Reliability of cutaneous landmarks for the catheter length assessment during peripherally inserted central catheter insertion: A retrospective observational study

Abstract

Introduction: Peripherally inserted central catheters are very common devices for short, medium and long-term therapies. Their performance is strictly dependent on the correct tip location, at the junction between the upper caval vein and the right atrium. It is very important to obtain an estimated measure of the catheter, in order to reach the cavo-atrial junction and optimize the catheter length. Estimated measures are often obtained using cutaneous landmarks. Objective: Evaluate the reliability of cutaneous landmark-based length estimation during catheter insertion. Identify any patient’s related factors that may affect cutaneous landmarks reliability. Methods: We used two distinct techniques and collected data about cutaneous landmark-based length estimation, electrocardiographic guided intravascular length, age, weight and height. We studied the reliability of possible correcting factors, balancing the error average by regression models, and we found and tested two different models of prediction. Results: A total number of 519 patients were studied. The average bias, between the two studied length assessment by cutaneous landmarks and electrocardiographic guided catheter length, were 3.77 ± 2.44 cm and 3.28 ± 2.57 cm, respectively. The analysed prediction models (deviance explained 43.5%, Akaike information criterion = 1313.67% and 43.4%, Akaike information criterion = 1313.92), fitted on the validation set, showed a root mean square error of 3.07 and 3.06. Conclusion: Landmark-based length estimation for preventive catheter length assessment seems to be unreliable, when associated with post-procedural tip location. They are useful for distal trimming catheters to optimize the ‘out of skin’ portion when associated with electrocardiographic tip location. Models identified for balancing bias are probably not useful.

Determination of optimal tip position of peripherally inserted central catheters using electrocardiography: a retrospective study

“…Therefore, although clinically acceptable, placing the catheter tip in the suboptimal location is not recommended. The rate of malposition of the PICC tip after blind insertion is high (37-76%) and estimating insertion length based on anatomical landmarks often gives unreliable results [5,13,18,23]. Current technology still has many limitations; Fluoroscopy guidance or CXR is not applicable for implementation at the patient's bedside or in assisted living facilities [5,6,9,24], and carries the risk of false-positive or false-negative diagnosis [25][26][27].…”

“…Current ivECG-based techniques are reported to be a reliable method with high accuracy of close to 100% [5,7,28,29], but still show false-negative rates of 0.7-7% of P-wave changes during PICC insertion [30,31]. The amplitude of the P-wave may also be maximal before reaching the CAJ when the ivECG electrode contacts the SVC in the part of the pericardial reflection [15,32].…”

“…Central venous catheter (CVC), including peripherally inserted central catheter (PICC), has been used to deliver total parenteral nutrition, chemotherapy, antibiotics, and other medications in the critical care management of patients with long-term illnesses [1][2][3][4]. The performance of the PICC depends on tip position, and incorrect tip positioning of the PICC can cause complications [5]. The tip of a PICC or CVC should be placed in a large vein without contacting the vein or heart wall [6].…”

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

“…The first kind of concession (technique A) is related to the length of catheter needed to ensure the capacity to observe the P-wave modifications (P-wave maximal amplitude in the absence of initial deflection) and by this means to position the catheter at the CAJ. Operators may need up to 2 cm of extra catheter length (72) while Elli put forward a 3.8 cm discrepancy between ECG measure and cutaneous landmark (73); ultimately, these leeway centimeters will reverberate at the insertion point (30) and may have uncertain repercussions (74).…”

Contrast enhanced ultrasound as a new tool to estimate the performance of midline catheters in the single patient

“…All the enrolled patients expressed and signed an informed consent. We gathered data regarding patients’ BMI, distance from the catheter’s insertion point to the RA (by measuring the distance from the exit site to the ipsilateral clavicle–sternal articulation plus adding 10 cm for the access from the right arm or 15 cm for the access from the left arm (Ocado Technique) 9 ), insertion procedure (cannulated vein, vein diameter, MBT), administered therapy, and catheter dwell time. Radiographic distance between tip of MC and RA (measured from the tip of the catheter to the sternoclavicular joint and then adding 10 cm for the MCs inserted in the right arm and 15 cm for those inserted in the left arm—Figure 2) was recorded if, for clinical reasons, a chest X-Ray was performed during catheter dwell time.…”