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Background: Infiltration and extravasation are common complications during peripheral intravenous infusion in the neonatal intensive care unit, and diagnosis is usually clinical, by inspection and palpation. Delay in diagnosis due to poor surveillance or misinterpretation of clinical signs may carry serious damage to the tissues of the neonate. Recently, a novel technology based on optical detection of infiltration has become available. Methods: We have studied two groups of term and preterm infants receiving non-vesicant intravenous infusions by the peripheral route (24G short peripheral cannulas), and we evaluated the incidence of infiltration. In the first group, we have compared the clinical detection of infiltration versus the detection obtained by a novel optical device, blinding the alarms of the device. In the second group, the comparison was carried out without blinding the alarms. Results: Of the neonates included in this study, 60% were female, 86% had a gestational age <37 weeks (34 & PLUSMN; 2.5 weeks) and a mean birth weight of 2.08 & PLUSMN; 0.4 g. Total recorded monitoring time was 1318 h and average monitoring time for each short peripheral cannula was 26.4 h. The incidence of infiltration was 80%, most of them having a Millam score <2. The novel device showed an overall sensitivity of 88.9% in detecting infiltration. Specificity was 84.4%, as evaluated assuming as standard the clinical diagnosis. Interestingly, in cases of documented infiltration, the event was diagnosed by the optical device approximately 6 h before the clinical diagnosis. Conclusions: Continuous monitoring of the insertion site, as automatically ensured by this novel optical device, may play a complementary role in early detection of infiltration, even if the percentage of false positives and false negatives suggests that periodic clinical assessment by expert nurses cannot be omitted.

Objective Epicutaneo-caval catheters (ECCs) are essential for the care of sick infants who require long-term medical and nutritional management. The aim of this study was to investigate the use of real-time ultrasound as an alternative to X-rays to reduce the incidence of primary malpositions during catheter insertion.Study Design Data on ECCs were retrospectively collected in a tertiary neonatal intensive care unit. Catheter were analyzed considering the tip location technique (standard chest-abdominal radiograph vs real-time ultrasound)Results A total of 248 ECCs were analyzed. Of these, 118 catheters had primary malposition (47.6%). The tip of 165 catheters was assessed using standard chest-abdominal X-rays and 107 (64.8%) were found to be in an inappropriate location. In the group of 83 catheters that were placed using real-time ultrasound for tip location, only 11 catheters (13.2%) had primary malposition. The rate of malposition among the two groups showed a statistically significant difference ( p < 0.001). Hypothetically, 300 chest X-rays could have been saved if real-time ultrasound had been used to locate the tip, reducing radiation exposure to infants.Conclusion The use of a real-time ultrasound may be beneficial in reducing primary catheter malpositions compared with conventional radiography. In addition, secondary malpositions and catheter-related complications can be monitored over time.

Intrahepatic cholestasis of pregnancy (ICP) complicates among 0.2-2% of pregnancies and has been associated with adverse perinatal outcomes, including sudden stillbirth, meconium strained fluid, preterm birth, perinatal asphyxia, and transient tachypnea of the newborn. The diagnosis of "bile acids pneumonia" was previously proposed and a causative role of bile acids (BA) was supposed with a possible mechanism of action including surfactant dysfunction, inflammation, and chemical pneumonia. In the last few years, the role of lung ultrasound (LUS) in the diagnosis and management of neonatal respiratory distress syndrome has grown, and LUS scores have been introduced in the literature, as an effective predictor of the need for surfactant treatment among neonates with respiratory distress syndrome. We present four cases of infants born from pregnancies complicated by ICP, who developed respiratory distress syndrome early after birth. Lung ultrasound showed the same pattern for all infants, corresponding to a homogeneous alveolar-interstitial syndrome characterized by a diffuse coalescing B-line pattern (white lung). All infants evaluated require non-invasive respiratory support and in three cases surfactant administration, despite the near-term gestational age, with rapid improvement of respiratory disease and a good clinical outcome.

