The safety and accuracy of ECG-guided PICC tip position verification applied in patients with atrial fibrillation

A new wireless device for bedside assessment of tip location of central venous access devices using intracavitary ECG: A retrospective study

Intracavitary electrocardiography (IC-ECG) is a non-invasive method for intraprocedural tip location during central venous catheterization. Over the last 20 years, the IC-ECG method has been thoroughly investigated and many studies have confirmed its wide applicability and feasibility, as well as its great accuracy and safety in different populations of patients and in different types of central venous access devices (CVADs). This retrospective study presents a two-center experience with tip location of central venous catheters using IC-ECG, by means of a new wireless portable device. Tip location was performed during 983 insertions of CVADs at bedside, using this new device. Clinical conditions with limited or no applicability of IC-ECG were excluded. The feasibility of IC-ECG, as performed using the novel device, was 92.2%. This wireless device may play an important role in central venous catheterization at bedside, since it is pocket-sized, particularly easy to use, and easy to sanify after use.

Impact of distance of the catheter tip from cavo-atrial junction on bubble test (delay) time: A prospective study

INTRODUCTION

Correct tip positioning is a critical aspect in central vascular access devices insertion. The verification of positioning at the cavo-atrial junction is usually performed by intracavitary electrocardiography. Recently, echocardiographic techniques were proposed, including the direct visualization of the catheter or the visualization of a saline/air bolus (i.e. "bubble test"). As for the latter, a push-to-bubbles delay time below 2 s was proposed to indicate a correct positioning of the catheter tip. The aim of this study was to measure the variations of the push-to-bubbles time at increasing distance from the cavo-atrial junction, to verify if a cut-off of 1-2 s correspond to a well-positioned catheter.

METHODS

We performed a prospective study including patients with clinical indication of positioning a peripherally inserted central catheter. The catheter tip was positioned at the cavo-atrial junction (P0) via intracavitary electrocardiography, and the push-to-bubbles delay time was measured. The catheter was then retracted 5 cm (P1) and 10 cm (P2), and the test was repeated at this positioning. Push-to-bubbles time measurements were performed off-line by analyzing an audio/video recording which included the echography screen and the voice signal of the operator.

RESULTS

Forty-nine patients were included. The average push-to-bubble time when the catheter tip was in the reference position was 0.41 ± 0.21 s. Retraction of the PICC catheter of 5 and 10 cm determined a significant increase of the push-to-bubbles time: mean time difference was +0.34 (95% IC 0.25-0.43, p < 0.001) s between P0 and P1 (5 cm distance), and +0.77 (95% IC 0.62-0.92, p < 0.001) s between P0 and P2 (10 cm distance). When the catheter was at the reference position (i.e. cavo-atrial junction) only 2.1% of bubbles delay times were above 1 s.

CONCLUSION

The push-to-bubbles time is very low when the catheter tip is at the cavo-atrial junction. This delay increases progressively with increasing distance from the target. Push-to-bubbles delay time above 1 s might indicate a catheter not close to the cavo-atrial junction.

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.

The positioning of the catheter tip with an intracavitary electrocardiogram in epicutaneo-caval catheter placement via lower limbs in newborns: A retrospective study

OBJECTIVE

Few studies have been conducted on whether catheterisation via the lower limb pathway is suitable for intracavitary electrocardiogram (ECG) technology. This study explored the positioning of the epicutaneo-caval catheter (ECC) tip with intracavitary ECG via the lower limbs in newborns to determine its optimal placement and to improve the success rate of ECC placement using this method.

METHODS

Twenty-eight cases were selected for the observation group. The tip location with intracavitary ECG method was used to observe the changes in specific atrial depolarisation (P-wave) during the catheterisation process to determine whether the catheter tip was in the correct position. For comparative observation, chest X-rays and abdominal radiographs were taken within 24 h to determine sensitivity and specificity. The control group included 28 cases where the ECCs were inserted via the lower limbs, and chest X-rays and abdominal radiographs were taken within 24 h after the line was placed to confirm the correct positioning.

RESULTS

The success rate of the observation group was 91.30% (there were two cases of primary malposition), and the success rate of the control group was 78.57% (there were six cases of primary malposition). The success rate of the observation group was higher compared with the control group.

CONCLUSION

The tip location with intracavitary ECG method improved the success rate of ECC placement via the lower limbs in neonates. This method can effectively prevent the occurrence of lower limb primary catheter malposition and has significant clinical application value.

