A randomized controlled study of bedside electrocardiograph-guided tip location technique & the traditional chest radiography tip location technique for peripherally inserted central venous catheter in cancer patients

Cost comparison of four venous catheters: Short peripheral catheter, Long peripheral line, Midline, and PICC for peripheral infusion

INTRODUCTION

The use of midline catheters for patients requiring a peripheral IV infusion is sometimes limited by their cost. Although decision trees allow them to be positioned in relation to short peripheral cannulas (SPC), Midlines, and PICCs, their economic impact has not yet been evaluated. A study was conducted to estimate and compare the actual costs of using the three types of catheters for durations of 7, 14, and 21 days.

METHODS

A budget impact analysis compared midlines or mini-midlines/long peripheral cannulas (LPCs) with SPCs and PICCs for typical medical indications excluding indications requiring central line (infusion of irritant or vesicant drugs): treatment of peritonitis over 7 days, cystic fibrosis infection over 14 days, and meningitis over 21 days. A micro-costing study identified resources used during catheter care procedures (consumables, medical/nursing care, examinations, mechanical complications). The cost of remote systemic complications was estimated from the French national cost study. Literature review compared data based on published complication frequencies.

RESULTS

Midline is more economic than the SPC (saving of 39€ over 7 days and 174€ over 14 days), and than the PICC (saving of 102€ over 14 days and 95€ over 21 days).

DISCUSSION

Despite a much higher acquisition cost of the Midline than a SPC, the cost of using a Midline is lower. Although this approach cannot be the only argument for choosing a medical device, it can contribute to it in a tense economic context. The micro-costing has been performed in a center placing PICCline using fluoroscopy for catheter tip positioning. The implantation of a PICC with ECG technique does not require an interventional radiology facility and involves significantly lower logistical and personnel costs. This factor is a limitation in this study. However, even with the use of EGC, the cost difference is in favor of Midline.

Intracavitary electrocardiogram guidance for peripherally inserted central catheter placement: A systematic review and trial sequential meta-analysis

BACKGROUND

The intracavitary electrocardiogram (IC-ECG) localization technique has been widely used in peripherally inserted central catheter (PICC) placement. However, the accuracy of IC-ECG on PICC tip localization and complications remains controversial. The purpose of this work is to evaluate the clinical efficacy and safety of IC-ECG on PICC placement.

MATERIALS AND METHOD

We retrieved randomized control trials from PubMed, Web of Science, Cochrane Library, EMBASE, and CNKI databases published before October 30, 2024. Patients guided by IC-ECG technology or landmark, and then used radiography to confirm the tip position, regardless of age, race, nationality, and region. Interventions other than IC-ECG or landmark were excluded. We used the Cochrane Bias Risk Assessment tools version 2 to evaluate the quality of enrolled trials. The Grading of Recommendations Assessment, Development, and Evaluation Statements online tool was used to determine the certainty of the evidence. The primary outcome was the success rate on the first attempt.

RESULTS

Sixteen studies involving 6707 PICC patients are included. The results of the meta-analysis indicate that the IC-ECG group has a significantly higher success rate on first attempt of PICC placement (RR = 1.23, 95% CI [1.09-1.37], p < 0.00001). Total complications and phlebitis events decreased in the IC-ECG group compared with the landmark group. The mean procedure time, thrombogenesis, infection, and arrhythmia in the IC-ECG group are not statistically significant compared with the landmark group. Trial-sequential analysis (TSA) of the results indicate that sufficient events had been observed in the outcomes in success rate on first attempt, overall successful rate, total complications, phlebitis events, and infection events.

CONCLUSION

The IC-ECG guided method has a higher success rate on the first attempt and lower total complication for catheter tip localization in PICC placement. IC-ECG may be considered the preferred method for accurate catheter tip placement. (PROSPERO registration number, CRD42023456651).

