Extravasale Lage von zentralen Venenkathetern bei korrekter EKG-Ableitung

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.

Peripherally inserted central catheters: dependency of radiation exposure from puncture site and level of training

Background Several interventional procedures show a dependency on fluoroscopy times (FT) and level of training. Furthermore, FT and dose area products (DAP) vary depending on access site and target vessel for chest port implantations, but not for other thoracic interventions such as percutaneous coronary interventions. Purpose To evaluate the influence of the combination of venous access site and level of training on FTs and DAPs during peripherally inserted central catheters (PICC) implantations in a large cohort of patients. Material and Methods In this retrospective study, PICC implantations of 681 consecutive patients (385 women, 296 men; mean age = 55.0 ± 16.7 years) were analyzed. Two groups of junior (< 50 interventions) and senior (≥ 50 implantations) radiologists were investigated in respect to FT and DAP during PICC placement procedures. Statistical analysis included the Mann-Whitney U test and the Kruskal-Wallis test. P values < 0.05 were considered significant. Results Senior radiologists required significantly less FT (senior = 0.43 s, junior = 0.53 s, P = 0.041), but there was no significant difference in DAPs (senior = 56.3 µGy*m², junior = 60.6 µGy*m², P = 0.151). PICC implantations through the left side resulted in a significant reduction of the median FT by 60.9% (left = 0.45 s, right = 1.15 s, P = 0.010). Conclusion Due to considerable dose reduction, the left-sided puncture, especially via the basilic and brachial veins, performed by well-trained interventional radiologists seem to be the preferable approach for PICCs.

Totally Implantable Central Venous Port Catheters: Radiation Exposure as a Function of Puncture Site and Operator Experience

BACKGROUND

Totally implantable central venous port systems provide a safe and effective, long-term means of access for administration of hyperosmolar, local irritant medication, such as chemotherapy, antibiotics and parenteral nutrition.

AIM

To evaluate the combination of access site and level of experience on fluoroscopy times (FT) and dose area products (DAP) during implantation of port catheters in a large patient population.

MATERIALS AND METHODS

A total of 1,870 patients (992 women, 878 men; age: 61±13.14 years) were reviewed investigating two groups of junior (≤50 implantations) and senior (>50) radiologists.

RESULTS

Senior radiologists required less FT/DAP (0.24 s/57.3 μGy m2 versus 0.43 s/68.2 μGy m2, respectively; p<0.001). Right jugular vein access required the least FT/DAP (0.25 s/56.15 μGy m2) and right-sided implantation lower FT/DAP (right: 0.26 s/56.4 μGy m2, left: 0.40 s/85.10 μGy m2, p<0.001).

CONCLUSION

Due to DAP/FT reductions, the right jugular vein seems to be the most favorable implantation side for port systems. For further dose reduction, residents should be well-trained.

Optimierte Positionierung zentraler Venenkatheter durch eine modifizierte Anwendung der intravasalen Elektrokardiographie

BACKGROUND

Intraatrial electrocardiography (ECG) is a well-established method for central-venous catheter (CVC) placement and an intraatrial position is assumed, when a significantly increased P-wave is registered. However, an increase in P-wave amplitude also occurs in other positions. Therefore we evaluated CVC tip positioning by means of transesophageal echocardiography (TEE) at a maximum P-wave amplitude.

PATIENTS AND METHODS

In this prospective randomized study the right or left internal jugular vein was cannulated with 100 patients in each group and catheter tip positioning was guided by means of ECG. The catheter was fixed at the position of maximum P-wave amplitude and the insertion depth was registered. The relationship of the CVC tip position to the superior edge of the crista terminalis was demonstrated with the help of TEE.

RESULTS

In all patients the catheter tip was found +/- 0.5 cm from the superior edge of the crista terminalis at the transition from the superior vena cava to the right atrium. On x-ray control, all catheters ran along the length of the vessel wall of the superior vena cava.

CONCLUSIONS

A maximum P-wave is derived even at the entrance to the right atrium. This explains why ECG-guided CVC placement -- based on the largest P-wave amplitude -- consistently resulted in correct positioning of the CVC tip at the transition from the superior vena cava to the right atrium.