Does Electrocardiogram Offer an Alternative to Radiological Imaging in the Confirmation of Tip Positioning for the Insertion of Peripherally Inserted Central Catheters; A Comparison of 120 Patients

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 1314-1314 ◽  
Author(s):  
Sasha D Brimacombe ◽  
Lisa McMonagle ◽  
Ashutosh Wechalekar ◽  
Christopher J McNamara

Abstract Background: Within the Haematology and Oncology department at a London Teaching Hospital Peripherally Inserted Central Catheters (PICC) are inserted by the Nurse Practitioners (NP) and tip position is checked by radiological confirmation post procedure. Inpatients were found to be waiting on average 5 hours for a chest xray (CXR), delaying therapies. Confirming tip position post insertion also led to repeat procedures if the tip was found to be malpositioned on the CXR film. Introduction: ECG can be used to verify tip positions of central venous catheters. The technique was first introduced in the 1940s in Europe but the potential was not realised until 50 years later. The practice works by attaching the patient to a cardiac monitor, and connecting an extra lead to the PICC. Pulses from the Sinoatrial Node are detected by the PICC as it enters the Superior Vena Cava. The impulse grows stronger as the tip advances down the vein, signified by an enlarged p-wave visible on the ECG. Passing the node causes a deflection in the wave, communicating to the inserter that the tip is positioned beyond the Cava-Atrial Junction (CAJ) i.e. into the right atrium, and should be retracted. The ideal tip position for a PICC line is between the distal SVC and within one centimetre of the right atrium. This method of insertion is not suitable for all patient groups. It is well documented that obese, the young or patients with AF will not obtain a clear p-wave rise. Also the presence of a pacemaker will mean that the p-wave size is not affected by the PICC tip position. Ideal tip position of a PICC line provides reliable venous access with optimal therapeutic delivery, while minimizing short-and-long term complications. Prior to engaging in the data collection, the Nurse Practitioners completed an ECG course, participated in a company workshop and consolidated their training by visiting another trust who were also performing ECG guided PICC insertions. Figure 1 Figure 1. Method: A study of 120 patients compromising of 66 females and 54 males from October 2013 – July 2014 was performed. 103 PICC lines were required for chemotherapy treatment, the remaining 17 PICC line were for supportive therapies. 36 PICC lines were inserted on the left side and 84 PICC lines inserted on the right. PICCs were placed under ECG guidance and a post-procedural CXR was performed. The NP predicted the position of the tip based on the ECG tracing, and comparison was made once the CXR was performed and the radiological report made available. Results Out of 120 cases, 10 patients failed to obtain a p-wave rise that the inserter deemed significant. However according to the radiological image all of these lines were found to be suitably positioned. The incidence of this phenomenon was greatly reduced once the practitioners gained experience of this technique. There was one case where the p-wave rise was deemed significantly high by both practitioners to predict a positioning of the CAJ. However following a CXR, the line was incorrectly positioned at the top of the SVC. This was of concern; however the patient was a complex case, with Budd-Chiari syndrome, causing abdominal distension and compression of the organs. In published literature, below diaphragm abnormalities can impact on the sensitivity of the technique. For this reason complicated patients, such as described will require consideration of radiological imaging. In all other cases where the P wave was appropriately elevated the chest radiograph image that followed demonstrated a definite correlation between the height (size) of the P-wave and the location of the terminal tip is within the SVC. Conclusion The data significantly supported ECG guidance as an accurate verification for PICC tip position. Currently the department is planning on foregoing the post-insertion CXR if the ECG method has produced a positive result. The Nurse Practitioners recognise that there will always be cases that require a CXR. However use of the ECG method will reduce the time between insertion and use of the PICC line, diminish radiation exposure to our patients and lower the costs of repeated insertion due to malpositioning of lines. Disclosures No relevant conflicts of interest to declare.