An Italian expert consensus on the choice of the method of tip location for central venous access devices

Tip location of central venous access devices is considered highly relevant for the purpose of reducing catheter-related complications and prolong the duration of the access. Though, the choice of the method of tip location currently relies upon the operator's experience, preference, and training, on the local availability of specific resources and technologies, and on local policies. On the contrary, considering the relevance of tip location, such clinical choice should preferably be based on the best available evidence. Though current guidelines recommend intra-procedural rather than post-procedural methods of tip location, many clinicians still adopt the strategy of assessing the position of the tip by radiological methods after the completion of the procedure. Also, though current guidelines and evidence-based documents recommend the intra-cavitary electrocardiography and/or trans-thoracic echocardiography as preferred methods of intraprocedural tip location, many clinicians still adopt fluoroscopy. While the pros and cons of each different method of tip location are well known, there is no evidence-based document that offer robust recommendations about the choice of tip location of different central venous access devices in different population of patients (neonates, children, adults). Therefore, the Italian Group of Long-Term Venous Access Devices (GAVeCeLT) and the Italian Vascular Access Society (IVAS) have developed a national consensus on the choice of the most appropriate method of tip location. After a systematic review of the available evidence, the panel of the consensus (which included 22 Italian experts with documented competence in this area) has provided structured recommendations answering six key questions regarding the choice between intra-procedural and post-procedural tip location, as well as the appropriate indication of the four different methods of intra-procedural tip location currently available (trans-esophageal echocardiography, trans-thoracic echocardiography, intracavitary electrocardiography, and fluoroscopy). Only statements reaching a 100% agreement were included in the final recommendations.

Value of projectional imaging relative to cross-sectional imaging to assess catheter tip position in the superior vena cava: evaluation of reader variability

OBJECTIVES

The cavo-atrial junction (CAJ) is the most appropriate central venous catheters CVC tip location to reduce complications. Among chest X-ray (CXR) landmarks for tips assessment, only the pericardial reflection lies in the same plane as the vascular structures. We aimed to evaluate the observer variability to determine tip positioning on CXR, using CT as a gold standard.

METHODS

We retrospectively analyzed 107 CT scans of patients with port catheters (January-December 2021). The tip to CAJ distance (DCAJ) was measured on both projectional (PJ) and cross-sectional (CS) CT images by 2 × 2 observers (within and between evaluations). Observational statistics included paired t-tests, repeatability coefficients (RC), and intraclass correlation coefficients (ICC), with data visualized using Bland-Altman plots.

RESULTS

All ICC were >0.9, indicating excellent reliability. The mean difference between observers comparing CS and PJ was 0.13 ± 0.80 cm (P = .10) with outer 95% confidence limits of 1.92 cm and -2.17 cm and an RC of 1.79 cm.

CONCLUSION

CXR provides a reliable method for CVC tip localization, though assessment variability is ±2 cm.

ADVANCES IN KNOWLEDGE

CXR assessment of CVC tips shows both intra- and inter-individual variability, due to challenges in identifying the CAJ and catheter tip . While considering the 3 cm anatomical zone around the CAJ acceptable, operators should be aware of the 2 cm variability resulting from CXR assessment. To account for this variability and avoid the risk of positioning the tip beyond 3 cm from the CAJ, operators should reduce the CXR-based acceptable zone to 1 cm around the CAJ, impacting approximately 30% of procedures.

A narrative review on tip navigation and tip location of central venous access devices in the neonate: Intracavitary ECG or real time ultrasound?

The proper location of the tip of a central venous access device plays a crucial role in minimizing the risks potentially associated with its use. Recent guidelines strongly recommend preferring real-time, intra-procedural methods of tip location since they are more accurate, more reliable and more cost-effective than post-procedural methods. Intracavitary electrocardiography and real time ultrasound can both be applied in the neonatal setting, but they offer different advantages or disadvantages depending on the type of central venous access device. Reviewing the evidence currently available about the use of these two methods in neonates, in terms of applicability, feasibility and accuracy, it can be concluded that (a) real time ultrasound is the only acceptable methodology for tip navigation for any central venous access device in neonates, (b) intracavitary electrocardiography is the preferred method of tip location for central catheters inserted by ultrasound-guided cannulation of the internal jugular vein or the brachiocephalic vein, and (c) real time ultrasound is the preferred method of tip location for umbilical venous catheters, epicutaneo-cava catheters, and central catheters inserted by ultrasound-guided cannulation of the common femoral vein.

A feasible and safe standardized protocol for ultrasound and intracavitary electrocardiogram-based tip navigation and tip location during placement of peripherally inserted central catheters

BACKGROUND

Peripherally inserted central catheters (PICCs) are performed for medium and long term intravenous therapy. The most recent guidelines recommend the use of ultrasound-guided venipuncture to reduce surgery-related complications. In recent years, bedside ultrasound has also been used as evidence of accuracy in tip navigation and tip positioning. This paper is aimed to investigate using tip navigation with the ultrasonic technique and intracavitary electrocardiogram during the catheterization, and to suggest a feasible and safe standardized protocol for clinical practice.