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.

Time to abandon chest X-rays in favor of intracavitary ECG or echocardiography for central venous access tip location: A case of a malpositioned CICC into the internal mammary vein

Central vascular access devices (CVADs) correct tip location is of paramount importance to avoid malposition related complications. Despite recent guidelines recommend avoiding postprocedure radiograph in favor of alternative tip location technology, chest X-rays are still widely used in clinical practice as a CVADs tip location method. We present a clinical case of a central inserted central catheter (CICC) malposition in the right internal mammary vein, erroneously interpreted by chest X-rays as correctly placed, in a critically ill patient.

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.

Accuracy of chest radiography compared to ultrasound for positioning the umbilical venous catheter in neonates: A meta-analysis and systematic review

This study was aimed to investigate the accuracy of anteroposterior chest radiography for tip position verification for the umbilical venous catheters in neonates compared to ultrasound. A search in the PubMed, Embase, the Cochrane Library, and EBSCO was conducted to evaluate all the related articles on umbilical venous catheter (UVC), ultrasound AND neonates updated to August, 2020. Study selection, data extraction, and quality assessment were performed independently by two investigators. Random effects model was used to estimate the pooled sensitivity, specificity, and diagnostic odds ratio (DOR). The summary receiver operator characteristic (SROC) curve was constructed, and the area under the SROC curve (AUC) was calculated. Fourteen related studies were finally included for meta-analysis. The overall diagnostic sensitivity and specificity of X-ray on tip verification of UVC were 0.90 (95% CI 0.71-0.97) and 0.82 (95% CI 0.53-0.95), respectively. The pooled DOR was 3.69 (95% CI 1.64-5.71). The AUC was 0.93 (95% CI 0.90-0.95). The meta-regression analysis suggested that study sample size, study design, different US confirming method, and different gold standard in original design might be potential sources of heterogeneity. Our conclusion is that the commonly used anteroposterior X-ray is not reliable in identifying the exact anatomical location of UVC tip in neonates. Studies suggested ultrasound or echocardiography with saline contrast injection could be the gold standard for verification of catheter location and should be considered whenever possible, especially in premature patients. More studies are needed to expand the use of ultrasound or echocardiography in tip position confirming of UVCs.

Impact of peripherally inserted central venous catheter-associated phlebitis in neonate guided by intracavitary electrocardiogram: A systematic review and meta-analysis of randomised controlled trials

Because the application of intracavitary electrocardiogram (IC-ECG)-guided peripherally inserted central catheter (PICC) in the treatment of neonates is controversial in terms of phlebitis reduction compared with traditional X-ray positioning technique, a systematical evaluation is needed on the impact of IC-ECG on this common complication following PICC. Literature retrieval was conducted on large databases including PubMed, Google Scholar, Cochrane library, and CNKI. Randomised controlled trials (RTCs) of intracavitary electrocardiogram-guided peripherally inserted central catheter tip placement in the treatment of neonates up to July 7, 2022, were collected. Then indicators of included studies were compared and analysed by two researchers. Meta-analysis was performed on the STATA 17.0 software. After excluding invalid trials, 11 out of 316 randomised controlled trials were included for further analysis. Meta-analysis results showed that compared with the control group, IC-ECG-guided PICC could decrease the incidence of phlebitis (I²  = 0.00%, P = 0.76, OR = 0.33, 95% CI 0.19-0.56) and that no significant difference was observed between preterm neonates and term neonates (P = 0.74). Meanwhile, total complications were decreased in neonates (I²  = 0.00%, P = 0.00 OR = 0.23, 95% CI 0.16-0.33). IC-ECG-guided PICC could also improve the accuracy of optimal tip location (I²  = 0.00%, P = 0.53, OR = 5.37, 95% CI 3.80-7.59). IC-ECG-guided PICC could achieve reduced phlebitis incidence and total complications in the treatment of neonates, as well as increased accuracy of optimal tip location, no matter if those neonates were preterm or not. This study was registered in inplasy.com with No. INPLASY202280012 (DOI: 10.37766/inplasy2022.8.0012).

Diagnostic accuracy of ultrasound for localising peripherally inserted central catheter tips in infants in the neonatal intensive care unit: a systematic review and meta-analysis

BACKGROUND

Chest radiography after peripherally inserted central catheter insertion in infants is the reference standard method for verifying catheter tip position. The utilisation of ultrasound (US) for catheter placement confirmation in the neonatal and paediatric population has been the focus of many recent studies.