2008 ◽  
Vol 13 (2) ◽  
pp. 82-87 ◽  
Author(s):  
Donna Loupus ◽  
Susan Schuetrumpf ◽  
Laura F. Vazquez

Abstract Introduction: Peripherally Inserted Central Catheters (PICCs) are a proven and cost effective alternative to traditional short term central venous catheters inserted via subclavian or jugular vein routes. It has been theorized that persons with cervical spinal cord injury (SCI) are more prone to upper extremity deep venous thrombosis (DVT) post PICC insertion. Purpose: This study was conducted to determine if there is a statistically significant increase in the incidence of PICC-related upper extremity thrombosis in persons with quadriplegia as compared to other patient populations. Methods: A retrospective chart review of 56 PICC insertions, performed on 44 patients, was conducted to identify risk factors associated with symptomatic upper extremity DVTs. Results: The overall incidence of symptomatic DVTs was 7.1% per PICC line insertion (95% CI 2.8% - 17.0%) and 9.1% per patient (95% CI 3.6% - 21.2%) and the number of DVTs per 1,000 catheter days was 3.14. DVT diagnosis was not significantly associated with any of the patient or PICC-related characteristics examined. The incidence of symptomatic DVTs per PICC line insertion was not significantly different than the lowest incidence of thrombosis reported in the scientific literature among all patients receiving PICCs. Conclusions: Results from this study do not suggest that persons with cervical spinal cord injuries are at increased risk for developing upper-extremity DVTs related to PICC insertion. Due to the retrospective nature of the present study and small sample size, prospective studies are recommended to further examine DVTs in patients' with spinal cord injuries. Estimates from the present study can be used in planning prospective studies.


1983 ◽  
Vol 245 (4) ◽  
pp. H580-H583
Author(s):  
R. A. Bedont ◽  
J. A. Abildskov ◽  
R. L. Lux ◽  
L. S. Green

Studies were done on eight mongrel dogs anesthetized with pentobarbital sodium to assess the effects of acute changes in heart volume on the magnitude of electrocardiographic potentials recorded from the right atrium. Following midsternotomy, acute changes in heart volume were produced by occlusion of the superior vena cava (SVC), inferior vena cava (IVC), or both vena cavae while heart rate was controlled by pacing the right atrium. P-wave area, defined by integrating absolute value of the P wave over time, increased by 8.2 +/- 7.4% during SVC occlusion, 13.3 +/- 8.5% during IVC occlusion, and 23.6 +/- 16.2% during occlusion of both vena cavae. Areas of ventricular complexes appearing in atrial electrograms decreased by 6.6 +/- 6.2% during SVC occlusion, 11.1 +/- 6.7% during IVC occlusion, and 15.2 +/- 9.2% during occlusion of both vena cavae. These results are compatible with predominately tangential activation of the atrium and radial excitation of the ventricle and provide experimental confirmation of the "Brody effect."


Author(s):  
Thaís Aquino Carneiro ◽  
Keline Soraya Santana Nobre ◽  
Fernanda Cavalcante Fontenele ◽  
Ana Paula Melo Façanha ◽  
Roberta Pinheiro Ferreira

ABSTRACT Objective: to assess the use of peripherally inserted central catheters regarding the neonate’s profile, indications for use, and catheterized vein; the relation between the number of puncture attempts and vein; and assessment of the catheter tip position. Method: documentary, descriptive, retrospective, quantitative study, developed in a tertiary maternity hospital in Ceará. A total of 3,005 PICC insertion formularies was included and 1,583 were excluded due to incomplete data, with a convenience sampling of 1,422 insertions being obtained. Results: There were 1,200 (84.4%) newborns with gestational age below 37 weeks; 781 (54.9%) males; Apgar score above 7 in the first (628–44.2%) and fifth minutes (1,085–76.3%); and weight between 1,000 and 1,499 grams on the day of insertion (417–29.3%). Antibiotic therapy had 1,155–53.8% indications for insertion; the basilic was the most used vein (485–34.1%); basilic and cephalic veins had lower median puncture attempts and 1,124–79% insertions were centrally positioned. Conclusion: The results of this research highlight the continuous need to improve technical-scientific knowledge to qualify actions in neonatology.


