Central venous catheter placement in children: evaluation of electrocardiography using J-wire

Intracavitary electrocardiography for tip location during central venous catheterization: A narrative review of 70 years of clinical studies

Intracavitary electrocardiography is an accurate and non-invasive method for central venous access tip location. Using the catheter as a traveling intracavitary electrode, intracavitary electrocardiography is based on the increase in the detected amplitude of the P wave while approaching the cavoatrial junction. Despite having been adopted diffusely in clinical practice only in the last years, this method is not novel. In fact, it has first been described in the late 40s, during electrophysiological studies. After a long period of quiescence, it is in the last two decades of the XX century that intracavitary electrocardiography became popular as an effective mean of central venous catheters tip location. But the golden age of this technique began with the new millennium, as documented by high-quality studies in this period. In fact, in those years, intracavitary electrocardiography has been studied broadly, and important achievements in terms of comprehension of the technique, accuracy, and feasibility of the method in different populations and conditions (i.e. pediatrics, renal patients, atrial fibrillation) have been gained. In this review, we describe the technique, its history, and its current perspectives.

Intracavitary electrocardiography-guided positioning of central vascular access device can spare unnecessary ionizing radiation exposure in pediatric patients

BACKGROUND

Most hospital protocols-including those of our own institute-require the use of radiography to validate tip position in every central vascular access device placement. This study evaluated whether unnecessary ionizing radiation exposure could be spared in the pediatric population when intracavitary electrocardiography is used to guide catheter placement.

MATERIAL AND METHODS

Retrospective study of intracavitary electrocardiography-guided central vascular access device placements in our pediatric surgery department between 2013 and 2018. We evaluated the operating time, success in positioning the catheter, and accuracy of final tip position. We also assayed the effects of catheter type and of catheter access point on operating time, success, accuracy, and complications. We applied the chi-square test for statistical analysis.

RESULTS

In total, 622 interventions of central vascular access device placements were evaluated; 340 intracavitary electrocardiography-guided central vascular access device placements were included in the study. The electrocardiography method successfully positioned the tip of the catheter in 316/340 (92.94%) of placements. Where intracavitary electrocardiography placement was successful, radiography confirmed accuracy of tip position in 314/316 (99.41%) of placements.

CONCLUSION

When electrocardiography-guided positioning is uneventful and a valid P-Wave pattern is seen, postprocedure radiograph imaging for verification is unnecessary. Any effort should be made to upgrade hospital policies according to evidences and newest guidelines to spare pediatric patients harmful exposure to radiation by limiting the use of radiography only to selected cases.

Monitoring of Central Dual-Lumen Catheter Placement in Haemodialysis by Endocavitary Electrocardiography: A Simple and Safe Technique for the Clinical Nephrologist

Complications in the placement of central venous catheter (CVC) may occur in up to 20% of cases. The catheter can be misplaced in the contralateral brachiocephalic vein, the ipsi or controlateral internal jugular vein, and usually a chest X-ray is necessary to evaluate its location. We believe that the best technique, first described by Serafini et al, to establish the position of a CVC is the endocavitary electrocardiography (EC-ECG) and its employment is recommended in all uraemic patients requiring haemodialysis. This technique uses the tip of the CVC as reference lead in a standard electrocardiograph. The best use of this technique has been obtained by echotomographic visualization of the internal jugular vein executed just before transcutaneous puncture of the vessel. From 1991 to December 1999 we have successfully applied this technique in CVC placement in 612 patients requiring haemodialysis. In our opinion, this method is a safe and simple technique that avoids the need for thoracic X-ray controls and time lost waiting for radiographs that prolong the start of the haemodialysis session. According to our experience, we believe that the EC-ECG technique is a method in compliance with Food and Drug Administration guidelines regarding catheter tip location in uraemic patients.

The Placement of Central Venous Catheters in Hemodialysis: Role of the Endocavitary Electrocardiographic Trace. Case Reports and Literature Review

At present, the placement of a central venous catheter is becoming more and more a routine procedure nevertheless it involves different operators in fields such as oncology, nutrition, nephrology, and emergency medicine. It is well known that complications in the placement of CVC may occur in up to 20% of cases. One fifth of the catheters may result to be misplaced either in the internal omolateral jugular vein or in the innominate vein or in the controlateral brachiocephalic veins and usually a chest radiogram is necessary to evaluate its location. On the basis of 10 years of experience including more than 1,000 CVC placements, we now believe that endocavitary electrocardiography EC-ECG, initially studied and applied by Dr. Serafini, constitutes the best technique, more secure and more comfortable for the patient, to verify the position of the tip of a CVC. The technique EC-ECG, very simple and secure, utilizes the CVC as an endocavitary electrode. This is connected to a standard electrocardiograph, the same one to which the patient is connected during the placement of the CVC, and provides, in derivation V1 or D3, an electrocardiographic pattern extremely sensitive to the position of the catheter tip.

