ECHOTIP-Ped: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in pediatric patients

Central venous access devices are routinely used in pediatric care for administration of fluids and medications and for drawing blood samples. The adoption of ultrasound guided venipuncture, the availability of bedside ultrasound devices and the use of intraprocedural methods for tip location have been shown to reduce procedure-related complications, as documented by the recommendations of most recent guidelines. In pediatric patients, bedside ultrasound is a promising tool not only for optimizing the choice of the vein and guiding the venipuncture, but also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in pediatric patients, and to suggest a structured protocol for clinical practice.

Appropriateness of Replacing Fluoroscopic Guidance With ECG-Electromagnetic Guidance for PICC Insertion: A Randomized Controlled Trial

OBJECTIVE. Coupled ECG-electromagnetic (EM) guidance shows promise for use in placement of peripherally inserted central catheters (PICCs) when compared with the classic blind technique. However, ECG-EM guidance has not been appropriately compared with the reference standard of fluoroscopy (FX) guidance. Here, we aimed to compare ECG-EM guidance with FX guidance with regard to the final tip position of PICCs. SUBJECTS AND METHODS. A total of 120 patients (age range, 19-94 years) referred for PICC placement were randomized to the ECG-EM or FX group. All interventions were performed by PICC team members who had the same standardized training and experience. Final tip position was assessed using chest radiography and was classified as optimal, suboptimal, or inadequate requiring repositioning on the basis of the distance from the PICC tip to the cavoatrial junction (CAJ). Statistical analyses were performed using the Mann-Whitney U test for final catheter tip position (mean distance from CAJ) and Fisher and chi-square tests for proportions. RESULTS. PICCs were successfully inserted in 118 patients (53 men and 65 women). Catheter tip positions were optimal or suboptimal in 100% of the FX group and 77.2% of the ECG-EM group. Furthermore, precision of placement was significantly better (p = .004) in the FX group (mean distance from the PICC tip to the CAJ = 0.83 cm) than in the ECGEM group (mean distance from the PICC tip to the CAJ = 1.37 cm). Thirteen (22.8%) of the PICCs placed using ECG-EM guidance, all of which were inserted from the left side, were qualified as inadequate requiring repositioning and required another intervention. CONCLUSION. Our results revealed significant differences in final tip position between the ECG-EM and FX guidance techniques and indicate that ECG-EM guidance cannot appropriately replace FX guidance among unselected patients. However, ECGEM guidance could be considered as an acceptable technique for patients in whom the PICC could be inserted from the right side. TRIAL REGISTRATION. ClinicalTrials.gov NCT03652727.

Modified surface measurement method to determine catheter tip position of totally implantable venous access port through right subclavian vein

BACKGROUND

Optimal catheter tip position of a totally implantable venous access port (TIVAP) is important to maintain its function and to avoid severe complications. In this study, we aimed to assess the reliability of a modified surface measurement method to determine optimal tip position of a TIVAP catheter inserted through the right subclavian vein.

METHODS

Clinical and radiologic information of 105 patients who underwent TIVAP implantation through the right subclavian vein was collected retrospectively. The length of the implanted catheter was determined by a modified surface measurement method, as follows. The distance from the puncture point (point A) to the middle point of the sternal notch (point B), then from the middle point of the sternal notch (point B) to the middle point of Louis angle (point C) was added up. The equation for the catheter length is given by catheter length (cm) = AB + BC + 3. Postprocedure plain chest radiography (CXR) and enhanced chest computed tomography (CT) were used to check the catheter tip position and to calculate optimal position rate. Distance from the carina to the catheter tip and the length of the vertebral body unit were measured on both CXR and CT. Distances from carina to caval-atrial junction (CAJ) and from catheter tip to CAJ were measured on CT.

RESULTS

Mean length of the implanted catheter of all patients was 17.0 ± 0.7 cm (male vs female, 17.3 ± 0.5 cm vs 16.7 ± 0.7 cm; P < .001). On CXR, a catheter tip located within 2.4 vertebral body units below the carina was identified as the optimal position, and the optimal position rate was 97.1% (102/105 cases). On CT, two definitions of optimal position were used: within 2 cm above or below the CAJ and within 2 cm above or at the CAJ; the optimal position rate was 92.4% (97/105 cases) and 78.1% (82/105 cases), respectively. Median follow-up time was 9.4 months. During the follow-up, no severe cardiac complication was recorded.

CONCLUSIONS

The modified surface measurement had high reliability in determining the optimal catheter length to accurately place the tip in the superior vena cava near the CAJ.

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.