Chest and abdominal X-rays after the insertion of an epicutaneo-caval catheter in infants are the standard method of checking the tip location in many neonatal intensive care units. The role of ultrasound in the tip location of the epicutaneo-caval catheter in neonates has been the subject of many recent studies. This systematic review investigates the accuracy of epicutaneo-caval catheter tip location by comparing ultrasound and conventional radiology. We performed a systematic literature search in multiple databases. The selection of studies yielded nineteen articles. The systematic review and meta-analysis were performed according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analysis). The analyses showed that ultrasound is a better imaging technique for epicutaneo-caval catheter tip location in the neonatal intensive care unit than conventional radiology. By improving operator training and selecting a standardized echography protocol, ultrasound could become the gold standard for visualizing the epicutaneo-caval catheter tip in the neonatal intensive care unit. This would have some important benefits: (1) increased accuracy in tip location (2); a more rapid use of the central venous access (3); and a significant reduction in radiation exposure.

Pericardial effusion (PE) in pediatric population can be asymptomatic or a life-threatening event. Reports on neonates or preterm infants are scarce and generally related to pericardiocentesis of large amounts of PE in emergency situations. We describe a diagnostic pericardiocentesis in a preterm infant with small and loculated pericardial effusion and suspected cardiac mass. We used an ultrasound-guided long-axis in-plane pericardiocentesis technique, with a needle-cannula. The operator obtained a subxiphoid pericardial effusion view with a high frequency linear probe and entered the skin below the tip of the xiphoid process with a 20-gauge closed IV needle-cannula (ViaValve (R)). The needle was identified in its entirety as it courses through soft tissue up to pericardial sac. The main advantages of this approach are a continuous viewing and angulation of the needle through all planes of the tissue and the use of a small, practical, closed IV needle-cannula with blood control septum to prevent fluid exposure while disconnecting the syringe. This novel approach is easy and safe in neonatal population, for diagnostic or emergency drainages and can be performed at bedside in a neonatal intensive care unit.

Centrally inserted central catheters (CICCs) are placed by ultrasound guided puncture of the internal jugular or brachio-cephalic vein. It is crucial to achieve a good level of sedation and analgesia in order to keep the babies still thus reducing the risk of procedural failure. The aim of this study is to evaluate the efficacy of the combination of ketamine and fentanyl during the CICC placement procedure. We retrospectively collected data from 72 infants who underwent CICC insertion after sedation with KetaFent protocol. The primary outcome was to assess the success of the procedure defined as CICC placement. Secondary outcome was intubation during the procedure in non-ventilated infants (noninvasive ventilation or spontaneous respiration), need for repeat doses of study medications to complete the procedure, time to complete the procedure, the level of analgesia assessed using vital parameters. The procedure was completed in 100% of cases. There were no cases of hypotension during and at the end of the procedure. No intubation was performed on non-ventilated infants. The combination of ketamine and fentanyl for sedation and analgesia in infants requiring insertion of a CICC is 100% successful. It is associated with a low risk of side effect like apnea and intubation. Insertion of a central venous catheter is a painful procedure for infants. Adequate sedation is mandatory to keep the baby still thus reducing the risk of procedural failure.

BackgroundArtificial intelligence (AI) is a promising field in the neonatal field. We focused on lung ultrasound (LU), a useful tool for the neonatologist. Our aim was to train a neural network to create a model able to interpret LU. MethodsOur multicentric, prospective study included newborns with gestational age (GA) & GE; 33 + 0 weeks with early tachypnea/dyspnea/oxygen requirements. For each baby, three LU were performed: within 3 h of life (T0), at 4-6 h of life (T1), and in the absence of respiratory support (T2). Each scan was processed to extract the region of interest used to train a neural network to classify it according to the LU score (LUS). We assessed sensitivity, specificity, positive and negative predictive value of the AI model's scores in predicting the need for respiratory assistance with nasal continuous positive airway pressure and for surfactant, compared to an already studied and established LUS. ResultsWe enrolled 62 newborns (GA = 36 & PLUSMN; 2 weeks). In the prediction of the need for CPAP, we found a cutoff of 6 (at T0) and 5 (at T1) for both the neonatal lung ultrasound score (nLUS) and AI score (AUROC 0.88 for T0 AI model, 0.80 for T1 AI model). For the outcome "need for surfactant therapy", results in terms of area under receiver operator characteristic (AUROC) are 0.84 for T0 AI model and 0.89 for T1 AI model. In the prediction of surfactant therapy, we found a cutoff of 9 for both scores at T0, at T1 the nLUS cutoff was 6, while the AI's one was 5. Classification accuracy was good both at the image and class levels. ConclusionsThis is, to our knowledge, the first attempt to use an AI model to interpret early neonatal LUS and can be extremely useful for neonatologists in the clinical setting.

