POCUS using the neo-ECHOTIP protocol plus the retract, advance, and position (RAP) technique to improve lower extremity catheter positioning in neonates

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Abstract
Background: International guidelines recommend point-of-care ultrasonography (POCUS) in neonatology for diagnostic, therapeutic, and procedural purposes. However, there are few standard protocols for using POCUS to confirm lower extremity catheter tip positioning. Methods: In this prospective study, subcutaneously tunneled femorally inserted central catheters (ST-FICCs) were placed in eligible neonates according to physician orders. In line with the Neo-ECHOTIP (NE) protocol, a subcostal longitudinal view was used to identify the catheter, and saline flush test (SFT) was performed to confirm catheter tip placement below the right atrium. During the study, a novel “retract, advance, and position (RAP)” technique was added to the existing NE-SFT protocol to improve catheter positioning. Two-view radiographs of the chest and abdomen were obtained to verify catheter tip position for all subjects. The agreement rate with post-procedural radiographs and the total number of radiographs needed to achieve proper catheter positioning were assessed. Results: The agreement rate of POCUS with radiographs for catheter terminal tip position was 75% (39/52) for the NE-SFT group compared to 100% (48/48) for the NE-SFT + RAP group ( p < 0.001). Catheters in the NE-SFT group required repositioning (25%); no malpositioned catheters were observed in the NE-SFT + RAP group. Repositioning of the catheter in the NE-SFT group resulted in 22 repeat radiographs in the NE-SFT group; none were required in the NE-SFT + RAP group ( p < 0.0001). Conclusions: This single-center study demonstrated that applying the RAP technique to the Neo-ECHOTIP protocol improved the ease and accuracy of lower extremity catheter tip position localization in neonates, thus eliminating the use of radiography.

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