METHODS

A total of 1727 tumor clients who suffered from combined the ultrasonic technique with intracavitary electrocardiogram (ECG + US group) to confirm the tip location of PICC were included in Peking Union Medical College Hospital in 2020. And based on electronic medical records according to the types of cancer as 1:1 to select 1727 cases who only underwent electrocardiogram (ECG group) to verify the tip location of catheters with the same team in 2019. Compared two groups of purpose of catheter, insertion site of upper limbs, times of puncture and delivery catheters, tip location and malposition of peripherally inserted central catheter, and analysis of the safety and feasibility.

RESULTS

There were no significant differences between the two groups in the purpose of catheter, insertion site of upper limbs, times of puncture, and delivery catheters. The percentage of optimal tip location in ECG + US group was significantly higher than that in ECG group, and the rate of malposition of catheters was obviously lower than that in ECG group (p < 0.001).

CONCLUSIONS

Tip navigation based with ultrasound and intracavitary electrocardiogram has high accuracy to confirm tip location of PICC, and it is also feasible and safe, which can not only to make up for the deficiency of patients without surface P waves who could not be applied ECG but also to fit for all patients.

Effect of intracavitary electrocardiographic localization on the success rate and complications of PICC in infants

BACKGROUND

Peripherally inserted central catheter (PICC) is widely used in chemotherapy of children with malignant tumors because of its safe operation and long indwelling time.

OBJECTIVE

To investigate the effect of intracavitary electroencephalogram (CEEG) localization technique on the success rate and complications of PICC in infants.

METHODS

A total of 180 children with PICC catheterization and maintenance at Shijiazhuang People's Hospital First Hospital from January 2017 to January 2020 were selected and divided into control group (n= 90 cases) and observation group (n= 90 cases). The control group observed the tip position of the fixed catheter through X-ray film and adjusted the catheter until its tip was located in the superior vena cava. The observation group used intracavitary electrocardiogram positioning technology. Comparison of the effects of two groups on the success rate and complications of PICC puncture in infants and young children.

RESULTS

The success rate of one puncture in the observation group was significantly higher than that in the control group (P< 0.05). Within one month of catheterization, 13 cases had complications, with an incidence rate of 16.00% lower than the control group's 34.00% (27/80) (P< 0.05). The screening test results showed that the specificity, sensitivity, Youden index, accuracy, kappa coefficient, positive and negative predictive value were 88.89%, 97.56%, 0.86, 96.00%, 0.86, 0.86, respectively. The measured values were 97.56% and 88.89% respectively, and the cost and time of localization were lower than those of X-ray.

CONCLUSION

The technique of intracavitary electrogram can be more accurate for infants to place the tip of central venous catheter through peripheral vein, which can effectively improve the success rate of one puncture with low cost, and has high reliability, accuracy and practicability, which is safe and effective.

A randomised trial of intracavitary electrocardiography versus surface landmark measurement for central venous access device placement

BACKGROUND

Malpositioned central venous access devices (CVADs) can lead to significant patient injury including central vein thrombosis and dysrhythmias. Intra-cavitary electrocardiography (IC ECG) has been recommended by peak professional bodies as an accurate alternative for bedside CVAD insertion, to reduce risk of malposition and allowing immediate use of the device. Our objective was to compare the effect of IC ECG on CVAD malposition compared to traditional institutional practice for CVAD placement.

METHODS

Randomised controlled trial of IC ECG CVAD insertion verses traditional CVAD insertion (surface landmark measurement with post insertion x ray). Patient recruitment was from December 2016 to July 2018. The setting was a 900-bed tertiary referral hospital based in South Western Sydney, Australia. Three hundred and forty-four adult patients requiring CVAD insertion for intravenous therapy, were enrolled and randomly allocated (1:1 ratio) to either IC-ECG (n = 172) or traditional (n = 172) CVAD insertion. Our primary outcome of interest was the rate of catheters not requiring repositioning after insertion (ready for use). Secondary outcomes were comparison of procedure time and cost.

