Seeing the Unseen: The Power of Ultrasound in Neonatal Catheter Malposition

Introduction

Central venous catheters (CVCs) are devices positioned at the junction of the superior vena cava (SVC), inferior vena cava (IVC), and the right atrium. They are commonly used in neonatal intensive care practice. CVCs are indicated in cases of hemodynamic instability or need for inotropic support, postoperative monitoring, central venous pressure measurement, administration of large volumes of fluids or blood products, and total parenteral nutrition (TPN). Another important indication in neonates is to reduce the need for repeated painful procedures in patients requiring frequent blood sampling.

However, the use of central catheters is not without risk; potential complications include malposition, pneumothorax, arrhythmias, and effusions. Although modern techniques and the use of ultrasound have significantly reduced complication rates compared to the previously used “blind” methods, these risks remain clinically relevant.

For many years, chest radiography has been the standard method for determining catheter tip location. However, it is now well recognized that radiography is insufficient for detecting catheter malposition and associated complications. With the increasing use of ultrasound and the feasibility of intracavitary electrocardiographic (ECG) monitoring, these methods are gradually replacing chest X-ray as the standard clinical practice for verifying catheter tip location. The growing use of point-of-care ultrasound (POCUS) enables real-time, bedside assessment, facilitating not only catheter placement and tip localization but also early detection of complications [1].

In this case, we aimed to highlight the critical role of POCUS in the early detection of catheter malposition, despite successful management and multimodal catheter tip verification (including ECG monitoring, ultrasound-guided evaluation, and chest radiography) during central catheter insertion in a neonate requiring total parenteral nutrition and surgical intervention.

Case Presentation

A female preterm infant born at 34+1 weeks of gestation with a birth weight of 1290 grams–classified as small for gestational age (SGA)–was admitted to the neonatal intensive care unit (NICU) due to prematurity, SGA, and a prenatal suspicion of meconium ileus. During postnatal follow-up, the infant exhibited abdominal discoloration and absence of meconium passage. On postnatal day 2, she underwent surgery for a closed intestinal perforation, internal hernia resection, and creation of a double-barrel ileostomy.

In the postoperative period, due to the need for prolonged total parenteral nutrition, electrolyte support, and intermittent transfusions, a peripherally inserted central catheter (PICC; 2F epicutaneo-caval catheter) was placed. The infant was managed with this PICC for 14 days. As ileostomy closure was planned on postnatal day 32, central venous access was again required to maintain total parenteral nutrition and facilitate painless laboratory testing during the subsequent postoperative period.

Following proper sterilization and sedation, vascular structures were evaluated under ultrasound guidance. Using an in-plane technique with an 8 MHz probe, venous puncture of the subclavian vein was performed, and the needle was visualized in real time. Advancement of the guidewire was monitored sonographically. During this process, cardiac rhythm changes were observed on electrocardiographic monitoring, coinciding with the progression of the guidewire. The catheter was visualized within the superior vena cava via ultrasound. Following placement using standard procedural technique, blood was aspirated from the catheter, and a 1 mL saline flush was administered. The catheter tip was then evaluated and confirmed in position using ultrasound. A chest X-ray obtained after the procedure showed the catheter tip at the junction of the superior vena cava and the right atrium ([Fig. 1a]). The catheter was then put into use.

Fig. 1 a:Chest X-ray confirming the catheter tip positioned at the superior vena cava level at the entrance of the right atrium (chevrons). b: Ultrasound image showing a parallel echogenic stripe (white arrow) the “rail-road sign” indicating the central venous catheter malposition, pleura (arrowhead), ribs (star).

However, approximately one hour after the procedure, during the preoperative assessment and ostomy inspection conducted by the surgical team, an insufficient analgesic response to fentanyl administered via the catheter prompted suspicion of catheter malposition. Bedside contrast-enhanced echocardiography revealed no filling of the right atrium. Thoracic ultrasound using a 12 MHz linear probe demonstrated the “rail-road sign,” indicating extravascular positioning of the catheter ([Fig. 1b], Video 1). When 1 mL of saline was injected through the catheter for confirmation, contrast filling was observed in the lung fields, definitively diagnosing catheter malposition. The catheter was immediately removed. The patient was closely monitored and did not develop any pulmonary complications.

Written informed consent was obtained from the patient’s parents prior to submission for publication.

Publication History

Received: 06 November 2025

Accepted after revision: 19 January 2026

Article published online:
18 February 2026

• References

• 1 Pittiruti M. et al. A GAVeCeLT bundle for central venous catheterization in neonates and children: A prospective clinical study on 729 cases. J Vasc Access 2023; 24: 1477-1488
• 2 Pittiruti M, Hamilton H, Biffi R. et al. ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr 2009; 28: 365-377
• 3 La Greca A. et al. Improving the “global use” of ultrasound for central venous access: a new supraclavicular scan by microconvex probe. Crit Ultrasound J 2014; 6: A11
• 4 Kim H, Choi KH. Central catheter-induced cardiac tamponade in neonates: Two case reports. Heart Surg Forum 2023; 26: E672-E675
• 5 Shannon D. Central venous catheter-induced pericardial effusion in a neonate: a case study and recommendations for practice. Neonatal Netw 2014; 33: 341-348
• 6 Maruyama K, Koizumi T. Hydromediastinum associated with a peripherally inserted central venous catheter in a newborn infant. J Clin Ultrasound 2006; 34: 195-198
• 7 Sztajnbok J, Troster EJ. Acute abdomen due to late retroperitoneal extravasation from a femoral venous catheter in a newborn. Sao Paulo Med J 2002; 120: 59-61
• 8 Sancak S, Tuten A, Yildirim TG. et al. Massive pleural effusion on the contralateral side of a venous peripherally inserted central catheter. J Clin Ultrasound 2018; 46: 140-144
• 9 Köstekci YE, Bayram Ö, Mertek S. et al. Complications of epicutaneo-caval catheters: Pericardial effusion and cardiac tamponade in three preterm infants. J Vasc Access 2024; 25: 1690-1694
• 10 Barone G, Pittiruti M, Biasucci DG. et al. Neo-ECHOTIP: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in neonates. J Vasc Access 2022; 23: 679-688