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• Digitally enhanced PACS Xray images are useful
  Vengudi S Sankar
  Published on: 22 March 2016
• Long Lines in neonates and complications
  Mahesh Masand
  Published on: 22 March 2016

• Published on: 22 March 2016

  Digitally enhanced PACS Xray images are useful

  • Vengudi S Sankar, Consultant Paediatrician
  • Other Contributors:
    • Daniel T. Hindley, Ahmed El Azabi

  Dear Editor

  The authors of the recent case report[1] make an important point about the use of radio-opaque contrast to determine accurately, the position of the central line in neonates. This could perhaps be considered as ‘the gold standard’. There is however a real risk of line migration, the risk increasing with the time the line is left in. Thus, an appropriately positioned silastic line evaluated to be safe by ini...

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  Dear Editor

  The authors of the recent case report[1] make an important point about the use of radio-opaque contrast to determine accurately, the position of the central line in neonates. This could perhaps be considered as ‘the gold standard’. There is however a real risk of line migration, the risk increasing with the time the line is left in. Thus, an appropriately positioned silastic line evaluated to be safe by initial radiography may still migrate to an unsafe position later.[1,2]

  The PACS (picture archiving and communications system) digital image archiving system3 offers image enhancement facilities. The image ‘sharpening’ tool (‘magic glass sharpen’) can be used to visualize with clarity, lines (silastic and other long lines, UAC, UVC) and tubes (ET tubes, NG tubes) inserted during neonatal intensive care. We have found this digital Xray archiving service extremely good and have found the ‘sharpened’ images particularly useful to monitor the tip position of silastic long lines.

  Image 1 showing the silastic longline (with and without sharpened image)
  

  Image 2 showing NG tube coiled in the upper oesophagus – not visible in the ‘un sharpened’ image
  

  References

  (1) N Makwana, A Lander, R Buick, and B Kumararatne Unusual complication of a central venous line in a neonate Arch Dis Child Fetal Neonatal Ed., Sep 2003; 88: F440.

  (2) P Madhavi, R Jameson, M J Robinson Unilateral pleural effusion complicating central venous catheterization. Arch Dis Child Fetal Neonatal Ed 2000;82:F248-F249(May).

  (3) Nicola H Strickland PACS (picture archiving and communication systems): filmless radiology. Arch Dis Child, Jul 2000; 83: 82-86.

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  Long Lines in neonates and complications

  • Mahesh Masand, paediatrician

  Dear Editor

  The authors need to be congratulated for publishing this case report which I think must have been the lesson of the week for many budding and trained neonatologists.

  I would just like to make few comments:
  1. The long line from the picture in the article appears to have been inserted via left ante cubital fossa rather than the right as mentioned in the text.

  ...

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  Dear Editor

  The authors need to be congratulated for publishing this case report which I think must have been the lesson of the week for many budding and trained neonatologists.

  I would just like to make few comments:
  1. The long line from the picture in the article appears to have been inserted via left ante cubital fossa rather than the right as mentioned in the text.

  2. The use of contrast is obviously a must for silastic long lines as was obvious from this case, as their visibility depends on other factors like exposure of the film, edema of subcutaneous tissue etc, although polyurethane long lines do not need any contrast material as they are very radio opaque, as compared to silastic lines.

  3. The authors did not mention the length of the long line inserted, which could have given a clue to other experienced colleagues on the ward rounds on the fate of the unaccounted length of line. In some units it is a must for doctors to document the length of long line inserted on the baby’s notes and cot side "line chart". We have been able to prevent a lot of such potential complications just by that simple guideline.

  It is not uncommon for many units not to use contrast media, for silastic lines and an inexperienced operator is commonly carried away especially in easy cases to push the line more than the measured length or it may be a result of miscalculation of measurement or due to error in reading the markings on the long lines as the silastic lines only have markings every 5cm apart.

  In the said case I am sure the length of the long line inserted via left arm must have been more than 15-16cm to reach that position below the diaphragm, and the actual length of line needed to be inserted for a 800gram baby from left ante cubital fossa to reach SVC-right atrium junction would not be more than 11-12 cm in an average size baby. If one could not visualise this line beyond SVC after inserting 15-16cm of length then that should make one think harder and look for the missing portion somewhere as the lines have the habit of wandering to unwanted places, which unfortunately is beyond the control of the operator.

  Take home message
  If one cannot account for the whole length of long line inserted from insertion site on Xray, especially in cases where contrast has not been used, then think very hard and differ commencement of TPN till the tip is verified conclusively.

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  Conflict of Interest:
  None declared.

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