RESULTS

Of the 172 patients allocated to the IC ECG method, 170 (99%) were ready for use immediately compared to 139 of the 172 (81%) in the traditional insertion group (difference, 95% confidence interval (CI): 18%, 11.9-24.1%). The total procedure time was mean 15 min (SD 8 min) for IC ECG and mean 36 min (SD 17 min) for traditional CVAD insertion (difference-19.9 min (95% CI-14.6 to -34.4). IC ECG guided CVAD insertion had a cost reduction of AUD $62.00 per procedure.

CONCLUSIONS

Using IC-ECG resulted in nearly no requirement for post-insertion repositioning of CVADs resulting in savings in time and cost and virtually eliminating the need for radiographic confirmation.

TRIAL REGISTRATION

This trial is registered at the Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au). The registration number is ACTRN12620000919910.

A modified method for measuring the length of peripherally inserted central catheters to reduce the risk of malposition during catheter insertion

Background

Malposition may occur during peripherally inserted central catheter insertion. Accurately measuring the length of a peripherally inserted central catheter is crucial to preventing malposition, including "long peripherally inserted central catheter placement," in which the tip of a peripherally inserted central catheter is deeper than the target position. The traditional method of measuring peripherally inserted central catheter length involves measuring from the insertion site to the parasternal notch and down to the third or fourth intercostal space, which may result in overestimation because of the thickness of the pectoralis major and anterior chest wall. To avoid this overestimation, the authors developed and tested a modified method for reducing long peripherally inserted central catheter placement.

Methods

This study employed a retrospective design. Chest X-rays were used to examine the peripherally inserted central catheter tip positions in 48 patients in the medical intensive care unit who had undergone peripherally inserted central catheter insertion. The traditional and modified measurement methods were used to measure the peripherally inserted central catheter length in 17 and 31 patients, respectively. Fisher's exact test was used to examine between-group differences in the incidence of different types of peripherally inserted central catheter malposition.

Results

The peripherally inserted central catheter tip position was near the target position in five patients (29.41%) in the traditional measurement group and 17 patients (54.84%) in the modified measurement group (p = 0.132), whereas long peripherally inserted central catheter placement occurred in six patients (35.29%) in the traditional measurement group and one patient (3.23%) in the modified measurement group (p = 0.006). However, the incidence of other types of peripherally inserted central catheter malposition did not differ significantly between the groups.

Conclusions

The results of this study that the proposed modified measurement method may be able to reduce the incidence of long peripherally inserted central catheter placement among medical intensive care unit patients. The method must be further evaluated in prospective studies and studies with larger sample sizes in the future.

Automated precision localization of peripherally inserted central catheter tip through model-agnostic multi-stage networks

BACKGROUND

Peripherally inserted central catheters (PICCs) have been widely used as one of the representative central venous lines (CVCs) due to their long-term intravascular access with low infectivity. However, PICCs have a fatal drawback of a high frequency of tip mispositions, increasing the risk of puncture, embolism, and complications such as cardiac arrhythmias. To automatically and precisely detect it, various attempts have been made by using the latest deep learning (DL) technologies. However, even with these approaches, it is still practically difficult to determine the tip location because the multiple fragments phenomenon (MFP) occurs in the process of predicting and extracting the PICC line required before predicting the tip.

OBJECTIVE

This study aimed to develop a system generally applied to existing models and to restore the PICC line more exactly by removing the MFs of the model output, thereby precisely localizing the actual tip position for detecting its misposition.

METHODS

To achieve this, we proposed a multi-stage DL-based framework post-processing the PICC line extraction result of the existing technology. Our method consists of the following three stages: 1. Existing PICC line segmentation network for a baseline, 2. Patch-based PICC line refinement network, 3. PICC line reconnection network. The proposed second and third-stage models address MFs caused by the sparseness of the PICC line and the line disconnection due to confusion with anatomical structures respectively, thereby enhancing tip detection.