OBJECTIVE

In this systematic review we investigated the diagnostic accuracy of US for peripherally inserted central catheter tip confirmation in infants in the neonatal intensive care unit (NICU) MATERIALS AND METHODS: We conducted a systematic literature search of multiple databases. The study selection yielded eight articles, all of which had acceptable quality and homogeneity for inclusion in the meta-analysis. Sensitivity and specificity values were reported together with their respective 95% confidence intervals (CI).

RESULTS

After synthesising the eligible studies, we found that US had a sensitivity of 95.2% (95% CI 91.9-97.4%) and specificity of 71.4% (95% CI 59.4-81.6%) for confirming catheter tip position.

CONCLUSION

Analyses indicated that US is an excellent imaging test for localising catheter tip position in the NICU when compared to radiography. Ultrasonography is a sensitive, specific and timely imaging modality for confirming PICC tip position. In cases where US is unable to locate malpositioned PICC tips, a chest or combined chest-abdominal radiograph should be performed.

Effects of Peripherally Inserted Central Catheter (PICC) Catheterization Nursing on Bloodstream Infection in Peripheral Central Venous Catheters in Lung Cancer: A Single-Center, Retrospective Study

Background. Peripherally inserted central catheter (PICC), as one of the important intravenous routes for the rescue and treatment of critically ill patients, has been widely used in the fluid resuscitation of critically ill patients in intensive care. In particular, PICC can be widely used in the treatment of cancer patients. With the wide application of peripheral central venous catheterization, the clinical findings of bloodstream infection complications caused by PICC have gradually attracted the attention of doctors and patients. Aims. To investigate the effect of specialized placement and PICC placement care on patients with lung cancer who underwent PICC puncture. Patients were selected and divided into a comparison group and an observation group of 40 patients each according to the randomized residual grouping method. In the comparison group, routine PICC placement and catheter maintenance were performed, while the observation group was provided with specialized placement and PICC placement care. The differences in immune and tumor marker levels and nursing compliance between the two groups were observed and compared before and after nursing care. Results. There was no significant difference in the comparison of tumor marker levels between the two groups of patients before care, while the levels of CYFRA21-1, CA125, and VGEF in the observation group were significantly lower than those in the comparison group after care, and this difference was statistically significant ( $P<0.05$ ). There was no statistically significant difference in the comparison of immune levels between the two groups before care ( $P>0.05$ ), while the comparison of CD4+, CD3+, and CD4+/CD8+ after care was significantly different and higher in the observation group than in the comparison group, and the comparison was statistically significant ( $P<0.05$ ). The compliance rate of 93.8% in the observation group was significantly higher than that of 77.9% in the comparison group, and this difference was statistically significant for comparison ( $P<0.05$ ). Conclusion. PICC placement care is more effective in patients with lung cancer and performing PICC puncture, significantly improves patients’ immune and tumor marker levels, improves patients’ negative emotions, reduces disease uncertainty, and improves nursing compliance.

Effects of different concentrations of intraluminal sodium chloride solution on intracavitary ECG used for arm infusion port implantation

At present, there are few clinical studies on the application of high-concentration sodium chloride solutions in intracavitary ECG-guided catheter tip localization during the arm infusion port implantation. This study observed the effects of sodium chloride solutions with different concentrations on intracavitary ECG-guided arm infusion port implantation in the patients with cancer. The 657 patients receiving arm infusion port implantation in our hospital between January 2020 and August 2021 were randomly divided into 0.9% sodium chloride solution conduction group (group A), 5.45% sodium chloride solution conduction group (group B) and 10% sodium chloride solution conduction group (group C). The derived rate of stable intracavitary ECG, the occurrence rate of characteristic P wave, the time used for catheter tip localization and the optimal position rate of catheter tip were compared between the three groups. The derived rate of stable intracavitary ECG was significantly higher in the group B (97.78%) and group C (98.63%) than in the group A (93.90%) (all P < 0.05). The occurrence rate of characteristic P wave was also significantly higher in the group B (96.89%) and group C (97.72%) than in the group A (88.73%) (all P < 0.001). The time used for catheter tip localization was significantly shorter in the group B [(49.73 ± 8.15) s] and group C [(48.27 ± 8.61) s] than in the group A [(69.37 ± 19.99) s] (all P < 0.001). There was no significant difference in the optimal position rate of catheter tip among the three groups (P > 0.05). The 5.45% and 10% sodium chloride solutions are significantly superior comparing with 0.9% sodium chloride solution in the derived rate of stable intracavitary ECG, occurrence rate of characteristic P wave and time used for catheter tip localization, but there were no significant differences between 5.45 and 10% sodium chloride solutions. Moreover, the 5.45% sodium chloride solution is closer to physiological state comparing with 10% sodium chloride solution, so the 5.45% sodium chloride solution may be recommended for the intracavitary ECG-guided arm infusion port implantation.

