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.
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.
KeywordsPoint of care ultrasound (POC-US) X-ray Central venous line (CVL) Agreement Echocardiographic views
Central venous line
Generalized linear mixed model
Inferior vena cava
Neonatal intensive care unit
Peripherally inserted central catheter
Point of care ultrasound
Superior vena cava
Umbilical venous catheter
NZ contributed to the conception, organization, and oversight of the study, data analysis and interpretation, the writing of the original manuscript draft, and final approval of the version to be published.
LW contributed to data analysis and interpretation, critical manuscript revision, and final approval of the version to be published.
JCR contributed to data analysis and interpretation, critical manuscript revision, and final approval of the version to be published.
SP contributed to critical manuscript revision and final approval of the version to be published.
DK contributed to the oversight of the study, data analysis and interpretation, critical manuscript revision, and final approval of the version to be published.
This research was funded by Department of Pediatrics at Cohen Children’s Medical Center of NY given to NZ.
Compliance with ethical standards
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 2013 Helsinki declaration.
Conflict of interest
The authors declare that they have no conflict of interest.
Informed consent was not available as the study was approved by the Institutional Review Board as a quality improvement study and informed consent was not needed.
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