RESULTS

To verify the objective performance of the proposed MFCN, internal validation and external validation were conducted. For internal validation, learning (130 samples) and verification (150 samples) were performed with 280 data, including PICC among Chest X-ray (CXR) images taken at our institution. External validation was conducted using a public dataset called the Royal Australian and New Zealand College of Radiologists (RANZCR), and training (130 samples) and validation (150 samples) were performed with 280 data of CXR images, including PICC, which has the same number as that for internal validation. The performance was compared by root mean squared error (RMSE) and the ratio of single fragment images (RatioSFI) (i.e., the rate at which model predicts PICC as multiple sub-lines) according to whether or not MFCN is applied to seven conventional models (i.e., FCDN, UNET, AUNET, TUNET, FCDN-HT, UNET-ELL, and UNET-RPN). In internal validation, when MFCN was applied to the existing single model, MFP was improved by an average of 45 %. The RMSE improved over 63% from an average of 27.54 mm (17.16 to 35.80 mm) to 9.77 mm (9.11 to 10.98 mm). In external validation, when MFCN was applied, the MFP incidence rate decreased by an average of 32% and the RMSE decreased by an average of 65%. Therefore, by applying the proposed MFCN, we observed the consistent detection performance improvement of PICC tip location compared to the existing model.

CONCLUSION

In this study, we applied the proposed technique to the existing technique and demonstrated that it provides high tip detection performance, proving its high versatility and superiority. Therefore, we believe, in countries and regions where radiologists are scarce, that the proposed DL approach will be able to effectively detect PICC misposition on behalf of radiologists.

A retrospective two-center cohort study on the use of routine chest X-ray after peripherally inserted central catheter placement under ultrasound and intracavitary electrocardiography guidance

Background

The placement of peripherally inserted central venous catheters (PICCs) has traditionally relied on measurements and anatomical landmarks. It involves post-placement chest X-rays (CXRs) and occasional repositioning, which incur additional direct and indirect costs, such as delays in care and staff time. The aim of this study was to assess the cost-effectiveness of a routine post-procedural CXR in the era of ultrasound and intracavitary electrocardiography (IC-ECG)-guided PICC insertion.

Methods

A retrospective two-center study was conducted to review the clinical records of all patients who had PICCs in the Venous Access Center of Peking University Cancer Hospital & Institute and The Affiliated Qingdao Central Hospital of Qingdao University between 1 January 2019 and 30 June 2020. PICC placement was only available to patients who were 18 years or older, had in-sinus rhythm. The incidence of catheter misplacement after insertion was measured. Cavoatrial junction or the lower third of the superior vena cava (SVC) were defined as ideal catheter tip locations. A logistic regression analysis was performed to examine potential risk factors associated with PICC-related complications and a cost analysis was conducted to assess the economic impact of the use of CXR.

Results

There were 2,863 samples from 2,653 patients included. The overall incidence of intraprocedural and primary catheter misplacement was 7.3% (n=210) and 0.70% (n=20), respectively. There was a high risk of primary catheter misplacement when the left-arm was chosen for placement [odds ratio (OR): 11.163; 95% confidence interval (CI): 3.720-33.495; P<0.001]. The overall cost of performing CXR for screening of PICC-related complications was $23,858 per year, and that of using CXR to diagnose 1 case of catheter misplacement was $1,789.

Conclusions

This study confirms that misplacement of PICCs guided by ultrasound and IC-ECG is rare and that postprocedural CXR is very costly. In our setting, routine postprocedural CXR is unnecessary especially when the PICC is catheterized in the right arm, and is not a wise option.

Application of intracavitary ECG for positioning the totally implantable venous access port in the upper arm of cancer patients

Accurate positioning of the catheter tip is one of the most critical procedures in central venous catheter insertion. The traditional surface measurement method frequently has a large deviation and increases the X-ray exposure of doctors and patients. In the present retrospective study, cancer patients who received a totally implantable venous access port (TIVAP) in the upper arm using intracavitary electrocardiogram (ECG) guidance were compared with those where the traditional surface measurement method was used in terms of the rate of correct placement of the catheter tip, the rate of achieving the best position, the operation time and the complications. The results indicated that the correct placement rate and the best position rate of the catheter tip at the first attempt were higher in the ECG-guided group than in the traditional surface measurement method group (95.65 vs. 82.91% and 90.58 vs. 68.38%, respectively). The mean operation time was shorter in the ECG-guided group than in the surface measurement group (46.28 vs. 63.26 min). The incidence of complications in the ECG-guided group was 6.52%, while that in the surface measurement group was 10.26%. This indicated that the intracavitary ECG-guided tip positioning technique may improve the accuracy of tip catheter placement and shorten the operation time, thus reducing ionizing radiation caused by repeated positioning. Therefore, the intracavitary ECG-guided tip positioning technique is able to effectively place the tip of the TIVAD in the upper arm, holding great promise as a clinical application.