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

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.

Analysis of skew of visible laser reflections in a living sheep heart

Limited methods exist to confirm the position of cardiovascular devices in the heart. In our earlier work, an optical fiber was enclosed in a central catheter and guided to known positions in the superior vena cava and right atrium in the heart of a living sheep. The tissues were illuminated with two wavelengths of visible light and the reflections were analyzed using frequency domain techniques. In this follow-up work, the data were reanalyzed using statistical estimates of skew and kurtosis as a function of anatomic position. Skew values from a 520 nm laser were able to determine catheter tip position near the cavoatrial junction as validated against known positions previously determined with electrocardiogram and contrast-enhanced video fluoroscopy. This method successfully confirmed the location of the catheter tip at the cavoatrial junction in 84% of 840 trials. Further research with refined apparatus and algorithms on additional animal subjects is strongly suggested.

ECG method for positioning the tip of peripherally inserted central catheters in patients with atrial fibrillation

OBJECTIVE

To observe the changes of F waves on electrocardiograms (ECGs) in patients with persistent atrial fibrillation during the insertion of a peripherally inserted central catheter (PICC), and to analyze the application effect of the ECG method (through F wave changes) for guiding PICC tip positioning.

METHODS

Seventy-two patients who met the inclusion criteria and needed a PICC catheter were selected as the research subjects. We observed waveforms in the ECGs when the tip of the catheter reached a predetermined position. The chest X-ray results were used as the gold standard to calculate the sensitivity and specificity, and judge the safety and accuracy of ECG-guided PICC tip positioning in patients with atrial fibrillation.

RESULTS

Of the 72 patients, there was no significant difference between the ECG method and chest X-ray results (χ² = 0.2, p > 0.05). Sixty-one patients had F wave changes on ECG and 10 had no obvious changes (X-ray results confirmed that five patients had a tip position that was too shallow, two had ectopic tip positions, and three were located in the correct place). The sensitivity of the method was 95.7% and the specificity was 80%.

CONCLUSION

As the ECG baselines of patients with persistent atrial fibrillation were difficult to judge and the F wave was irregular, we found that the F wave was significantly higher than before catheter insertion and fell back while withdrawing the catheter, so the catheter should be fed until the F wave significantly increased as the correct position of the catheter tip.

Experience of Radiology Technologists Performing Peripherally Inserted Central Catheters (PICC)

Purpose We conducted this study to review our local experience of performing peripherally inserted central catheters by interventional radiology technologists.

Materials and Methods This is a retrospective study of peripherally inserted central catheters performed by interventional radiology technologists. These procedures were performed using ultrasound guidance for venous puncture and fluoroscopy or electrocardiography guidance followed by chest X-ray to confirm tip location.

Results We reviewed all peripherally inserted central catheters performed in interventional radiology between May 2017 and July 2020. The review process included the success rate, number of venous puncture attempts, method of guidance, procedure time, fluoroscopy time, catheter duration to removal, and complications.

Conclusion Interventional radiology technologists can perform peripherally inserted central catheters safely with high success rate. Extending interventional radiology technologists' role to perform peripherally inserted central catheters allow interventional radiologists to do more complex procedures. This enhances the workflow, increases the interventional radiology team efficiency, and improves the waiting time.

Application of intracavitary electrocardiogram classification in peripherally inserted central catheter localization in cancer patients

OBJECTIVE

This study aimed to analyze the application value of intracavitary electrocardiogram (ECG) classification in peripherally inserted central catheter (PICC) tip localization in patients with cancer.

METHODS

Using a self-control study method, 325 patients with cancer underwent intracavitary ECGs to position the tip of a PICC catheter. The P wave, QRS wave amplitude, and waveform changes of each intracavitary ECG were recorded. Chest X-ray examination was performed after the catheterization to compare the results of different intracavity ECG maps with the results of the chest X-ray.

