Benjamin W Kozyak, María V Fraga, Courtney E Juliano, Shazia Bhombal, David A Munson, Erik Brandsma, Jason Z Stoller, Ankit Jain, Russell Kesman, Malorie Meshkati, Caroline Y Noh, Aaron G Dewitt, Andrew T Costarino, David A Hehir, Alan M Groves. Pediatr Crit Care Med. 2022;23(5):e257-e266. doi: 10.1097/PCC.0000000000002919. Epub 2022 Mar 7. PMID: 35250003
Take Home Points:
- Ultrasound guidance, coupled with liver pressure, can markedly improve successful placement of umbilical venous catheters in neonates with congenital heart disease (CHD).
- Routine use and training of this point-of-care ultrasound technique may reduce x-ray imaging and spare central veins, which are essential in patients with complex CHD.
Commentary from Dr. Milan Prsa (Switzerland, Europe), section editor of Congenital Heart Disease Interventions Journal Watch:
Umbilical venous access is routinely obtained in neonatal ICUs and is indispensable for optimal care of patients with complex congenital heart disease (CHD). However, successful placement of an umbilical venous catheter (UVC) at the inferior cavoatrial junction has been reported at only 50-75%. The authors describe and report on the success of their technique to rescue malpositioned UVCs.
Over a period of 26 months, 32 neonates with CHD underwent ultrasound-assisted UVC placement by experienced neonatologists across three centers, all after previous failed attempts at traditional, blind insertion. The technique used starts with imaging the trajectory the UVC will follow from the umbilical vein (UV) to the portal sinus, and then through a patent ductus venosus (DV) to the inferior cavoatrial junction. Patency of the DV is evaluated with color Doppler or injection of agitated saline. The catheter is then advanced under direct visualization to the portal sinus, where probe pressure on the liver distorts the portal sinus to enhance its alignment with the DV, allowing a straighter trajectory from the UV and preventing malposition of the catheter in the portal veins (Figure 1). With this technique, malpositioned UVCs were rescued in 23 of 32 patients (72%), including 18 of 24 patients (75%) on prostaglandin. None of the patients required other central venous access, and there were no catheter-associated complications or cases of portal vein thrombosis.
Figure 1. Effect of liver pressure on producing a straighter trajectory from the UV to the DV (*), avoiding malposition in the portal veins (# and arrows).
This multicenter case series demonstrates that use of point-of care ultrasound (POCUS) to rescue malpositioned UVCs has a high success rate in neonates with complex CHD. However, this was possible in large academic centers with providers who had significant prior experience with POCUS. Nevertheless, the potential benefits of preserving precious central veins and reducing radiation exposure in patients with complex CHD should serve to encourage providers in centers with POCUS capabilities to undergo formal training and implement this technique.