Echocardiographic Determination of Percutaneous Central Venous Catheters in the Superior Vena Cava: A Prospective Cohort Study

Malposition of percutaneous central venous catheters (PCVCs) in the superior vena cava (SVC) is common. We previously showed that real-time sonography was safer and faster than radiography in identifying PCVC tip location in the inferior vena cava (IVC). However, in preterm infants, determining PCVC tip location in the SVC is complicated by endotracheal or nasogastric tubes in situ and emphysematous lung conditions. We aimed to find an appropriate sonographic view by which to assess PCVC tip location in the SVC compared to the sonographic examination of PCVC in the IVC. Neonates (n = 50) with PCVCs in the SVC were enrolled and their data (gestational age, gender, birth weight, body weight at intervention, repositioning rate, and duration of tip assessment) were compared with retrospective data of 50 neonates with PCVCs in the IVC. The mean gestational age in the groups of IVC and SVC was 31.43 weeks and 32.16 weeks, respectively. The mean birth weight in the groups of IVC and SVC was 1642.18 g and 1792.00 g, respectively. Placement of an S12-4 ultrasound sector transducer to obtain clear parasternal views of the aorta allows visualization of PCVC tips in the SVC and near the cavoatrial junction. PCVC repositioning rates were not significantly different between the two groups (p = 0.092). Sonography examinations in the SVC had a longer duration than those in the IVC (p < 0.001). Sonography provides an accurate method for determining PCVC tip location in the SVC.

Intracavitary electrocardiography for femorally inserted central catheter tip location in adult patients

BACKGROUND

In this study, the intracavitary electrocardiogram (ECG) P-wave and QRS-wave changes during femorally inserted central catheter (FICC) placement in adults were observed with the aim of reducing malposition occurrence. The observed method provides venous access in patients who have limited upper limb venous catheterization potential and require medium-term and long-term infusions.

METHODS

A retrospective analysis of 34 adult patients who underwent FICC placement was conducted. After body surface measurements were taken, all patients were connected to an ECG during catheter placement, and the P-wave and QRS-wave changes were observed. Next, the catheter tip position was confirmed with an abdominal X-ray, and an analysis of the changes occurring during the procedure was conducted.

RESULTS

In the 34 patients included in the present study, the catheter tips were located below the diaphragm level in the inferior vena cava. Of the patients, 18 showed negative P waves, biphasic P waves, and positive high-amplitude P waves with increasing the insertion depth. In 16 patients, no P-wave characteristic changes were observed during catheterization, and an abdominal X-ray confirmed that the catheter tip was positioned below the level of the first lumbar vertebra.

CONCLUSION

Negative P waves, biphasic P waves, and positive high-amplitude P waves appeared during FICC placement in adults. Catheter withdrawal until the P wave reverted to normal indicated that a tip position close to the inferior vena cava above the diaphragm level was ideal.

Effects of indwelling centrally inserted central catheter on tip location of peripherally inserted central catheter with intracavitary electrocardiogram guidance: A retrospective case-control study

BACKGROUND

Intracavity electrocardiogram (IC-ECG) guidance is an effective technology for monitoring the tip locations of centrally inserted central catheters (CICCs) and peripherally inserted central catheters (PICCs). However, for patients with an indwelling CICC, there has been no study on whether the CICC affects PICC tip positioning with IC-ECG guidance.

METHODS

Thirty people with a CICC requiring PICC insertion, matched with age to controls without a CICC. The stability of IC-ECG waveforms, the amplitude of P-waves, and the accuracy of PICC tip location were compared.

RESULTS

There was no significant difference in the stability of the IC-ECG waveforms (χ² = 0.22, p = 0.64). The amplitudes of baseline P-waves and ideal P-waves also showed no significant difference (t1 = 0.06, p1 = 0.96, t2 = 0.80, p2 = 0.43). Neither the accuracy of tip location (χ² = 1.40, p = 0.50) nor the distance of PICC tip (t = -0.03, p = 0.98) were significantly different.

CONCLUSION

For patients with an indwelling CICC, the position of PICC tip can be accurately determined by the dynamic changes in the P-wave amplitude.

