Objective of the study was to compare number of X-rays performed for neonatal central line tip positioning when real-time US is used compared to X-ray only, and to assess consequences on position accuracy, irradiation and cost. Retrospective monocentric cohort study conducted at Evelina London Children's Hospital Neonatal Unit over 6 months. Study was conducted during implementation of US for line tip localisation with formulation of US protocol. Tip position on X-ray was reviewed by one neonatologist and one radiologist and inter-rater agreement calculated. Criteria for good, satisfactory or inadequate position of the tip were defined. Estimated effective radiation dose and cost for each X-ray was determined. Two hundred seventy-four lines were inserted (nPICC, UVC, UAC). Eighty-three lines were scanned with US (US group); 191 lines were not (no-US group). Number of X-rays performed was significantly lower in the US group: 1.19 vs. 1.5 (p 0.001), related to a significantly lower percentage of lines requiring multiple X-rays (38.7% no-US group vs. 19.9% US group; p 0.004). Accuracy was higher in US group with more lines at cavoatrial junction (p 0.05) and was significantly increased with US use for lines inserted from lower limbs (22.9% and 76.2%, p 0.001). Inter-rater agreement was strong (k > 0.8). US group received lower mean radiation dose (p < 0.001) and cost related to X-ray was significantly reduced (p 0.001).Conclusion: Real-time US use for line tip positioning in the NICU significantly decreased the number of X-rays performed and was associated with better-positioned lines, decreased irradiation and cost. What is Known:• The use of point-of-care ultrasound (PoCUS) by critical care providers in neonatology has increased in recent years. International guidelines advocate for the use of PoCUS as valid guidance to practical procedures in neonatology. • Central catheters (umbilical catheters and neonatal peripherally inserted central catheters) are among the most commonly used devices to support NICU patients. Proper positioning is crucial to avoid complications and PoCUS has high sensitivity and specificity in accurately determining line tip position. The current standard practice for line tip position confirmation in neonatology is still conventional radiography despite multiple evidenc suggest significant inaccuracy of X-ray compared to ultrasound. What is New: • PoCUS implementation for line tip positioning leads to a significant decrease in the number of X-rays performed, in radiation effective dose and costs. PoCUS evaluation of central catheters significantly increases the accuracy of the final line tip position with more lines at the cavoatrial junction. • Training is fundamental for univocal interpretation of ultrasound images and an effective learning strategy is being proposed.
No consensus exists regarding the definition of ventilator-associated pneumonia (VAP) in neonates and reliability of chest X-ray (CXR) is low. Lung ultrasound (LU) is a potential alternative diagnostic tool. The aim was to define characteristics of VAP in our patient population and propose a multiparameter score, incorporating LU, for VAP diagnosis. Between March 25, 2018, and May 25, 2019, infants with VAP were identified. Clinical, laboratory and microbiology data were collected. CXRs and LU scans were reviewed. A multiparameter VAP score, including LU, was calculated on Day 1 and Day 3 for infants with VAP and for a control group and compared with CXR. VAP incidence was 10.47 episodes/1000 ventilator days. LU and CXR were available for 31 episodes in 21 infants with VAP, and for six episodes in five patients without VAP. On Day 1, a VAP score of > 4, and on Day 3 a score of > 5 showed sensitivity of 0.94, and area under the curve of 0.91 and 0.97, respectively. AUC for clinical information only was 0.88 and for clinical and CXR 0.85. Conclusion: The multiparameter VAP score including LU could be useful in diagnosing VAP in neonates with underlying lung pathology. What is Known: • Ventilator associated pneumonia (VAP) is common in infants on the neonatal unit and is associated with increased use of antibiotics, prolonged ventilation and higher incidence of chronic lung disease. • Commonly used definitions of VAP are difficult to apply in neonates and interpretation of chest X-ray is challenging with poor inter-rater agreement in patients with underlying chronic lung disease. What is New: • The multiparameter VAP score combining clinical, microbiology and lung ultrasound (LU) data is predictive for VAP diagnosis in preterm infants with chronic lung disease. • LU findings of VAP in neonates showed high inter-rater agreement and included consolidated lung areas, dynamic bronchograms and pleural effusion.
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