Essentials of Point-of-Care Ultrasound Coding and Billing at the Neonatal Intensive Care Unit Setting in the United States.

Point-of-care ultrasound (POCUS) has increasingly been used by neonatal providers in neonatal intensive care units in the United States. However, there is a lack of literature addressing the complexities of POCUS coding and billing practices in the United States. This article describes the coding terminology and billing process especially those relevant to neonatal POCUS. We elucidate considerations for neonatal POCUS billing framework and workflow integration. Directions on image storage and supporting documentation to facilitate efficient reimbursement, compliance with billing regulations, and appeal to insurance claim denial are discussed. KEY POINTS: · Code neonatal POCUS procedure precisely allows accurate reimbursement and reduced errors in billing.. · Document details to support medical necessity and reimbursement claims effectively.. · Adhere to regulations to avoid audits, denials, and ensure proper reimbursement..

Lifestyle intervention in obese pregnancy and cardiac remodelling in 3-year olds: children of the UPBEAT RCT.

BACKGROUND/OBJECTIVES: Obesity in pregnancy has been associated with increased childhood cardiometabolic risk and reduced life expectancy. The UK UPBEAT multicentre randomised control trial was a lifestyle intervention of diet and physical activity in pregnant women with obesity. We hypothesised that the 3-year-old children of women with obesity would have heightened cardiovascular risk compared to children of normal BMI women, and that the UPBEAT intervention would mitigate this risk. SUBJECTS/METHODS: Children were recruited from one UPBEAT trial centre. Cardiovascular measures included blood pressure, echocardiographic assessment of cardiac function and dimensions, carotid intima-media thickness and heart rate variability (HRV) by electrocardiogram. RESULTS: Compared to offspring of normal BMI women (n = 51), children of women with obesity from the trial standard care arm (n = 39) had evidence of cardiac remodelling including increased interventricular septum (IVS; mean difference 0.04 cm; 95% CI: 0.018 to 0.067), posterior wall (PW; 0.03 cm; 0.006 to 0.062) and relative wall thicknesses (RWT; 0.03 cm; 0.01 to 0.05) following adjustment. Randomisation of women with obesity to the intervention arm (n = 31) prevented this cardiac remodelling (intervention effect; mean difference IVS -0.03 cm (-0.05 to -0.008); PW -0.03 cm (-0.05 to -0.01); RWT -0.02 cm (-0.04 to -0.005)). Children of women with obesity (standard care arm) compared to women of normal BMI also had elevated minimum heart rate (7 bpm; 1.41 to 13.34) evidence of early diastolic dysfunction (e prime) and increased sympathetic nerve activity index by HRV analysis. CONCLUSIONS: Maternal obesity was associated with left ventricular concentric remodelling in 3-year-old offspring. Absence of remodelling following the maternal intervention infers in utero origins of cardiac remodelling. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: The UPBEAT trial is registered with Current Controlled Trials, ISRCTN89971375.

Real-Time Ultrasound Guidance for Umbilical Venous Cannulation in Neonates With Congenital Heart Disease.

OBJECTIVES: Umbilical venous cannulation is the favored approach to perinatal central access worldwide but has a failure rate of 25-50% and the insertion technique has not evolved in decades. Improving the success of this procedure would have broad implications, particularly where peripherally inserted central catheters are not easily obtained and in neonates with congenital heart disease, in whom umbilical access facilitates administration of inotropes and blood products while sparing vessels essential for later cardiac interventions. We sought to use real-time, point-of-care ultrasound to achieve central umbilical venous access in patients for whom conventional, blind placement techniques had failed. DESIGN: Multicenter case series, March 2019-May 2021. SETTING: Cardiac and neonatal ICUs at three tertiary care children's hospitals. PATIENTS: We identified 32 neonates with congenital heart disease, who had failed umbilical venous cannulation using traditional, blind techniques. INTERVENTIONS: Real-time ultrasound guidance and liver pressure were used to replace malpositioned catheters and achieve successful placement at the inferior cavoatrial junction. MEASUREMENTS AND MAIN RESULTS: In 32 patients with failed prior umbilical venous catheter placement, real-time ultrasound guidance was used to successfully "rescue" the line and achieve central position in 23 (72%). Twenty of 25 attempts (80%) performed in the first 48 hours of life were successful, and three of seven attempts (43%) performed later. Twenty-four patients (75%) were on prostaglandin infusion at the time of the procedure. We did not identify an association between patient weight or gestational age and successful placement. CONCLUSIONS: Ultrasound guidance has become standard of care for percutaneous central venous access but is a new and emerging technique for umbilical vessel catheterization. In this early experience, we report that point-of-care ultrasound, together with liver pressure, can be used to markedly improve success of placement. This represents a significant advance in this core neonatal procedure.