Central venous access devices are often required in neonates, particularly in preterm babies or in newborns who are candidate to intensive care procedures, surgery, or parenteral nutrition. A venous access device is ‘central’ when its tip is located in the superior vena cava (SVC) or in the right atrium (RA) or in the inferior vena cava (IVC). According to the terminology adopted by the WoCoVA Foundation (WoCoVA = World Congress on Vascular Access), central venous access devices in neonates should be classified as follows: • Umbilical venous catheter (UVC)—inserted in the umbilical vein, tip at the junction between RA and IVC. • Epicutaneo-cava catheters (ECC)—inserted in superficial veins of the limb or the scalp, tip in the SVC or at the junction between RA and SVC • Centrally Inserted Central Catheters (CICC)—inserted by ultrasound guidance in deep veins of the supra/infraclavicular area, tip at the junction between RA and SVC • Femorally Inserted Central Catheters (FICC)—inserted by ultrasound guidance in deep veins of the groin and the thigh, tip in the IVC or at the junction between RA and SVC.

Respiratory distress (RD) is one of the most common causes of admission to the neonatal intensive care unit. Correct diagnosis and timely intervention are crucial. Lung ultrasonography (LU) is a useful diagnostic tool for the neonatologist in the diagnosis of RD; the neonatal lung ultrasonography score (nLUS) can be used in the diagnostic process, but some authors hypothesise that it is also useful for the management of some neonatal RD. The aim of this study is to analyse the changes in nLUS score before (T0) and after (T1) the start of respiratory support with nasal CPAP in neonates over 32 weeks of age with RD. Thirty-three newborns were enrolled in this retrospective study. LU was performed before and after the start of CPAP. The median nLUS scores at T0 and T1 were 9 (IQR 7–12) and 7 (IQR 4–10), respectively, and showed a significant difference (p < 0.001). The magnitude of reduction in nLUS score, expressed as a percentage, was inversely related to the need for subsequent administration of exogenous surfactant. The study suggests the usefulness of the nLUS score in assessing the response to CPAP in neonates over 32 weeks gestational age.

Background: Placement of peripheral intra-venous cannulas and epicutaneo-caval catheters is routinely performed in in Neonatal Intensive Care Unit (NICU), and both devices require visible superficial veins easy to cannulate. NICU patients are intrinsically characterized by poor and fragile vein asset, so that puncture and cannulation of superficial veins is often a challenge even for trained clinicians and cannulation frequently results in a stressful, painful, difficult procedure. Methods and results: Rapid Superficial Vein Assessment is meant to offer a systematic pre-procedural evaluation of all superficial veins of the newborn, so to allow a rational choice of the best insertion site, tailored on the single patient, and optimized for the specific type of venous access device. The superficial veins are examined systematically, both with and without NIR technology, exploring seven skin areas in the following order: (1) medial malleolus, (2) lateral malleolus, (3) retro-popliteal fossa, (4) back of the hand and wrist, (5) antecubital fossa, (6) anterior scalp surface, and (7) posterior scalp surface. Conclusions: The aim of the protocol is to increase the first attempt success rate and reduce the duration of the procedure, the number of attempts for single patient and possibly to limit complications, stress, and pain in neonates.

