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Abstract

Introduction: Peripherally inserted central venous catheters (PICC) are widely used central venous system access devices. Reported complications associated with PICC line insertion are serious and life threatening. Centrally placed PICC lines have lower complication rates and optimal placement of these access devices is crucial. X-ray is the gold standard method used to confirm placement of these catheters; consequently, it is associated with radiation exposure and inability to adjust the PICC line position in real time. We propose the use of bedside focused ultrasound (FUS) study to establish PICC line position in children. Methods: Patients age 1 month to 18 years requiring PICC line placement were enrolled. Following successful catheter insertion the position of the catheter tip was evaluated using a SonoSite Ultrasound System. Bilateral IJ veins were evaluated, followed by a focused cardiac ultrasound consisting of three cardiac views. The cardiac views utilized included suprasternal, parasternal and subcostal view as described by Pediatric Council of the American Society of Echocardiography. The ultrasound was performed by a PICU fellow who was blinded to the x-ray results. Portable AP chest x-ray was used for final line position assessment. X-ray landmark for optimal PICC line location was bifurcation of trachea to two vertebral spaces below. X-ray report by radiologist was interpreted for final PICC line position assessment. The PICC line was adjusted based on x-ray report only. Results: Total of 43 catheter placement events were evaluated. Mean patient age was 8.1 years (SD 5.98). The most common reasons for PICC line insertion were antibiotic treatment (40%), parenteral nutrition (23%) and chemotherapy (21%). The overall number of PICC lines found to be malpositioned was 34 out of 43 (74%). Mean FUS time was 10.9 min (SD 3.06). Agreement between the X-ray and FUS reports on line position was observed in 36 out of 43 studies (84%). The FUS had sensitivity of 67%, specificity of 90%, NPV of 88%, and PPV of 73%. Gender, BMI, side, and site did not have significant associations with agreement of catheter position based on FUS vs. x-ray (p>0.05). Conclusions: Our study demonstrated that an FUS performed by an experienced operator provides precise information regarding the position of the PICC line tip with accuracy of 84% when compared to gold standard X-ray. Additional training and exposure of the ultrasonographer may improve the accuracy. We also showed that PICC line position was not affected by insertion site, side, BMI and gender. Future large sample size studies are needed to evaluate these associations and to show the full potential of this modality to decrease costs, radiation exposure, shorten procedure time and reduce length of sedation in pediatric population.