Ventricular remodeling in preterm infants: computational cardiac magnetic resonance atlasing shows significant early remodeling of the left ventricle.

BACKGROUND: Premature birth is associated with ventricular remodeling, early heart failure, and altered left ventricular (LV) response to physiological stress. Using computational cardiac magnetic resonance (CMR) imaging, we aimed to quantify preterm ventricular remodeling in the neonatal period, and explore contributory clinical factors. METHODS: Seventy-three CMR scans (34 preterm infants, 10 term controls) were performed to assess in-utero development and preterm ex-utero growth. End-diastolic computational atlases were created for both cardiac ventricles; t statistics, linear regression modeling, and principal component analysis (PCA) were used to describe the impact of prematurity and perinatal factors on ventricular volumetrics, ventricular geometry, myocardial mass, and wall thickness. RESULTS: All preterm neonates demonstrated greater weight-indexed LV mass and higher weight-indexed end-diastolic volume at term-corrected age (P < 0.05 for all preterm gestations). Independent associations of increased term-corrected age LV myocardial wall thickness were (false discovery rate <0.05): degree of prematurity, antenatal glucocorticoid administration, and requirement for >48 h postnatal respiratory support. PCA of LV geometry showed statistical differences between all preterm infants at term-corrected age and term controls. CONCLUSIONS: Computational CMR demonstrates that significant LV remodeling occurs soon after preterm delivery and is associated with definable clinical situations. This suggests that neonatal interventions could reduce long-term cardiac dysfunction.

High-resolution rapid neonatal whole-body composition using 3.0 Tesla chemical shift magnetic resonance imaging.

BackgroundTo evaluate a whole-body rapid imaging technique to calculate neonatal lean body mass and percentage adiposity using 3.0 Tesla chemical shift magnetic resonance imaging (MRI).MethodsA 2-Point Dixon MRI technique was used to calculate whole-body fat and water images in term (n=10) and preterm (n=15) infants.ResultsChemical shift images were obtained in 42 s. MRI calculated whole-body mass correlated closely with measured body weight (R2=0.87; P<0.001). Scan-rescan analysis demonstrated a 95% limit of agreement of 1.3% adiposity. Preterm infants were born at a median of 25.7 weeks' gestation with birth weight 840 g. At term-corrected age, former preterm infants were lighter than term-born controls, 2,519 vs. 3,094 g regressing out age and group as covariates (P=0.005). However, this was not because of reduced percentage adiposity 26% vs. 24% (P=0.28). At term-corrected age, former preterm infants had significantly reduced lean body mass compared with that of term-born controls 1,935 vs. 2,416 g (P=0.002).ConclusionRapid whole-body imaging for assessment of lean body mass and adiposity in term and preterm infants is feasible, accurate, and repeatable. Deficits in whole-body mass in former preterm infants at term-corrected age are due to reductions in lean body mass not due to differences in adiposity.

Introduction to neonatologist-performed echocardiography.