The umbilical venous catheter (UVC) is one of the most commonly used central lines in neonates. It can be easily inserted soon after birth providing stable intravenous access in infants requiring advanced resuscitation in the delivery room or needing medications, fluids, and parenteral nutrition during the 1st days of life. Resident training is crucial for UVC placement. The use of simulators allows trainees to gain practical experience and confidence in performing the procedure without risks for patients. UVCs are easy to insert, however when the procedure is performed without the use of ultrasound, there is a quite high risk, up to 40%, of non-central position. Ultrasound-guided UVC tip location is a simple and learnable technique and therefore should be widespread among all physicians. The feasibility of targeted training on the use of point-of-care ultrasound (POCUS) for UVC placement in the neonatal intensive care unit (NICU) among neonatal medical staff has been demonstrated. Conversely, UVC-related complications are very common and can sometimes be life-threatening. Despite UVCs being used by neonatologists for over 60 years, there are still no standard guidelines for assessment or monitoring of tip location, securement, management, or dwell time. This review article is an overview of the current knowledge and evidence available in the literature about UVCs. Our aim is to provide precise and updated recommendations on the use of this central line.

Background: The correct position of the tip of a central venous access device is important in all patients, and especially in neonates. The traditional method of tip location (approximated intra-procedural length estimation + post procedural chest X-ray) is currently considered inaccurate and not cost-effective by most recent guidelines, which recommend the adoption of tip location by intracavitary electrocardiography (IC-ECG) whenever possible. Methods: This study prospectively investigated the applicability, the feasibility, the accuracy, and the safety IC-ECG for tip location in neonates requiring insertion of ultrasound-guided centrally inserted central venous catheters (CICCs) with caliber 3Fr or more. All catheter tip locations were verified using simultaneously both IC-ECG and ultrasound-based tip location, using the Neo-ECHOTIP protocol. Results: A total of 105 neonates were enrolled. The applicability of IC-ECG was 100% since a P wave was evident on the surface ECG of all neonates recruited for the study. The feasibility was also 100% since an increase of the P-wave was detected in all cases. The accuracy was also 100%, since a perfect match between IC-ECG based tip location and ultrasound-based tip location was found. There were no adverse events directly or indirectly related to the IC-ECG technique; no arrhythmias occurred. Conclusions: When applied to ultrasound guided CICCs, tip location by IC-ECG is applicable and feasible in neonates, and it is safe and accurate.

ObjectiveRecently, a novel approach to imaging Superior Vena Cava (SVC) flow has been presented, showing better repeatability and better agreement with MRI-derived SVC flow measures. The objective was to establish normal values of SVC flow with the novel approach in the first 48 h of life. Study DesignThis was a prospective, observational study. All infants with gestational age (GA) less than 31 weeks were eligible. Echocardiographic evaluation was performed at 5, 12, 24, 48 h of postnatal life. A subgroup of uncomplicated infants was studied to define a normal range for SVC flow. ResultsForty-five infants were enrolled. We estimated normative values in a subgroup of 31 uncomplicated infants. The median SVC flow significantly increases from 83 ml/kg/min at 5 h of life to 153 ml/kg/min at 48 h (p < .001). ConclusionUsing the novel approach we derived normal values of SVC flow in a cohort of uncomplicated preterm population at high risk for developing IVH.

The COVID-19 pandemic has upset habits in any workplace. In hospitals, several precautions have been taken to maintain health-care workers' safety and to avoid disease spread or the possible creation of new epidemic outbreaks. The use of medical devices makes the contamination and the nosocomial virus spread possible, causing infection in medical operators and hospitalized patients. In the neonatal intensive care unit, ultrasound has been an increasingly used tool because it is a non-invasive, repeatable method and it is side effect-free as the newborn is not exposed to radiation. It makes a fast diagnosis and then therapy possible such as in the lung diseases and other life-threatening conditions. The use of portable devices such as the wireless probe has many advantages in routine clinical practice, and during the COVID-19 pandemic, it has proved to be fundamental for the patient and the physician's safety because it reduced the risk of contamination. We report the use of the wireless ultrasound probe in 2 isolated neonates born to SARS-CoV-2-positive mothers.