The application of intracavitary electrocardiogram for tip location of femoral vein catheters in chemotherapy patients with superior vena cava obstruction

BACKGROUND

Most studies focused on the application of intracavitary electrocardiogram (IC-ECG) location in superior vena cava access catheterization, this study aimed to explore the effect of IC-ECG for tip location of femoral vein catheters in chemotherapy patients with superior vena cava obstruction (SVCO).

METHODS

A total of 158 patients placed catheters through superficial femoral vein from July 2016 to May 2019 were enrolled in the randomized controlled study. The patients were divided into two groups by envelope lottery method: X-ray location was used in the control group (n = 79); IC-ECG location was used in the observation group (n = 79). The catheters should be located at or near the inferior vena cava (IVC)-right atrium (RA) junction (above the level of diaphragm within the IVC). The general information of patients, clinical catheterization effects and catheter-related complications were compared between the groups.

RESULTS

No significant differences in general information, catheter obstruction, catheter-related thrombosis, catheter exit-site bleeding and infection were found between the groups. The rate of successful insertion at the first attempt and patient satisfaction in the observation group were significantly higher than that in the control group (p < 0.05). The time and cost of location and the incidence of catheter-related complications in the control group were 32.57 min and 140.51 Yuan and 21.5%, which were significantly higher than 6.94 min and 13.59 Yuan and 7.6% in the observation group (p < 0.05).

CONCLUSION

IC-ECG accurately located the tip of femoral vein catheters, reduced the incidence of catheter-related complications and the time and cost of location, improved patient satisfaction.

Surface measurement, intracardiac electrocardiogram and tracheal bifurcation techniques for locating the catheter tips of totally implantable venous access port

BACKGROUND

The purpose of our study is to compare the reliability and consistency of three commonly used techniques, which are surface measurement, intracardiac electrocardiogram (IECG) and tracheal bifurcation methods in measuring the tip location of totally implantable venous access port (TIVAP) in the same patient.

METHODS

The thirty-five patients scheduled for implantation of TIVAP were included and right subclavian vein was selected for venous access. We used surface measurement method (Group L) to estimate the length and position of catheter before catheterization, and then we used IECG method (Group E) to confirm the position of catheter during catheterization and after catheterization used tracheal bifurcation method by CT (Group T) for measurement. The differences of catheter length measured by three methods were compared by non-parametric Kruskal-Wallis test. Intraclass correlation coefficient (ICC) was used to evaluate the reliability of three methods and Bland-Altman chart was used to evaluate consistency.

RESULTS

There are no difference in the length of TIVAP catheter between L and T groups (P > 0.05), but they have significant differences comparing with E group (P < 0.05). The three positioning methods have a good consistency (ICC = 0.886, P < 0.05).Through linear regression analysis, the regression equation are: catheter length (mm) = 77.32 + 0.66 × height (cm), 36.25 + 0.81 × height (cm) and 68.82 + 0.70 × height (cm). The distances from catheter tip to the junction of superior vena cava and right atrium measured by IECG (Group E) was closer to the target value.

CONCLUSIONS

All three methods can be used to measure the length of TIVAP catheter, and IECG method is the most accurate. And similar to most studies, returning the catheter 20 mm after positioning can avoid catheter entering the right atrium, but we found that 10 mm is a sufficient length to achieve this.

Iatrogenic Pleural Effusion Due to Extravasation of Parenteral Nutrition via an Epicutaneo Cava Catheter in Neonates: A Prospective Cohort Study