Cardiac ultrasound techniques are increasingly used in the neonatal intensive care unit to guide cardiorespiratory care of the sick newborn. This is the first in a series of eight review articles discussing the current status of "neonatologist-performed echocardiography" (NPE). The aim of this introductory review is to discuss four key elements of NPE. Indications for scanning are summarized to give the neonatologist with echocardiography skills a clear scope of practice. The fundamental physics of ultrasound are explained to allow for image optimization and avoid erroneous conclusions from artifacts. To ensure patient safety during echocardiography recommendations are given to prevent cardiorespiratory instability, hypothermia, infection, and skin lesions. A structured approach to echocardiography, with the same standard views acquired in the same sequence at each scan, is suggested in order to ensure that the neonatologist confirms normal structural anatomy or acquires the necessary images for a pediatric cardiologist to do so when reviewing the scan.

Effectiveness of echocardiography simulation training for paediatric cardiology fellows in CHD.

Simulation is used in many aspects of medical training but less so for echocardiography instruction in paediatric cardiology. We report our experience with the introduction of simulator-based echocardiography training at Weill Cornell Medicine for paediatric cardiology fellows of the New York-Presbyterian Hospital of Columbia University and Weill Cornell Medicine. Knowledge of CHD and echocardiographic performance improved following simulation-based training. Simulator training in echocardiography can be an effective addition to standard training for paediatric cardiology trainees.

Expert consensus statement 'Neonatologist-performed Echocardiography (NoPE)'-training and accreditation in UK.

Targeted echocardiographic assessments of haemodynamic status are increasingly utilised in many settings. Application in the neonatal intensive care units (NICU) is increasingly demanded but challenging given the risk of underlying structural lesions. This statement follows discussions in UK led by the Neonatologists with an Interest in Cardiology and Haemodynamics (NICHe) group in collaboration with the British Congenital Cardiac Association (BCCA) and the Paediatricians with Expertise in Cardiology Special Interest Group (PECSIG). Clear consensus was agreed on multiple aspects of best practice for neonatologist-performed echocardiogram (NoPE)-rigorous attention to infection control and cardiorespiratory/thermal stability, early referral to paediatric cardiology with suspicion of structural disease, reporting on standardised templates, reliable image storage, regular skills maintenance, collaboration with a designated paediatric cardiologist, and regular scan audit/review. It was agreed that NoPE assessments should confidently exclude structural lesions at first scan. Practitioners would be expected to screen and establish gross normality of structure at first scan and obtain confirmation from paediatric cardiologist if required, and subsequently, functional echocardiography can be performed for haemodynamic assessment to guide management of newborn babies. To achieve training, NICHe group suggested that mandatory placements could be undertaken during core registrar training or neonatal subspecialty grid training with a paediatric cardiology placement for 6 months and a neonatology placement for a minimum of 6 months. In the future, we hope to define a precise curriculum for assessments. Technological advances may provide solutions-improvements in telemedicine may have neonatologists assessing haemodynamic status with paediatric cardiologists excluding structural lesions and neonatal echocardiography simulators could increase exposure to multiple pathologies and allow limitless practice in image acquisition. CONCLUSION: We propose developing training places in specialist paediatric cardiology centres and neonatal units to facilitate training and suggest all UK practitioners performing neonatologist-performed echocardiogram adopt this current best practice statement. WHAT IS KNOWN: Neonatologist-performed echocardiogram (NoPE) also known as targeted neonatal echocardiography (TNE) or functional ECHO is increasingly recognised and utilised in care of sick newborn and premature babies. There are differences in training for echocardiography across continents and formal accreditation processes are lacking. WHAT IS NEW: This is the first document of consensus best practice statement for training of neonatologists in neonatologist-performed echocardiogram (NoPE), jointly drafted by Neonatologists with interest in cardiology & haemodynamics (NICHe), paediatric cardiology and paediatricians with expertise in cardiology interest groups in UK. Key elements of a code of practice for neonatologist-performed echocardiogram are suggested.

Cardiovascular magnetic resonance of cardiac function and myocardial mass in preterm infants: a preliminary study of the impact of patent ductus arteriosus.