2021 ◽  
Vol 49 ◽  
Author(s):  
Monique Machado Louredo Machado Louredo Teles Bombardelli ◽  
Tatiana Champion ◽  
Julio Cezar Juk Fischborn ◽  
Ana Bianca Ferreira Gusso

Background: Analysis of the electrocardiogram may suggest atrial and ventricular overloads. However, it has a low sensitivity and specificity for diagnosis of cardiac chamber overload. The accuracy of electrocardiographic interpretation can be improve using new cut-offs for the duration and amplitude of the electrocardiographic waves. Our objective was to evaluate the use of the electrocardiogram in the diagnosis of atrial and ventricular overload, using echocardiography as the gold standard test for the diagnosis of atrioventricular overload. We aimed to define new cut-off values that would increase the sensitivity and specificity of the electrocardiogram for diagnosis of chamber overload in dogs.Materials, Methods & Results: Eletrocardiogram records were obtained in 81 dogs divided into 3 groups: Group 1A (healthy dogs 10 kg); Group 1B (dogs 10 kg with mitral or tricuspid valve disease); Group 2 (dogs weighing between 10.1 and 20 kg) and Group 3 (dogs > 20.1 kg). Duration in milliseconds (ms) and amplitude in millivolts (mV) of P waves and QRS complexes, PR and QT segment, T wave amplitude and ST segment were evaluated in lead DII. Using leads I and III, the mean cardiac electrical axis in the frontal plane, expressed in degrees, was determined as the mean of three consecutive measurements. For Group 1A and 1B the duration of P wave was < 45 ms and QRS duration < 55 ms. In Group 2 the duration of P wave was < 47 ms and QRS duration < 57 ms. In Group 3 the duration of P wave was < 50 ms and duration QRS < 64 ms. These values (duration of P wave and QRS duration) were compared with echocardiographic measurements of the left atrium, considering the reference value AE/Ao < 1.4 and measurements of the left ventricle in M-mode according to the body weight, respectively. A P wave amplitude < 0.4 mV suggested that the right atrium size was normal and this was compared with the area of the right atrium measured on the echocardiogram. The right ventricle was assessed using the amplitude of S wave and right axis deviation and compared with the right ventricular area obtained by echocardiography. The reference value of the right atrium and right ventricle is according to the body weight. For both the right and left atria, there was concordance between the diagnoses with electrocardiography and echocardiography. For the right and left ventricle was no agreement between the diagnoses. All criteria examined had low sensitivities, usually with high specificities. But it was not possible to determine a new cut-off that would improve the sensitivity of the electrocardiogram for diagnosis of atrial and ventricular overload in dogs. Discussion: The electrocardiogram analysis produced false interpretations for the measures indicative of atrioventricular overloads and should not be used alone, for diagnosis of cardiac chamber overload. The standard electrocardiographic reference values, for P wave duration and amplitude, were excellent for identification of normal atrial size. However, QRS duration, R wave amplitude (dependent of the dog’s weight) and S wave amplitude, associated with cardiac electrical axis cannot be used for diagnosis of ventricle overload. Electrocardiographic analysis should not be used as a tool to assess cardiac chamber overload, which should be diagnosed by echocardiography and clinical investigation. Based on our findings echocardiogram is the gold standard test indicated to identify overload of cardiac chambers.


2007 ◽  
Vol 12 (1) ◽  
pp. 29-31 ◽  
Author(s):  
Christine L. Naylor

Abstract Catheter malposition is a common occurrence with the insertion of peripherally inserted central catheters (PICCs). Santa Rosa Memorial Hospital (SRMH) in Santa Rosa, California, trialed and implemented a new tip location device to evaluate whether malposition rates could be reduced. This article compares 6 months of data. Three of these months were compiled before using the tip locator device. The right atrial malposition rate remained consistent at 18% with or without the use of the tip locator device. All other malpositions were 13.4% without use of the tip locator. The overall malposition rate was 2.5% with the use of the tip locator device. By using this technology, supply and labor costs were reduced, as were referrals to interventional radiology and delays in treatment. Overall staff satisfaction improved.


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