From December 1991 to December 2000, this technique has been used successfully in our departments of nephrology and applied to 1,139 patients that needed a CVC for hemodialysis. EC-ECG and a standard chest radiogram controlled the first 100 CVC we placed and in the other 1,039 cases, the control was made by EC-ECG alone. Only in 31 patients (2.7% of all cases), due to arrhythmia, the technique EC-ECG was not utilized. According to our experience, the procedure EC-ECG is an extremely reliable technique, sensitive and specific in 100% of cases, easy for the operator to perform, comfortable for patient. It doesn't need additional time to be performed and eliminates the need of taking a chest radiogram that up to now was considered indispensable in order to verify the position of the catheter tip. In this manner serious complications such as pneumothorax, and haemothorax that can complicate the placement of a CVC can also be avoided.

Based on our experience, we now believe that this technique, that today has a large application in nephrology, oncology, clinical nutrition and in various branches of general medicine whenever the placement of a CVC is required, should be considered as a possible new guide line in controlling the placement of a CVC together with a chest X-ray when it is necessary.

Effectiveness of electrocardiographic guidance in CVAD tip placement

BACKGROUND

International standard practice for the correct confirmation of the central venous access device is the chest X-ray. The intracavitary electrocardiogram-based insertion method is radiation-free, and allows real-time placement verification, providing immediate treatment and reduced requirement for post-procedural repositioning.

METHODS

Relevant databases were searched for prospective randomised controlled trials (RCTs) or quasi RCTs that compared the effectiveness of electrocardiogram-guided catheter tip positioning with placement using surface-anatomy-guided insertion plus chest X-ray confirmation. The primary outcome was accurate catheter tip placement. Secondary outcomes included complications, patient satisfaction and costs.

RESULTS

Five studies involving 729 participants were included. Electrocardiogram-guided insertion was more accurate than surface anatomy guided insertion (odds ratio: 8.3; 95% confidence interval (CI) 1.38; 50.07; p=0.02). There was a lack of reporting on complications, patient satisfaction and costs.

CONCLUSION

The evidence suggests that intracavitary electrocardiogram-based positioning is superior to surface-anatomy-guided positioning of central venous access devices, leading to significantly more successful placements. This technique could potentially remove the requirement for post-procedural chest X-ray, especially during peripherally inserted central catheter (PICC) line insertion.

The Intracavitary ECG Method for Positioning the Tip of Central Venous access Devices in Pediatric Patients: Results of an Italian Multicenter Study

Purpose

The Italian Group for Venous Access Devices (GAVeCeLT) has carried out a multicenter study investigating the safety and accuracy of intracavitary electrocardiography (IC-ECG) in pediatric patients.

Methods

We enrolled 309 patients (age 1 month-18 years) candidate to different central venous access devices ( VAD) - 56 peripherally inserted central catheters (PICC), 178 short term centrally inserted central catheters (CICC), 65 long term VADs, 10 VADs for dialysis - in five Italian Hospitals. Three age groups were considered: A (<4 years, n = 157), B (4-11 years, n = 119), and C (12-18 years, n = 31). IC-ECG was applicable in 307 cases. The increase of the P wave on IC-ECG was detected in all cases but two. The tip of the catheter was positioned at the cavo-atrial junction (CAJ) (i.e., at the maximal height of the P wave on IC-ECG) and the position was checked during the procedure by fluoroscopy or chest x-ray, considering the CAJ at 1-2 cm (group A), 1.5-3 cm (group B), or 2-4 cm (group C) below the carina.

Results

There were no complications related to IC-ECG. The overall match between IC-ECG and x-ray was 95.8% (96.2% in group A, 95% in group B, and 96.8% in group C). In 95 cases, the IC-ECG was performed with a dedicated ECG monitor, specifically designed for IC-ECG (Nautilus, Romedex): in this group, the match between IC-ECG and x-ray was 98.8%.

Conclusions

We conclude that the IC-ECG method is safe and accurate in the pediatric patients. The applicability of the method is 99.4% and its feasibility is 99.4%. The accuracy is 95.8% and even higher (98.8%) when using a dedicated ECG monitor.

Defining Central venous Line Position in Children: Tips for the Tip

Purpose

The purpose of this study is to analyse literature related to the position of centrally inserted central venous catheters and to review topics related to assessment of tip position of those catheters in children. Applications of specific techniques to PICCs (Periferally Inserted Central Catheters) and umbilical venous catheter will also be reviewed.

