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Hi everyone. Um Welcome to another session on um Radiological teachings it relating to the neonatology unit. Um Today, I thought would be a good idea to talk about peripheral line, such central lines to peak lines or sometimes referred to as long lines in some units. Um The learning objectives today would be largely about recognizing ideal um long line placements and recognizing suboptimal positions of the long line as well. I will also briefly talk about some indications for long line insertion and recognizing complications of um declines as well. Um Today's session is not going to go into the technical details of how wins at the long line um and things like that, right. So um for the most part, long lines are inserted in, in extremely preterm or very preterm babies with some form of restriction or was just unexpected not to establish feeding as early and in some very critically ill babies, maybe with surgical conditions like diaphragmatic ANAs, abdominal wall defects and severe N EC where there's possibly long term delays in establishing feeds, inter nutrition. So parenteral nutrition is perhaps the most common indication for long line incision. Sometimes we need a long line for hyposmolar fluids. Um, babies with need for liquid concentrations, more than about 12.5%. You need essential access for that. And then we can also administer fluids, electrolytes medications via the long line. And it also helps with minimizing handling and, and problems especially. So, where do we insert long lines? Um, we can insert them right around the upper limbs or the lower limbs in the upper limbs. We tend to go for the antecubital veins. Um and most especially we go for the cephalic and the basilic veins and very rarely, we in very difficult situations, we go for the axillary vein as well, but we generally tend to start low and then go go higher. And as the case may be in the lower limbs, we tend to go for again, we start low usually at the, the the sol venous heart, but then generally tend to end up at the greater venous vein somewhere along its course, the small subvenous vein, the deeper popliteal vein and very rarely, we go for the femoral vein. Very rarely. In very rare cases. Also very rare. We use these kind of veins, that's the superficial temporal veins and it's quite, you need the skill for this and it's not very commonly done in most places. There's also the risk of um inad cannulated the superficial temporal artery which runs parallel to the the veins. Uh you need to be adequate skills to, to do. Um scalp vein, um cannulation down to the um ideal position of the catheter tips. So we want the catheter tip um to be at the cavoatrial junction. So that's um at the junction between the IV S VC or the IVC. And we want it to be outside the cardiac silo on X ray. Um maybe about 0.5 to one centimeter outside the cardiac silo and premise and about 1 to 2 centimeters outside the cardiac um in, in 10 babies um with local limb cannulation, this tends to be at about the level of T four. And with lower limb cannulation, it tends to be at about ct nine to T 11. There. About um the image to the right, just illustrates the target zone, the ideal zone. Um This is from the um Children's Hospital of Orange, Orange County, I think. So, basically, it's a triangle starting at the current level of the carina going down about 1.5 vertebral body unit. So your vertebra body unit is a vertebral body and it's adjacent disc space. So we go down about 1.5 to 1.7 vertebral body units. And uh last point is at the level of the, the right main bronchus. So we want the cat to be somewhere within the zone or above and slightly above it. But again, generally, as long as the catheter tip is outside the cardiac silhouette within these given dimensions. Um And within the IVC or the S VC, we are happy to go ahead and use the long line. But the lower limb, as we see, like um the lower limb lung line, like I mentioned earlier, we want it to be at a level of T nine to T 11, which is usually roughly at the level of the, the diaphragm roughly and the eye to be in the eye infrarenal cover. Again, this corresponds to about T four limb decline and level of T nine ish. And for a lower limb decline, when taking the x-rays, it's important to ensure the baby's position is optimal. We want the baby in its usual um regular position that's sine um adopted and in the midline and in a neutral position that's not excessively flexed or extended as all of this can affect the position of the long line. We also want to ideally not be rotated. But of course, we know this can be quite difficult. In, in, in practice occasionally, we might need to use contrast media like the only part to better visualize the long line, particularly in smaller catheters like the premier. And there's been an increasing shift or lean towards using bedside ultrasound scans instead of x rays just to minimize the amount of x rays that babies are exposed to cause ionizing radiation are carcinogenic. And we want to ideally limit the exposure. So in, in more in the future, it might be more OK. That's patient point of care ultrasound scans used in confirming line placement instead of x-rays, right. So this x-ray is just showing optimal placement of the picc line. This line is inserted in the right upper limb. And as you can see it ends in the superior vena cava, which is outside the cardiac silhouette about 0.5 to one centimeter outside the cardiac silhouette. This is an optimal position. We can see that the ett is a bit low. In this picture, we might need to put it back about a centimeter. Baby also seems to have a UVC and the lungs look like there's some IDS going on with particular nodular opacities in there. But generally, this is good ll placement. This slide just illustrates the potential need for contrast in better visualizing long line tips. As you can see on the left panel, the long line tip is very difficult to visualize. We can see how far down it goes. But when they repeat X ray with contrast administered um and with baby's position optimized, we can see that the long line is in a fairly acceptable position outside the cardiac and within the IVC. Sorry, the S VC. This slide illustrates the scalp, long line. As you can see, it is the long line comes from the head and the scalp and, and in the superior vena cava outside the cardiac, it's a bit rotated but it's still in a good