Background: Although Epicutaneo cava catheters (ECCs) are being routinely used for intravenous access for long-term parenteral nutrition and prolonged medication administration in neonates, ECC use can be associated with rare but acute life-threatening events such as pleural effusion (PE). It is important to identify and maintain the ECC tip in a central location for preventing complications. Recently, intracavitary electrocardiogram (IC-ECG) has been developed for the real-time monitoring and verification of ECC tip position. Objective: To investigate the causes and preventive measures of ECC-related PE in neonates. Methods: This prospective cohort study was conducted between January 2013 and December 2017. We observed and analyzed the clinical characteristics and causes of ECC-related PE. From January to December 2017, all ECCs were guided by IC-ECG. The incidence of ECC-related PE and first-attempt success rates were analyzed before and after the introduction of IC-ECG. Additionally, the sensitivity and specificity of IC-ECG were evaluated. Results: ECC-related PE was identified in 14 infants. Catheters were malpositioned in three cases; in the other 11 cases, catheters were located centrally on insertion but had migrated to non-central locations at the time of PE. After the introduction of IC-ECG, the incidence of PE was zero (P < 0.05). The incidence of ECC-related PE was lower when veins of the lower extremities were selected as the insertion site (P < 0.05). The first-attempt success rate was significantly higher in the group with IC-ECG-guided ECC placement than in the group without (P < 0.05). The sensitivity and specificity of IC-ECG were 97.9 and 84.6%, respectively. Conclusion: ECC-related PE can be associated with either primary malposition or migration of the catheter tip. IC-ECG can help detect malposition and migration of catheter tips and improve the first-attempt success rate. Choosing a lower extremity insertion site may help decrease the rate of ECC-related PE. In neonates, IC-ECG is a reliable positioning method for ECCs with superior sensitivity and specificity.

The electrocardiographic method for positioning the tip of central venous access device

BACKGROUND

The electrocardiogram-based insertion method is non-radiative, allowing real-time positioning verification and reducing the need for postoperative repositioning.

METHODS

Relevant databases published from January 1990 to January 2019 in PubMed, Web of Knowledge, Medline and Ovid's database were searched, comparing the effectiveness of electrocardiogram-guided catheter tip positioning (electrocardiogram-guided group) and the landmarks-guided insertion plus chest X-ray confirmation (landmarks-guided group). The primary outcome was accurate catheter tip placement and the secondary outcomes were complications.

RESULTS

A total of 13 studies were finally included with a total of 4988 patients, of whom 2789 cases were in the electrocardiogram-guided group and 2199 cases received landmarks-guided insertion plus chest X-ray. Compared with the landmarks-guided group, our meta-analysis showed that the electrocardiogram-guided group had a higher success rate of tip placement (odds ratio = 0.21, 95% confidence interval = 0.14-0.34, p < 0.00001) and fewer total complications (odds ratio = 0.10, 95% confidence interval = 0.04-0.23, p < 0.000001).

CONCLUSION

Based on our findings, electrocardiogram-guided tip placement for central venous access device was more accurate and safer than landmarks-guided positioning, which may be considered as an alternative method to the standard radiological control of tip placement.

Meta-analysis of intracavitary electrocardiogram guidance for peripherally inserted central catheter placement

Background:

Recently, intracavitary electrocardiogram technology has been applied to peripherally inserted central catheter placement and demonstrates many potential advantages. However, the tip positioning accuracy of intracavitary electrocardiogram technology compared to conventional X-ray method is unknown.

Objective:

We did a meta-analysis to compare the tip positioning accuracy between intracavitary electrocardiogram technology and conventional X-ray method.

Data sources:

We searched several databases, including Cochrane Library, PubMed, Web of science, and Embase. Additional studies were identified through hand searches of bibliographies and Internet searches. All human studies published in full text, abstract, or poster form were eligible for inclusion. Search terms included peripherally inserted central catheter, PICC, intracavitary electrocardiogram, IC-ECG, EKG, ECG, and catheter tip location.

Study eligibility criteria:

Only randomized controlled trials of using intracavitary electrocardiogram technology versus X-ray method for peripherally inserted central catheter placement were included. All studies included adult patients aged at least 18 years.

Study appraisal and synthesis methods:

Independent extraction of articles by two authors using predefined data fields, including study quality indicators. Of the 178 citations identified, 5 studies that included 1672 patients met the eligibility criteria. It was found that statistical heterogeneity existed among the various studies (I2 = 16%, p < 0.00001); therefore, the fixed effect model was used in the meta-analysis (p < 0.05). The meta-analysis compared the tip positioning accuracy between intracavitary electrocardiogram technology and X-ray method and showed that intracavitary electrocardiogram technology had a better positioning accuracy (odds ratio: 2.88, 95% confidence interval: 2.15–3.87, p < 0.0001).

Limitations:

Only five randomized trial met inclusion criteria, and the lack of an incomplete search led to the publication bias seen in these results.

Conclusion:

The intracavitary electrocardiogram method had a more favorable positioning accuracy versus traditional X-ray method for peripherally inserted central catheter placement in adult patients. The intracavitary electrocardiogram can be a promising technique to guide tip positioning of peripherally inserted central catheter.