February 2026 - Line Placement

Case Summary

This case demonstrates why ultrasound should be the standard for confirming central line position in extremely preterm infants. In this population, millimetres matter. Small catheter movements can shift a line from a central to a non-central position, increasing the risk of extravasation, thrombosis, and catheter dysfunction. Unlike radiography, ultrasound provides real-time, anatomical confirmation of line position—without radiation.

Clinical Situation

This was a 25-week di/di twin, born by emergency Caesarean section following rupture of membranes of the first twin and an abnormal fetal heart tracing. There was no antenatal betamethasone or magnesium. The infant developed severe respiratory failure requiring intubation, high-frequency oscillatory ventilation, surfactant therapy, and treatment of persistent pulmonary hypertension of the newborn with inhaled nitric oxide. Due to ongoing critical illness, enteral feeding advancement was delayed. By day 7 of life, despite improving respiratory status, the infant required a peripherally inserted central catheter (PICC) to meet nutritional needs. A PICC line was placed by an expert vascular access nurse, and a chest X-ray was obtained. As part of the NICU POCUS initiative, ultrasound was also used to assess line position.

POCUS Examination

Given concern for catheter malposition, point-of-care ultrasound (POCUS) was performed using a linear transducer.

Ultrasound clearly demonstrated both the PICC line and the UVC positioned within the right atrium. The study was performed using a hockey-stick probe placed on the anterior chest, slightly right of midline, with the probe marker oriented cranially. This view allowed simultaneous visualization of the superior vena cava, right atrium, and inferior vena cava.

Under direct ultrasound guidance, the catheters were adjusted in real time until both were withdrawn to appropriate positions. 

This case also illustrates a key vulnerability in extremely preterm infants: the very short distance between the ductus venosus–IVC junction and the right atrium, making radiographic “acceptable” positions potentially misleading.

Teaching Points

Ultrasound outperforms chest X-ray for line assessment in neonates.

POCUS allows:

• Direct, real-time confirmation of central catheter position

• Immediate correction of malposition without repeated imaging

• Reduced risk of complications including extravasation, thrombosis, arrhythmia, and catheter dysfunction

• Elimination of unnecessary radiation exposure

Conclusion

This case reinforces that ultrasound should replace chest X-ray as the primary modality for confirming central line position in the NICU. While radiography offers indirect estimation, ultrasound provides live, anatomical visualization, enabling safer placement, immediate adjustment, and ongoing surveillance—particularly critical in extremely premature infants where margins for error are minimal.