BACKGROUND: Many pathologies seen in the preterm population are associated with abnormal blood supply, yet robust evaluation of preterm cardiac function is scarce and consequently normative ranges in this population are limited. The aim of this study was to quantify and validate left ventricular dimension and function in preterm infants using cardiovascular magnetic resonance (CMR). An initial investigation of the impact of the common congenital defect patent ductus arteriosus (PDA) was then carried out. METHODS: Steady State Free Procession short axis stacks were acquired. Normative ranges of left ventricular end diastolic volume (EDV), stroke volume (SV), left ventricular output (LVO), ejection fraction (EF), left ventricular (LV) mass, wall thickness and fractional thickening were determined in "healthy" (control) neonates. Left ventricular parameters were then investigated in PDA infants. Unpaired student t-tests compared the 2 groups. Multiple linear regression analysis assessed impact of shunt volume in PDA infants, p-value ≤ 0.05 being significant. RESULTS: 29 control infants median (range) corrected gestational age at scan 34+6(31+1-39+3) weeks were scanned. EDV, SV, LVO, LV mass normalized by weight and EF were shown to decrease with increasing corrected gestational age (cGA) in controls. In 16 PDA infants (cGA 30+3(27+3-36+1) weeks) left ventricular dimension and output were significantly increased, yet there was no significant difference in ejection fraction and fractional thickening between the two groups. A significant association between shunt volume and increased left ventricular mass correcting for postnatal age and corrected gestational age existed. CONCLUSION: CMR assessment of left ventricular function has been validated in neonates, providing more robust normative ranges of left ventricular dimension and function in this population. Initial investigation of PDA infants would suggest that function is relatively maintained.

Chloral hydrate sedation for magnetic resonance imaging in newborn infants.

BACKGROUND: The aim of this study was to look for clinically significant adverse effects of chloral hydrate used in a large cohort of infants sedated for magnetic resonance imaging. METHOD: Case notes of infants who underwent magnetic resonance imaging (MRI) scanning from 2008 to 2010 were reviewed, with patient demographics, sedation dose, comorbidities, time to discharge, and side effects of sedation noted. RESULTS: Four hundred and eleven infants (median [range] postmenstrual age per weight at scan 42 [31(+4) -60] weeks per 3500 g [1060-9900 g]) were sedated with chloral hydrate (median [range] dose 50 [20-80] mg·kg(-1)). In three cases (0.7%), desaturations occurred which prompted termination of the scan. One infant (0.2%) was admitted for additional observation following sedation but had no prolonged effects. In 17 (3.1%) cases, infants had desaturations which were self-limiting or responded to additional inspired oxygen such that scanning was allowed to continue. CONCLUSION: When adhering to strict protocols, MRI scanning in newborn infants in this cohort was performed using chloral hydrate sedation with a relatively low risk of significant adverse effects.

Neonatal cardiac MRI using prolonged balanced SSFP imaging at 3T with active frequency stabilization.

UNLABELLED: Cardiac MRI in neonates holds promise as a tool that can provide detailed functional information in this vulnerable group. However, their small size, rapid heart rate, and inability to breath-hold, pose particular challenges that require prolonged high-contrast and high-SNR methods. Balanced-steady state free precession (SSFP) offers high SNR efficiency and excellent contrast, but is vulnerable to off-resonance effects that cause banding artifacts. This is particularly problematic in the blood-pool, where off-resonance flow artifacts severely degrade image quality. METHODS: In this article, we explore active frequency stabilization, combined with image-based shimming, to achieve prolonged SSFP imaging free of banding artifacts. The method was tested using 2D multislice SSFP cine acquisitions on 18 preterm infants, and the functional measures derived were validated against phase-contrast flow assessment. RESULTS: Significant drifts in the resonant frequency (165 ± 23Hz) were observed during 10-min SSFP examinations. However, full short-axis stacks free of banding artifacts were achieved in 16 subjects with stabilization; the cardiac output obtained revealed a mean difference of 9.0 ± 8.5% compared to phase-contrast flow measurements. CONCLUSION: Active frequency stabilization has enabled the use of prolonged SSFP acquisitions for neonatal cardiac imaging at 3T. The findings presented could have broader implications for other applications using prolong SSFP acquisitions.

Assessment of PDA shunt and systemic blood flow in newborns using cardiac MRI.

