ECG-Based Techniques to Optimize Peripherally Inserted Central Catheters: Rationale for Tip Positioning and Practical Use

Abstract

Intracavitary electrocardiography is an accurate guidance technique for peripherally inserted central catheters (PICC) tip location that is spreading widely among providers using non x-ray-based facilities. The principle behind this technology relies on the transmission of the electrocardiographic signal at the tip of the catheter and its use as an internal mobile electrode, allowing the system to identify the cavo-atrial junction (CAJ) through internal P-wave amplitude modulations. The gain in popularity of intracavitary electrography and its large diffusion have led manufacturers to offer various devices with heterogeneous properties, among which clinician who place PICCs have to choose. It is therefore important to understand differences between available techniques and devices. The potential impact might not only affect availability and costs but also the clinical impact through advantages and limitations regarding electric signal transmission PICC selection. Current perspectives on intracavitary electrocardiography will also be discussed, to give the reader a global view of the management of electrocardiographically guided PICCs, especially in an environment without x-ray support.

Insertion of a totally implantable vascular access device in a patient with dextrocardia and colon cancer: a case report

“…Intracavitary ECG has been extensively used for venous infusion port tip positioning in the clinical setting. 10 ECG-guided catheter tip placement for TIVAD implantation is more convenient, safer, and more accurate than the standard fluoroscopy method. 10 , 11 However, little information is available regarding the use of ECG for TIVAD placement in patients with mirror dextrocardia.…”

Tip position of peripherally inserted central venous catheters inserted without fluoroscopy

“…Insertion of peripherally inserted central venous catheters (PICCs) under fluoroscopic guidance is considered to be the gold standard for this procedure, 1,2 but transfer to a fluoroscopy room (usually some distance from the pediatric intensive care unit) is risky for critically ill children. In our department, PICCs are inserted at the bedside without fluoroscopy.…”

“…The PICC tip position was assessed by two independent physicians by chest X‐ray immediately after insertion; a third physician made the decision when the first two physicians’ assessments differed. For the distal and proximal limits of the appropriate range, we adopted the lateral border of the first rib (distal end of the subclavian vein) and two vertebral body units below the level of the carina 2 (a surrogate landmark for the cavoatrial junction), respectively. The PICC tip positions were classified as appropriate, shallow, deep, or migrating (i.e., the tip was in the jugular vein or contralateral subclavian vein, or reversed within the same vessel).…”

“…Although we did not examine the occurrence of complications or catheter length in this study, it may be desirable to avoid placing the tips in the subclavian vein to avoid migration into the ipsilateral jugular vein. For real‐time PICC tip monitoring, electrocardiography‐based techniques were recommended as well as fluoroscopy‐guided techniques; 1,2 ultrasound‐guided techniques have also been reported to be effective 4 . In addition to real‐time tip monitoring, ipsilateral migration prevention techniques, such as abducting the upper limb by 90°, turning the patient's face toward the puncture side, and checking by ultrasound that there is no guidewire in the internal jugular vein, may be useful to avoid migration into the ipsilateral jugular vein 5 …”

The value of transthoracic echocardiography and chest X-ray in locating the tip of central venous catheter in dialysis patients: a comparative study with computed tomography imaging

“…In the 60 years since the creation of this method, hemodialysis technology has greatly improved [ 2 ]. For the insertion techniques for catheterization, we perform puncture according to anatomical markers [ 3 ], fluoroscopic puncture [ 4 ], ultrasound-guided puncture [ 5 ], and electrocardiogram-guided CVC tip positioning puncture [ 6 ]. These techniques can help evaluate the insertion depth of the catheter and monitor the CVC tip position during the catheter insertion process.…”