RESULTS

The intracavitary ECG positioning maps of the 325 patients were divided into four categories: (1) increased P wave (293 cases), accounting for 90.15% (293/325) of all cases; compared with the positioning results of the chest X-rays, the placement rate was 98.98% (290/293); (2) negative deepening of the P wave (1 case), accounting for 0.31% (1/325) of all cases and with a placement rate of 100% (1/1); (3) no change in P wave (19 cases), accounting for 5.85% (19/325) of all cases and with a placement rate of 42.11% (8/19); (4) atrial fibrillation/atrial flutter (12 cases), accounting for 3.69% (12/325) of all cases and with a placement rate of 58.33% (7/12). The four types of intracavitary ECG positioning maps had statistically significant differences (χ² = 133.924, P = 0.000).

CONCLUSION

There are four types of intracavitary ECG localization maps: increased P wave, negative deepening of the P wave, no change in P wave, and atrial fibrillation/atrial flutter. The increased P wave pattern had the highest occurrence probability and high positioning accuracy. It therefore has strong clinical application value for PICC tip localization in patients with cancer.

A clinical study on the tip localization of peripherally inserted central catheter (PICC) guided by intracavitary electrocardiography in newborns: a randomised trial

BACKGROUND

The present study aimed to investigate the P-wave changes in intracavitary electrocardiography (IC-ECG) during catheterization with a peripherally inserted central catheter (PICC) in order to provide guidance for the accurate localization of the tip of the PICC.

METHODS

A total of 106 newborns who needed a PICC were randomly divided into two groups-a study group and a control group-using a random number table, with 53 cases in each group. In the study group, the ECG monitor was connected after the successful puncture and insertion of the PICC into the right sternoclavicular joint, and the position of the catheter tip was determined according to the P-wave changes on the IC-ECG. Localization X-rays were taken at the same time. In the control group, after the successful routine puncture and insertion of the PICC into the location to a predetermined length, localization X-rays were taken. The accuracy, procedure duration, and cost of the two localization methods were evaluated.

RESULTS

The accuracy of the localization in the study group was 92.5%, but the difference was not significant when compared with the control group (P>0.05). The duration of the procedure in the study group was 5.12±1.57 minutes, and the cost was 7.12±0.56 yuan, both of which were significantly different when compared with the control group (P<0.05).

CONCLUSIONS

P-wave changes during IC-ECG have high accuracy in determining the location of the tip of the PICC. It is also a simple method and has certain clinical application value.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (number: ChiCTR2100047660).

Joint time-frequency analysis of visible laser reflections in a sheep heart

Limited methods exist to confirm the position of cardiovascular devices in the superior vena cava or right atrium of the heart. The aim of this study was to design, test and validate the feasibility of whether an optical fiber-based instrument could accurately distinguish when a cardiovascular catheter was located in the superior vena cava vs in the right atrium. An optical fiber was placed in a cardiovascular catheter which was inserted into a living sheep and guided to the vicinity of the heart where diode laser-based reflection intensity data were simultaneously gathered from two visible wavelengths of light reflected from the venous and atrial tissue surfaces near the cavoatrial junction. The time series data were postoperatively analyzed using methods of joint time-frequency analysis and validated against catheter positions determined with fluoroscopy and ECG. The system was successful in distinguishing the location of the superior vena cava from the right atrium.

Acute ischaemia of the upper limb following peripherally inserted central catheter-a venous to arterial complication cascade

Peripherally inserted central catheters (PICC) are useful access devices that allow for longer-term intravenous access. This allows patients requiring an extended period of intravenous medication to have this administered without the need for repeat vascular punctures. Even minimally invasive procedures such as line insertion come with risks. Of particular interest to this article is a limb threatening complication soon after line placement. We discuss the PICC line catheter tip as the likely cause for arrhythmia that lead to an embolic occlusion of an upper limb and required acute surgical intervention for limb salvage. We stress the rapid sequence of events that lead to this ultimate complication. We also stress the importance for all clinicians to be aware of these risks and take a cautious approach as the majority of patients requiring longer-term access are already at greater risks of thromboembolic disease due to their comorbidities.

Reconsidering the GAVeCeLT Consensus on catheter-related thrombosis, 13 years later

Catheter-related thrombosis represents one of the most common complications following central venous access insertion. Despite the amount of available studies, many aspects surrounding catheter-related thrombosis remain controversial. Thirteen years ago, the Italian Study Group for Long Term Central Venous Access (GAVeCeLT) developed a nationwide Consensus in order to clarify some key aspects on this topic. Despite most of them still remain valid, however, knowledge around catheter-related thrombosis has greatly evolved over the last decade, with a natural evolution in terms of catheter technologies, insertion techniques, and management bundles. Aims of this editorial are to readdress conclusions of the 2007 GAVeCeLT Consensus in the light of the new relevant evidences that have been added in the last 13 years and to analyze some unsolved issues that still remain debated.