Patent ductus arteriosus (PDA) remains common in preterm newborns, but uncertainty over optimal management is perpetuated by clinicians' inability to quantify its true haemodynamic impact. Our aim was to develop a technique to quantify ductal shunt volume and the effect of PDA on systemic blood flow volume in neonates. Phase contrast MRI sequences were optimized to quantify left ventricular output (LVO) and blood flow in the distal superior vena cava (SVC) (below the azygos vein insertion), descending aorta (DAo) and azygos vein. Total systemic flow was measured as SVC + DAo-azygos flow. Echo measures were included and correlated to shunt volumes. 75 infants with median (range) corrected gestation 33(+6) (26(+4) -38(+6) ) weeks were assessed. PDA was present in 15. In 60 infants without PDA, LVO matched total systemic flow (mean difference 2.06 ml/kg/min, repeatability index 13.2%). In PDA infants, ductal shunt volume was 7.9-74.2% of LVO. Multiple linear regression analysis correcting for gestational age showed that there was a significant association between ductal shunt volume and decreased upper and lower body flow (p = 0.01 and p < 0.001). However, upper body blood flow volumes were within the control group 95% confidence limits in all 15 infants with PDA, and lower body flow volumes within the control group limits in 12 infants with PDA. Echocardiographic assessment of reversed diastolic flow in the descending aorta had the strongest correlation with ductal shunt volume. We have demonstrated that quantification of shunt volume is feasible in neonates. In the presence of high volume ductal shunting the upper and lower body flow volume are somewhat reduced, but levels remain within or close to the normal range for preterm infants.

Mean cerebral blood flow measurements using phase contrast MRI in the first year of life.

Alterations in cerebral blood flow (CBF) are believed to be linked to many of the neurological pathologies that affect neonates and small infants. CBF measurements are nonetheless often difficult to perform in this population, as many techniques rely on radioactive tracers or other invasive methods. In this study, mean global CBF was measured in 21 infants under the age of one, using non-invasive MRI techniques adapted to the neonatal population. Mean CBF was computed as the ratio of blood flow delivered to the brain (measured using phase contrast MRI) and brain volume (computed by segmenting anatomical MR images). Tests in adult volunteers and repeated measurements showed the flow measurements using the proposed method to be both accurate and reproducible. It was also found that cardiac gating need not be employed in infants with no known cardiac pathology. The developed technique can easily be appended to a neonatal MRI examination to provide rapid, robust, and non-invasive estimates of mean CBF, thus providing a means to monitor developmental or pathology-related alterations in cerebral perfusion and the impact of different treatment courses. In the imaged cohort, mean CBF and flow to the brain were found to rapidly increase during the first year of life (from approx. 25 to 60 ml blood/100 ml tissue/min), in good agreement with literature from other modalities where available. Mean CBF also showed a significant correlation with arterial oxygen saturation level and heart rate, but no significant correlation was found between CBF and the hematocrit or body temperature.

Disruption of intracardiac flow patterns in the newborn infant.

INTRODUCTION: Consistent patterns of rotational intracardiac flow have been demonstrated in the healthy adult human heart. Intracardiac rotational flow patterns are hypothesized to assist in the maintenance of kinetic energy of inflowing blood, augmenting cardiac function. Newborn cardiac function is known to be suboptimal secondary to decreased receptor number and sympathetic innervation, increased afterload, and increased reliance on atrial contraction to support ventricular filling. Patterns of intracardiac flow in the newborn have not previously been examined. RESULTS: Whereas 5 of the 13 infants studied showed significant evidence of rotational flow within the right atrium, 8 infants showed little or no rotational flow. Presence or absence of rotational flow was not related to gestational age, birth weight, postnatal age, atrial size, or image quality. Despite absence of intra-atrial rotational flow, atrioventricular valve flow into the left and right ventricles later in the cardiac cycle could be seen, suggesting that visualization techniques were adequate. DISCUSSION: While further study is required to assess its exact consequences on cardiac mechanics and energetics, disruption to intracardiac flow patterns could be another contributor to the multifactorial sequence that produces newborn circulatory failure. METHODS: We studied 13 newborn infants, using three-dimensional (3D) cardiac magnetic resonance phase-contrast imaging (spatial resolution 0.84 mm, temporal resolution 22.6 ms) performed without sedation/anesthesia.

