The neonatal peripherally inserted central catheter (PICC) is commonly inserted in the neonatal intensive care unit (NICU) for long-duration intravascular access and the tip of PICC is normally placed at the junction of the right atrium and either superior or inferior vena cava [1]. Often the catheter tip is not in the correct place and requires manipulation and frequent radiographs [2,3]. In this study, we sought to determine the time taken-up by bedside ultrasound (as compared to X-ray) and its accuracy for PICC placement and tip confirmation.

A cross-sectional study was conducted at the neonatal intensive care unit, Manipal hospital, Bangalore from August, 2017 to September, 2018, among neonates requiring PICC line insertion as a part of their intensive care management. The study protocol was cleared by the Ethics Committee of Manipal Hospital. Data were collected in a pre-designed proforma after taking consent from parents. Neonates with major congenital anomalies involving thorax and abdomen were excluded from the study.

Objectively, the time taken during the confirmation of the tip of PICC by using bedside ultrasound and digital X-ray in each patient was determined, and also the number of attempts was documented. PICC line was placed by the neonatal fellow under the guidance of the consultant neonatologist. Ultrasound was performed by Philips CX50 by using an S 12-4 frequency footprint probe in the subcostal sagittal view to identifying the inferior vena cava and high parasternal view to identify superior vena cava. After the insertion of predetermined length, the tip was visualized and manipulated by using real-time ultrasound for optimal position. A small volume (1 mL) of sterile normal saline was injected to confirm the location of the catheter tip. Bedside digital X-ray was ordered at the same time. Time taken to confirm the position of the tip of PICC was recorded by using bedside ultrasound and X-ray. The start time was defined as the time of ordering X-ray after inserting the predetermined length of the PICC catheter. The starting time was the same for ultrasound and X-ray, whereas the completion time was defined as the time when ultrasound confirmed the tip of the PICC catheter and for the X-ray method when the X-ray was read by the neonatologist on-site. A single attempt was counted after the determination of tip by ultrasound and catheter fixed. The repositioning of the catheter was done if the position was not correct as confirmed by X-ray.

Forty neonates out of a total of 300 neonates admitted to neonatal intensive care unit during the study period which required PICC insertion; consent could not be obtained for seven neonates. For these 33 neonates (72% males, 72% appropriate for gestational age), the mean (SD) gestational age and birthweight were 29 (3) weeks and 1087 (561) g.

The mean (SD) time taken in tip confirmation by using bedside ultrasound was 5.1(1.2) minutes, X-ray it was 28 (8.1) minutes (P<0.001). The catheter tip was in an optimal position in the first attempt in 30 (91%) neonates after the ultrasound and confirmed by X-ray. In these three cases (9%) the tip of the PICC catheter was in the right atrium after first attempt confirmation. There was no inter-observer variation in the interpretation of the result.

Previous studies [4-8] have also shown that the mean time taken in confirmation of tip by using ultrasound is significantly less than standard care. The accuracy of ultrasound was also comparable with radiography. By using ultrasound, we can reduce radiation exposure, and ensure lesser handling of babies.

Bedside ultrasound is an accurate and time-efficient modality to guide the insertion and confirmation of the tip of the PICC line. However, training of neonatologists in ultrasound may be required before routine use of this modality.

Contributors: SS: collected data and wrote the article; HAV: planned study and supervised data collection; RS: statistical analysis and literature review; NKN: drafted and reviewed the final manuscript. All authors approved the final version of the manuscript.

Funding: None; Competing Interest: None stated

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