Selection and management of central venous access devices

Vascular access is an important aspect of patient care and management in all areas of healthcare. Safe, efficient and reliable venous access may require a central venous access device (CVAD), which can be used in primary and secondary care settings. Nurses may assist in device selection and be involved in their ongoing management, which includes recognising and addressing device complications. The appropriate choice of CVAD and early recognition of potential issues can improve the reliability and longevity of these devices and reduce the risk of long-term complications. This article describes the types of CVAD and their indications for use. It also outlines the management of CVADs, focusing on three areas: complications during insertion; infection prevention and control; and complications that may arise during the ongoing care of these devices.

Magnetic Tracking and Electrocardiography-Guided Tip Confirmation System Versus Fluoroscopy for Placement of Peripherally Inserted Central Catheters: A Randomized, Noninferiority Comparison

PURPOSE

To determine whether the use of a magnetic tracking and electrocardiography-guided catheter tip confirmation system (TCS) is safe and noninferior to fluoroscopy concerning positioning accuracy of a peripheral inserted central catheter (PICC).

METHODS

In this prospective, randomized, single-center study, adult patients scheduled for PICC insertion were assigned 1:1 either to TCS or fluoroscopy. The primary objective was a noninferiority comparison of correct PICC tip position confirmed by X-ray obtained immediately after catheter insertion. Time needed for PICC insertion and insertion-related complications up to 14 days after the procedure were secondary outcomes to be assessed for superiority.

RESULTS

A total of 210 patients (62.3 ± 14.4 years, 63.8% male) were included at a single German center between June 2016 and October 2017. Correct PICC tip position was achieved in 84 of 103 TCS (82.4%) and 103 of 104 fluoroscopy patients (99.0%). One-sided 95% lower confidence limit on the difference between proportions was -23.1%. Thus, noninferiority of TCS was not established (p > 0.99). Insertion of PICC took longer with TCS compared to fluoroscopy (8.4 ± 3.7 min vs. 5.0 ± 2.7 min, p < 0.001). Incidence of complications within a mean follow-up of 5.0 ± 2.3 days did not differ significantly between groups.

CONCLUSION

Noninferiority of TCS to fluoroscopy in the incidence of correct PICC tip position was not reached. Ancillary benefit of TCS over fluoroscopy including less radiation exposure and lower resource requirements may nonetheless justify the use of TCS. The study is registered with Clinical.Trials.gov (Identifier: NCT02929368).

Developing Appropriateness Criteria for Pediatric Vascular Access

OBJECTIVES

To describe the methodology undertaken to provide guidance on the appropriateness, as well as inappropriateness, of vascular access device selection, characteristics, and insertion technique for pediatric patients.

METHODS

The RAND Corporation-University of California, Los Angeles Appropriateness Method was used. After definition of key terms and scope, a systematic review of the pediatric vascular access literature was undertaken. Clinical scenarios were developed to reflect the common indications for vascular access across pediatric health care. These were sectioned according to (1) device selection, (2) device characteristics, and (3) insertion technique. An interdisciplinary panel of experts (N = 14) consisting of leading experts representing diverse pediatric clinical disciplines including anesthesiology, cardiology and cardiac surgery, critical care and emergency, general surgery, hematology and oncology, hospital medicine, infectious disease, interventional radiology, pharmacology, regional pediatric hospitalist, and vascular access nursing specialties was convened. The scenarios were rated for appropriateness by the panel over 2 rounds (1 [highly inappropriate] to 9 [highly appropriate]). Round 1 ratings were completed anonymously and independently by panel members and classified into 3 levels of appropriateness: appropriate, uncertain, and inappropriate, or disagreement. For round 2, panelists met in-person to discuss the round 1 ratings and independently rerated the indications. All indications were reclassified into 3 levels of appropriateness or disagreement.

CONCLUSIONS

The RAND Corporation-University of California, Los Angeles Appropriateness Method provides a rigorous, in-depth and transparent methodology to develop the first appropriateness criteria for the selection of pediatric vascular access devices in a range of patient groups.

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

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.

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.