**1. Introduction**

Point-of-care ultrasound (POCUS) is an imaging modality that continues to gain acceptance in pediatric and neonatal medicine. While ultrasound initially served as a clinical tool with a consultative model with radiology and cardiology disciplines, the value of POCUS in assessment of the heart and other organs is slowly being recognized. In neonatology throughout many areas of the world, functional echocardiography performed by neonatologists has been at the forefront in the growth of POCUS compared to non-cardiac POCUS. Technological

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

advances have pushed ultrasound (US) to have improved image quality and mobility while reducing cost and size of devices increasing the availability of ultrasound as a point-of-care bedside tool in several areas such as emergency medicine, obstetrics, and intensive care. Despite the early adoption in obstetrics and maternal-fetal medicine, the actual bedside implementation in neonatology has unfortunately been much slower. Examples in neonatology where POCUS may continue to expand include central line placement, endotracheal tube localization, diagnosis of pneumothoraces, cardiac function assessment, and bowel viability assessment just to name a few. What follows is a practical synopsis of the most active uses and opportunities for POCUS in neonatology.

to place in ideal position because of the doming of the diaphragm. The lateral chest radiograph is better than the AP view of the chest but this view is not as convenient with the infant

Current Neonatal Applications of Point-of-Care Ultrasound

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Ultrasound more accurately confirms the position of the catheter tip than radiographs and reduces the exposure of ionizing radiation. Ultrasound guidance results in faster placement and fewer manipulations and radiographs for both umbilical catheters and PICC as compared with conventional placement [3, 4]. POCUS can be very useful in localizing the tip of central catheters either during placement or after a catheter has been placed to follow any migration. Umbilical catheters can frequently migrate after placement in the first few days after insertion. This may be due to drying and shrinkage of a longer umbilical cord. POCUS allows for the direct visualization of the umbilical and PICC catheters and their tips and indirect visualization of the UVC in the hepatic portion of the catheter pathway where it is localized by the shadow cast by the catheter [4]. Ultrasound may be able to help guide the catheter and thereby reduce complications during UVC, UAC, or PICC insertion. Doppler ultrasound is also useful

to examine the aorta and renal vessels when placing or evaluating a UAC **(Figure 1)**.

**Figure 1.** Umbilical catheter placement (a) UVC-umbilical venous catheter, (b) UAC-umbilical arterial catheter.

Use of POCUS for vascular access for PICCs has been limited due to the greater skillset required to accessing these small veins compared to older children. Setting up dedicated PICC teams can help develop this expertise to promote this aspect of central catheter POCUS. With US, the UVC can be placed just beyond the IVC-RA junction. This permits good visualization and eliminates any risk of extravasation of the catheter in the liver. The UAC is readily placed just behind the heart which approximates the T7–8 position. The recognition of PICC movement in the large vessels makes it particularly challenging to manage the best position to place these catheters. Movement of the arm or leg to identify the deepest position of the PICC will ensure that the catheter does not inadvertently migrate deeper after placement and cause more risk of complications. For upper PICCs the arm position in a 45 degree flexed position at the shoulder and elbow usually represents the deepest point for a PICC while the knees bent close to the chest represent the deepest point for lower PICCs. The upper PICC can be placed at least 1 cm before the SVC-RA junction while the lower PICC is placed at 1–2 cm below the

typically secured down for the procedure.

IVC-RA junction (**Figure 2**).