Inotropes in preterm infants--evidence for and against.

There is significant uncertainty regarding the optimal circulatory management of preterm infants, with research in the field limited by the paucity of safe, reproducible biomarkers of circulatory function. This review discusses the physiology and pathophysiology of circulatory function in preterm infants, describes the mode of action and evidence for and against commonly used and recently trialled inotropic therapies and provides recommendations for managing circulatory dysfunction in the transitional period and in the context of sepsis/necrotizing enterocolitis. We recommend a pragmatic approach of assessing multiple aspects of circulatory function (blood pressure alone correlates weakly with volume of flow) in each infant, tailoring therapy on the basis of the change in function desired and frequently reassessing response to intervention.

Echocardiographic Quantification of Superior Vena Cava (SVC) Flow in Neonates: Pilot Study of Modified Technique.

Ultrasound Superior Vena Cava (SVC) flow assessment is a common measure of systemic and cerebral perfusion, although accuracy is limited. The aim of this study was to evaluate whether any improvements in accuracy could be achieved by measuring stroke distance from the instantaneous mean velocity, rather than from peak velocity, and by directly tracing area from images obtained with a high frequency linear probe. Paired phase contrast magnetic resonance imaging (PCMRI) and ultrasound assessments of SVC flow were performed in a pilot cohort of 7 infants. Median postnatal age, corrected gestation and weight at scan were 7 (2-74) days, 34.8 (31.7-37.2) weeks 1870 (970-2660) g. Median interval between PCMRI and ultrasound scans was 0.3 (0.2-0.5) h. The methodology trialed here showed a better agreement with PCMRI (mean bias -8 mL/kg/min, LOA -25-+8 mL/kg/min), compared to both the original method reported by Kluckow et al. (mean bias + 42 mL/kg/min, LOA -53-+137 mL/kg/min), and our own prior adaptation (mean bias + 23 mL/kg/min, LOA -25-+71 mL/kg/min). Ultrasound assessment of SVC flow volume using the modifications described led to enhanced accuracy and decreased variability compared to prior techniques in a small cohort of premature infants.

Impact of maternal obesity on neonatal heart rate and cardiac size.

BACKGROUND: Maternal obesity may increase offspring risk of cardiovascular disease. We assessed the impact of maternal obesity on cardiac structure and function in newborns as a marker of fetal cardiac growth. METHODS: Neonates born to mothers of healthy weight (body mass index (BMI) 20-25 kg/m2, n=56) and to mothers who were obese (BMI ≥30 kg/m2, n=31) underwent 25-minute continuous ECG recording and non-sedated, free-breathing cardiac MRI within 72 hours of birth. RESULTS: Mean (SD) heart rate during sleep was higher in infants born to mothers who were versus were not obese (123 (12.6) vs 114 (9.8) beats/min, p=0.002). Heart rate variability during sleep was lower in infants born to mothers who were versus were not obese (SD of normal-to-normal R-R interval 34.6 (16.8) vs 43.9 (16.5) ms, p=0.05). Similar heart rate changes were seen during wakefulness. Left ventricular end-diastolic volume (2.35 (0.14) vs 2.54 (0.29) mL/kg, p=0.03) and stroke volume (1.50 (0.09) vs 1.60 (0.14), p=0.04) were decreased in infants born to mothers who were versus were not obese. There were no differences in left ventricular end-systolic volume, ejection fraction, output or myocardial mass between the groups. CONCLUSION: Maternal obesity was associated with increased heart rate, decreased heart rate variability and decreased left ventricular volumes in newborns. If persistent, these changes may provide a causal mechanism for the increased cardiovascular risk in adult offspring of mothers with obesity. In turn, modifying antenatal and perinatal maternal health may have the potential to optimise long-term cardiovascular health in offspring.