Methods

Analysis of 68 original manuscripts, 42 specifically related to the paediatric population, 26 related to the adult population. The papers analysed were published between 1949 and 2014; all articles were in English except one in Italian and one in German.

Results

From the analysed literature, most of the guidelines recommend tip positioning at a level between the superior vena cava and the right atrium. Several methods have been described to evaluate tip position in the paediatric population, but none of those is considered completely reliable. The standard methods used to identify catheter tip position are radiography and fluoroscopy, but no specific landmark can be recommended in the paediatric population. The ultrasonographic approach has been investigated mainly for PICCs positioning in the neonatal population. The electrocardiographic method has been evaluated in the general paediatric population.

Conclusions

No specific recommendation can be given due to the low level of evidence. Ultrasound and ECG (electrocardiogram) techniques are a potential alternative to chest X-ray and further studies should be implemented to establish them. A wider application of these techniques may reduce neonatal and paediatric exposure to radiations and additionally reduce costs.

Umbilical vein catheterization under electrocardiogram guidance

BACKGROUND

In the neonate, umbilical venous catheters (UVC) are inserted and advanced blindly to a predetermined length from the umbilicus. The reported rates for UVC misplacement into the liver (and occasionally the spleen) range from 20 to 37%. Radiographs are routinely used to confirm the positioning of UVCs. This involves movement of often critically ill infants, as well as radiation exposure. This pilot study examines the potential value of confirming UVC placement in neonates using ECG.

METHODS

In critically ill neonates, a conductive Johans ECG adapter was connected to a UVC. A satisfactory tracing (lead II) was obtained (right arm lead connected to the adapter) when the UVC was filled with saline solution allowing the catheter tip to become a unipolar ECG electrode. The UVC was then advanced from the umbilicus until the tip reached the inferior vena cava (IVC) within the thoracic region, as demonstrated by appearance of normal sized QRS complexes with small P-waves. A small QRS indicated the catheter was below the diaphragm. The appearance of a tall positive P-wave indicated the tip was at the right atrium level. The UVC was then withdrawn until the P-wave size returned to normal. The final UVC position was later confirmed by X-ray.

RESULTS

Eight neonates were studied. The figure shows typical ECG tracings when the UVC was placed in the liver, IVC, and right atrium, respectively. Three malpositioned catheters were detected (2 into liver and 1 into spleen).

CONCLUSIONS

Based on these cases, the insertion of UVCs in neonates can be guided with ECG by observing sequential and characteristic alterations in P-waves and QRS complexes, thereby reducing the use of X-rays. In addition, this technique could prove to be beneficial in remote healthcare facilities where X-ray machines may not be readily available and quick intravenous access is required to transport sick neonates to major centers.

Clinical review: vascular access for fluid infusion in children

The current literature on venous access in infants and children for acute intravascular access in the routine situation and in emergency or intensive care settings is reviewed. The various techniques for facilitating venous cannulation, such as application of local warmth, transillumination techniques and epidermal nitroglycerine, are described. Preferred sites for central venous access in infants and children are the external and internal jugular veins, the subclavian and axillary veins, and the femoral vein. The femoral venous cannulation appears to be the most safe and reliable technique in children of all ages, with a high success and low complication rates. Evidence from the reviewed literature strongly supports the use of real-time ultrasound techniques for venous cannulation in infants and children. Additionally, in emergency situations the intraosseous access has almost completly replaced saphenous cutdown procedures in children and has decreased the need for immediate central venous access.

Intracardiac (superior vena cava/right atrial) ECGs using saline solution as the conductive medium for the proper positioning of the Shiley hemodialysis catheter: is it not time to forego [correction of forgo] the postinsertion chest radiograph?

Hemodialysis (HD) is often administered in critical care areas to patients with chronic renal failure as a continuation of the HD they are receiving on an ambulatory basis, and to patients who develop such a need for the first time or may require HD only transiently. The double-lumen Shiley central venous catheter (SCVC), inserted via the brachiocephalic veins, is often employed for HD, and it is customary to obtain a chest radiograph to ensure proper positioning of the tip of the SCVC within the superior vena cava (SVC) or high right atrium (RA). This practice is implemented to evaluate for complications stemming from the insertion of the SCVC and subsequent mishaps due to low positioning of the tip of the catheter in the RA or right ventricle. Intracardiac ECGs obtained via a saline solution-filled SCVC as the conductive medium can be easily recorded serially and periprocedurally to ensure proper positioning of the tip of the SCVC in the SVC or high RA based on the evaluation of the appearance and amplitude of atrial depolarization, thus rendering chest radiographs redundant.