inherent chemical characteristics of the catheter is most important in the initiation of intravascular catheter thrombus formation.

Hazards of calcium gluconate therapy in the newborn infant: intra-arterial injection producing intestinal necrosis in rabbit ileum

Five infants received 10% calcium gluconate via umbilical artery catheters, which resulted in intestinal bleeding and lesions of the buttock, anus, groin, and thigh. The effects of intra-arterial calcium gluconate in two animal models were investigated. Injection of calcium into the aorta in the region of the posterior mesenteric artery resulted in immediate hyperperfusion of the descending colon; this may be an early hemodynamic response to injury in the area of colon supplied by this vessel. Injections into the arterial arcade of the rabbit ileum resulted in intestinal necrosis and villous atrophy. The use of umbilical artery catheters for administration of calcium gluconate is potentially hazardous.

The placement of the umbilical venous catheter in the newborn and its relationship to the anatomy of the umbilical vein, ductus venosus and portal venous system

The importance of lateral as well as AP views for the correct placement of the umbilical venous catheter is stressed. The position of the catheter is related to the anatomy of the ductus venosus which is demonstrated by contrast injection. Air in the portal venous system is not always indicative of a serious process.

Umbilical vein catheterization and portal hypertension

Portal hypertension is a rarely encountered late complication of umbilical vein catheterization. A survey of the 38 cases previously published is presented together with an additional case report. It is concluded that catheterization for more than 2 days carries an increased risk of thrombosis, and that umbilical artery catheterization should be preferred in the majority of cases due to a reduced risk of complications. The correct position of the catheter tip must always be controlled by fluoroscopy or X-ray. Infusion of hypertonic solutions with unphysiological pH should be restricted and umbilical vessel catheterization should only be carried out in severe cases. Pretreatment of the catheters with heparin possibly reduces the hazards.