Delirium in the NICU: A Point Prevalence Study.

OBJECTIVES: Delirium is a well-described complication of critical illness, with occurrence rates of >25% in the PICU, and associated morbidity. Infants in the NICU are likely at risk. There have been no previous screening studies to quantify delirium rates in the neonatal population. We hypothesized that delirium was prevalent in term neonates in the NICU. In this pilot study, our objective was to estimate prevalence using a validated pediatric delirium screening tool, which has not yet been tested in NICUs. METHODS: In this point prevalence study, all term or term-corrected infants admitted to the NICU on designated study days were screened for delirium using the Cornell Assessment of Pediatric Delirium. RESULTS: A total of 149 infants were eligible for screening over 8 study days. A total of 147 (98.6%) were successfully screened with the Cornell Assessment of Pediatric Delirium. Overall, 22.4% (n = 33) screened positive for delirium. Delirium was more commonly detected in children on invasive mechanical ventilation (67% vs 17%, P < .01) and those with underlying neurologic disorders (64% vs 13%, P < .01). A multivariate logistic regression revealed that neurologic disability and mechanical ventilation were both independently associated with a positive delirium screen (aOR: 12.3, CI: 4.5-33.6 and aOR: 9.3, CI: 2.5-34.6, respectively). CONCLUSIONS: Our results indicate that delirium likely occurs frequently in term-equivalent infants in the NICU. Further research is necessary to establish feasibility, validity, and interrater reliability of delirium screening in this population.

3D airway model to assess airway dead space.

High flow therapy works partly by washout of airway dead space, the volume of which has not been quantified in newborns. This observational study aimed to quantify airway dead space in infants and to compare efficacy of washout between high flow devices in three-dimensional (3D) printed airway models of infants weighing 2.5-3.8 kg. Nasopharyngeal airway dead space volume was 1.5-2.0 mL/kg in newborns. A single cannula device produced lower carbon dioxide (CO2) levels than a dual cannula device (33.7, 31.2, 23.1, 15.9, 10.9 and 6.3 mm Hg vs 36.8, 35.5, 32.1, 26.8, 23.1 and 18.8 mm Hg at flow rates of 1, 2, 3, 4, 6 and 8 L/min, respectively; p<0.0001 at all flow rates). Airway pressure was 1 mm Hg at all flow rates with the single cannula but increased at higher flow rates with the dual cannula.Relative nasopharyngeal airway dead space volume is increased in newborns. In 3D-printed airway models, a single cannula high flow device produces improved CO2 washout with lower airway pressure.

The reliability of 2D and colour Doppler ultrasound in localising longline position.

BACKGROUND: The position of percutaneously inserted central venous catheters (longlines) in neonates is critical, as malpositioned longlines are associated with potentially fatal complications. AIM: To determine if cardiac ultrasound (two-dimensional (2D) and colour Doppler) is useful in evaluating longline position, when compared with the position identified by contrast radiography. SETTING: Single level 3 neonatal unit. PARTICIPANTS: Forty-four neonates undergoing insertion of 24-gauge silastic longlines between July 2004 and September 2005. METHODS: Infants who had a longline inserted underwent echocardiography by a novice and an experienced operator. Operators identified longline position using a 2D then colour Doppler echocardiography during a rapid bolus infusion of saline. The position was identified from contrast radiography by two independent observers. RESULTS: Using 2D echocardiography, the novice and experienced operators could identify 41 and 59% of longlines, respectively. However, only 34% of longlines were identified by both operators. In 15 infants whose longline positions were identified by both operators, there was agreement in only eight infants (53%). Colour Doppler improved the experienced operator's success but did not assist the novice operator. For radiographs, there was 68% agreement on longline position between observers. The experienced echocardiographer located three (7%) longlines within the heart that from radiographs were thought to be in a proximal central vessel. CONCLUSIONS: This technique is experience-dependent and complements rather than replaces the use of contrast radiography. However, some infants with an apparently acceptable longline position on contrast radiography have longlines located within the heart on echocardiography.