European Journal of Pediatrics

, Volume 178, Issue 2, pp 173–179 | Cite as

The superiority of point of care ultrasound in localizing central venous line tip position over time

  • Nahla ZaghloulEmail author
  • Laura Watkins
  • Jennie Choi-Rosen
  • Shahana Perveen
  • Dalibor Kurepa
Original Article


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.

Conclusions: Agreement between POC-US and X-rays for CVL tip position was high, with the highest in BW < 1000 g. The data suggest that POC-US can be used for initial confirmation and follow up of CVL tip position.

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.


Point of care ultrasound (POC-US) X-ray Central venous line (CVL) Agreement Echocardiographic views 



Agreement coefficient




Birth weight


Cavoatrial junction


Central venous line


Confidence intervals


Generalized linear mixed model


Inferior vena cava


Left atrium


Neonatal intensive care unit


Peripherally inserted central catheter


Point of care ultrasound


Right atrium


Superior vena cava




Umbilical venous catheter


Author contributions

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

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.


  1. 1.
    Ades A, Sable C, Cummings S, Cross R, Markle B, Martin G (2003) Echocardiographic evaluation of umbilical venous catheter placement. J Perinatol 23:24–28CrossRefGoogle Scholar
  2. 2.
    Alonso-Quintela P, Oulego-Erroz I, Rodiguez-Blanco S, Muñiz-Fontan M, Lapeña-López-de Armentia S, Rodriguez-Nuñez A (2015) Location of the central venous catheter tip with bedside ultrasound in young children: can we eliminate the need for chest radiography? Pediatr Crit Care Med 16(9):e340–e345. CrossRefGoogle Scholar
  3. 3.
    Brissaud O, Harper L, Lamireau D, Jouvencel P, Fayon M (2010) Sonography- guided positioning of intravenous long lines in neonates. Eur J Radiol 74(3):e18–e21. CrossRefGoogle Scholar
  4. 4.
    Collier PE, Goodman GB (1995) Cardiac tamponade caused by central venous catheter perforation of the heart: a preventable complication. J Am Coll Surg 181:459–463Google Scholar
  5. 5.
    Connolly B, Amaral J, Walsh S, Temple M, Chait P, Stephens D (2006) Influence of arm movement on central tip location of peripherally inserted central catheters (PICCs). Pediatr Radiol 36(8):845–850CrossRefGoogle Scholar
  6. 6.
    Dunn PM (1966) Localization of the umbilical catheter by post-mortem measurement. Arch Dis Child 4:69–75CrossRefGoogle Scholar
  7. 7.
    George L, Waldman JD, Cohen ML, Segall ML, Kirkpatrick SE, Turner SW, Pappelbaum SJ (1982) Umbilical vascular catheters: localization by two-dimensional echocardio/aortography. Pediatr Cardiol 2:237–243CrossRefGoogle Scholar
  8. 8.
    Gnannt R, Connolly BL, Parra DA, Amaral J, Moineddin R, Thakor AS (2016) Variables decreasing tip movement of peripherally inserted central catheters in pediatric patients. Pediatr Radiol 46(11):1532–1538. Epub 2016 Jun 7
  9. 9.
    Green C, Yohannan MD (1998) Umbilical arterial and venous catheters: placement, use, and complications. Neonatal Netw 17(6):23–28Google Scholar
  10. 10.
    Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C (2003) Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 16:327–361Google Scholar
  11. 11.
    Hsu JH, Wang CK, Chu KS, Cheng KI, Chuang HY, Jaw TS, Wu JR (2006) Comparison of radiographic landmarks and the echocardiographic SVC/RA junction in the positioning of long-term central venous catheters. Acta Anaesthesiol Scand 50:731–735CrossRefGoogle Scholar
  12. 12.
    Jain A, McNamara PJ, Ng E, El-Khuffash A (2012) The use of targeted neonatal echocardiography to confirm placement of peripherally inserted central catheters in neonates. Am J Perinatol 29:101–106. CrossRefGoogle Scholar
  13. 13.
    Jain A, Deshpande P, Shah P (2013) Peripherally inserted central catheter tip position and risk of associated complications in neonates. J Perinatol 33(4):307–312. CrossRefGoogle Scholar
  14. 14.
    Katheria AC, Fleming SE, Kim JH (2013) A randomized controlled trial of ultrasound-guided peripherally inserted central catheters compared with standard radiograph in neonates. J Perinatol 33(10):791–794. CrossRefGoogle Scholar
  15. 15.
    Matsushima K, Frankel HL (2011) Detection of central venous catheter insertion-related complication using bedside ultrasound: the CVC sono. J Trauma 70:1561–1563. CrossRefGoogle Scholar
  16. 16.
    Maury E, Guglielminotti J, Alzieu M, Guidet B, Offenstadt G (2001) Ultrasonic examination: an alternative to chest radiography after central venous catheter insertion? Am J Respir Crit Care Med 164:403–405CrossRefGoogle Scholar
  17. 17.
    McGee WT, Mailloux PT, Martin RT (2011) Safe placement of central venous catheters: a measured approach. J Intensive Care Med 26:392–396. CrossRefGoogle Scholar
  18. 18.
    Michel F, Brévaut-Malaty V, Pasquali R, Thomachot L, Vialet R, Hassid S, Nicaise C, Martin C, Panuel M (2012) Comparison of ultrasound and X-ray in determining the position of umbilical venous catheters. Resuscitation 83:705–709. CrossRefGoogle Scholar
  19. 19.
    Nadroo AM, Glass RB, Lin J, Green RS, Holzman IR (2002) Changes in upper extremity position cause migration of peripherally inserted central catheters in neonates. Pediatrics 110(1 Pt 1):131–136CrossRefGoogle Scholar
  20. 20.
    Ohki Y, Tabata M, Kuwashima M, Takeuchi H, Nako Y, Morikawa A (2000) Ultrasonographic detection of very thin percutaneous central venous catheter in neonates. Acta Paediatr 89:1381–1384CrossRefGoogle Scholar
  21. 21.
    Racadio JM, Doellman DA, Johnson ND, Bean JA, Jacobs BR (2001) Pediatric peripherally inserted central catheters: complication rates related to catheter tip location. Pediatrics 107(2):E28CrossRefGoogle Scholar
  22. 22.
    Sharpe E, Pettit J, Ellsbury DL (2013) A national survey of neonatal peripherally inserted central catheter (PICC) practices. Adv Neonatal Care 13(1):55–74. CrossRefGoogle Scholar
  23. 23.
    Shukla H, Ferrara A (1986) Rapid estimation of insertional length of umbilical catheters in newborns. Am J Dis Child 140:786–788Google Scholar
  24. 24.
    Tauzin L, Sigur N, Joubert C, Parra J, Hassid S, Moulies M (2013) Echocardiography allows more accurate placement of peripherally inserted central catheters in low birthweight infants. Acta Paediatr 102:703–706. CrossRefGoogle Scholar
  25. 25.
    Wirsing M, Schummer C, Neumann R, Steenbeck J, Schmidt P, Schummer W (2008) Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position? Chest 134:527–533. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Pediatrics, Division of NeonatologyCohen Children’s Medical CenterNew Hyde ParkUSA
  2. 2.Feinstein Institute for Medical ResearchManhassetUSA
  3. 3.Hofstra University School of MedicineHempsteadUSA
  4. 4.Department of Pediatrics, Pediatric Critical Care DivisionCohen Children’s Medical CenterNew Hyde ParkUSA
  5. 5.Department of Pediatrics, Pediatric Radiology DepartmentCohen Children’s Medical CenterNew Hyde ParkUSA

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