position, not within the heart, but and within the superior vena cava. This is a good line position. And these two images, these two x rays show suboptimal placement. The long lines are way too deep within the heart. On the left, it's within the right atrium and on the right, seems to have gone into the right atrium, possibly through a patent of valve into the left atrium and going towards the pulmonary um trunk. The risk of very low um lung line placement is um there's a risk of pericardial effusion and tid whatever fluid might be running through the line called um that cause any necrosis within the endocardium or diffuse or move by osmosis into the pericardial space and then accumulate and cause tampon. And there's also the risk of arrhythmia, sty or brady arrhythmias and sudden collapse in babies. So this needs to be pulled back into an acceptable position. Again, this is a scalpel line that's too high. Um It's never a good thing to see weekly lung lines. Um So this is suboptimal placement and needs to be I'd say removed. Um Some, some might try to sort of advance it and see if you can get it into the superior vena cava. But, and it's never a good thing to live suburbs and outlands in and this is a lower limb. Um peak line, the panel to the left is a bit busy and baby seems to have an NGT maybe even an an in gastric. So inal tube, um there's some electrode placement, maybe as an umbilical arterial line as well and an umbilical venous line. But here is the um P ICC that's the peak line on the left leg going up if you can see with me with the IFA and, and then at the level of about T nine, just outside the cardiac for that, which is a good position for, for the long line on the right is a less busy, more acceptable um, x-ray and he X ray today that is uh we can consider the long line again just at a level of T nine T 10. It's outside the cardiac s it's um it's a good position. It's a, it's a acceptable long time placement. These two x rays are lower on line basement. We can see on the left there's a right sided L line going up to about s one level ll five S one and then calling upon itself going back down and then about the femoral vein and level of the femoral vein. This is a good placement. Um and it needs to be pulled back. Um So you might need to come out and give it a go again. Um And on the right, we can see a left-sided, lower limb, long line going up crossing the midline and then the ending out about the region of the right renal vein again, not a good long line, but by pulling it back, we might be able to sort of like salvage this one and leave it in. This is another lower and long line on the left, this ends at the level of the hip joint, which is never a good thing. And it's to be advanced, sometimes you just can't advance it any further. And in that case, a long way is to come out because it's never a good thing to live longer than at the level of the joints and at the hip or the, or the shou shoulder joint. Um um on the right again, very busy, you can see a long line on the, on the right side going up, difficult to see where it ends somewhere here, maybe. Um Again, when it's difficult to see the tip of the lung line, it's it point eye red flag for a possible malposition. Um a lateral view X ray might help further identify where the lung line is. And if you can follow me, um you can see the lung line when into the spinal canal and that's a very dangerous um, risk um might need neurosurgical intervention. If you do a la lumbar puncture, you'll see possible parenteral nutrition or fluid um coming out of the, of the lumbar puncture and it's something we try to avoid as much as possible, want to make you. So this long line is to come out for sure. That's it. Um There's certain red flags and things that sort of give us an idea that the long line might be in a, in a bad position. If on insertion, the long line just can't be advanced any further, just seems to get stuck at the level of the joint, perhaps, then we might need to remove the long line and give it another attempt if it cannot be identified on an xray, like I mentioned earlier, if the long line goes, if you see very squiggly, very curly kinks and sharp deviations, all of that points towards a full long line poly placed long line. And again, if the long line lies at its level of the hip or shoulder joints, it's not a good position. Um, if the long line wouldn't flush easily or it's not bleeding back or if the pump keeps alarming high pressure, it's usually more than about 300 I think. Um, it's in a bad position and needs to be reassessed. And if um the therapeutic infusion is like a glucose infusion is not given a desired effect, you know, trying to occur hypoglycemia. Um, but you're not getting it corrected, then it means there's something wrong with your line and you need to reassess the position of that long line. Some other complications of long line placement include embolism from hand embolism at insertion or um, tremors called from on the line or in the line and then embolize and to other parts of the body, we don't want that. And if there's line sepsis from bacterial or fungal infections, the line is to come out and it's a central microscopy called trans sensitivity. Um sometimes it will have extravasation injuries. Um In which case again, the line needs to come out, the limb needs to be elevated. We need an X ray and possible plastic surgical consult. And like I mentioned earlier, if the line lies within the heart, there's a risk of effusion and cardiac tamponment as well as arrhythmias. There's also the risk of inadvertent artery replacement. Most of the veins we use um tend to lie in adjacent adjacent to the arteries. So in the, I think fo we have the break the brachial artery in the lower limbs, we have the posterior tibial artery um on the scalp. We have the superficial temporal arteries, all of which can be inadvertently cannulated and we do not want that. And the last um possible complication is the fact that I'm attempting to remove the long line. Sometimes it breaks it snaps and you leave like fragments and retain within the vein, which is not a good thing. So if there's some difficulty on removal, it's important to be dental possib, leave it alone, senior help. And I've tried to illustrate some fragment of a long line that was sadly left to on, on this to the right. These are my references for further reading if you like and I hope to see you in the next one.