The Electrocardiographic Method for Positioning the Tip of Central Venous Catheters

Abstract

Tip position of a central venous access is of paramount importance and should be verified before starting infusion. Intra-procedural methods for verifying the location of the tip are to be preferred, since they avoid the risks, delays and costs of repositioning the tip. Among the intra-procedural methods, the electrocardiography (EKG) method has many advantages since it is as accurate as fluoroscopy, but simpler, more readily available, less expensive, safer and more cost-effective. The only contraindication to utilizing the EKG method is the difficulty in identifying the standard P-wave on a surface EKG (this happens - usually because of severe arrhythmias, such as atrial fibrillation - in only approximately 7% of cases: although such patients are easily identified before the procedure, and are referred to other methods for tip positioning). When dealing with the insertion of peripherally inserted central catheters (PICC), the EKG method (using the column of saline technique) virtually has no risk of false positives. The EKG method removes the need for the post-procedural chest x-ray, as long as there is no expected risk of pleuropulmonary damage to be ruled out (example: ultrasound guided central venipuncture for central venous catheter insertion or any kind of PICC insertion). In conclusion, evidence is mounting that the EKG method may be a valid and cost-effective alternative to the standard radiological control of the location of the tip of any central venous access device (VAD), and that will rapidly become the preferential method for confirming the tip position during PICC insertion.

Superior success rate of intracavitary electrocardiogram guidance for peripherally inserted central catheter placement in patients with cancer: A randomized open-label controlled multicenter study

“…Most recommendations from the USA [8–10] propose that the tip should be placed in the lower third of the superior vena cava (SVC), while European guidelines [11, 12] often regard the upper part of the atrium as acceptable. Specifically, Pittiruti et al [13, 14] agreed that for chemotherapy, the tip should preferably be placed in the lower third of the SVC. Chinese nursing practice standards require that the catheter tip be placed in the SVC [15].…”

Anthropometric formulas versus intracavitary ECG for optimal tip position of central venous catheters

“…Intracavitary ECG was used to identify the optimum tip location since a maximal P wave indicates the cavo-atrial junction [3]. Post-insertion chest X-ray (CXR) was performed in all patients to verify the tip position.…”

Le PICC line, une nouvelle stratégie dans l’accès veineux

“…Le cathéter est avancé dans la veine jusqu'à visualisation du maximum l'onde P avant qu'elle ne devienne biphasique [16]. Cette méthode permet le contrôle en temps réel et donc de rectifier le positionnement du cathéter si nécessaire.…”