Comparing malposition and complications associated with Ultrasound-guided versus Radiography-guided central catheter tip-position in neonates: A Systematic Review and Meta-analysis

Background: There is a growing interest in ultrasound-guided central catheter (CC) tip-position, driven by its potential to improve accuracy and reduce complications. Objective: To systematically review and meta-analyze studies that reported complications associated with ultrasound-guided versus radiography-guided CC tip-position in neonates. Methods: We searched MEDLINE, COCHRANE, EMBASE, CINAHL, and clinicaltrials.gov for Randomized controlled trials (RCTs) and non-randomized controlled studies (NRSs) comparing the complications of ultrasound- versus X-ray-guided CC tip-position in neonates up to June 2024. RCTs and NRSs were analyzed separately. The outcomes included malposition, number of X-rays, procedure time, catheter manipulation, cardiac tamponade, extravasation, occlusion, and sepsis rates. Subgroup meta-analysis based on catheter type was performed. Statistical analyses were conducted using Review Manager 5.4.1 and R 4.1.0, and the GRADE methodology was applied to assess evidence certainty. Results: Seven studies (4 RCTs and 4 NRSs, N=1322 neonates) were included. Ultrasound-guided catheter tip-position significantly reduced malposition rates (3 RCTs, N=181, RR 0.51, CI 95% 0.37 to 0.70; 4 NRSs, N=1110, RR 0.25, CI 95% 0.11 to 0.57) and decreased the need for X-rays (2 RCTs, N=112, MD -1.22, CI 95% -2.32 to -0.11; 2 NRSs, N=401, MD -0.31, CI 95% -0.47 to -0.15). No significant differences were found in procedure time, catheter manipulation, or sepsis rates. All evidence was of low certainty per grade. Conclusions: The use of ultrasound-guided CC tip-position in neonates is associated with a reduction in malposition rates and radiation exposure (low-certainty evidence). Further research is needed to confirm the benefits of ultrasound-guided CC tip-position in neonates. Registration: The protocol was registered in OSF (https://doi.org/10.17605/OSF.IO/HA9Q6)