Ultrasound versus intracavitary electrocardiography for intraprocedural tip location during central venous catheterization in infants and children: A prospective clinical study

BACKGROUND

Both intracavitary electrocardiography (IC-ECG) and ultrasound (US) have been proven to be safe and accurate for intraprocedural tip location during central venous catheterization, and both are known to be easily applicable and feasible in pediatric patients. Though, no prospective clinical study has directly compared the two methods as regards their applicability, feasibility, and procedural time.

METHODS

This study prospectively enrolled all children requiring a central venous access device in non-emergency situations, during a period of 1 year. All devices were inserted according to a well-defined insertion bundle including both IC-ECG and US-based tip location. The primary endpoint of the study was to compare the two methods in terms of applicability, feasibility and time required.

RESULTS

This study included 100 consecutive central venous catheterizations in children of age ranging from 1 month to 18 years. The applicability of IC-ECG based tip location was 98% and its feasibility 100%; the time required for IC-ECG was 1.9 ± 2 min. The applicability of US-based tip location was 96% and its feasibility was 100%; the maneuver required 2.2 ± 3 min.

CONCLUSIONS

US is an appropriate alternative method for intraprocedural tip location in children. The combined use of US and IC-ECG (both maneuvers being accurate, inexpensive, cost-effective, non-invasive, and equally fast to perform) should be recommended for tip location in pediatric patients, and it will avoid completely the use of fluoroscopy or of post-procedural x-ray.

A comparison between two radiological criteria for verifying tip location of central venous catheters

INTRODUCTION

Current guidelines recommend intraprocedural methods-such as Intra-Cavitary ECG (IC-ECG) and echocardiography-for verifying the location of the tip of central venous catheters. Nonetheless, there are clinical conditions which may require to verify tip location by less accurate methods such as Chest X-Ray (CXR). We have compared the feasibility and accuracy of two radiological methods for tip location-the Sweet Spot Criterion (SSC) and the Carina Criterion (CC)-using IC-ECG as reference.

METHODS

In this retrospective multicenter study, we reviewed the radiology databases of three hospitals, examining all CXRs performed on patients after insertion of Peripherally Inserted Central Catheters (PICCs), as long as the tip location had been successfully performed during the procedure by IC-ECG. Tip location was verified using SSC and CC, comparing the two methods in terms of feasibility and accuracy.

RESULTS

We reviewed the CXR of 1116 PICCs successfully inserted by IC-ECG. CC was not feasible in 0.5% (impossible visualization of the carina) and difficult in 1.5%; in 97.7% of cases, the position of the tip was adequate (1-5 cm below the carina), in 0.6% too high (<1 cm), in 1.2% too low (6-9 cm). On the other hand, because of unclear visualization of radiological landmarks, SSC was not feasible in 0.9% and difficult in 10.5%; though, according to SSC the tip location was always acceptable (in 94.2% the tip was in the middle of the spot, in 2.5% close to the superior border, and in 2.3% close to the inferior border); no tip was visualized outside of the spot.

CONCLUSION

CC and SSC were similar in terms of feasibility (99.5% vs 99.1%) and accuracy (98.1% vs 100%), though CC was subjectively perceived to be easier and more rapid to perform.

A new pressure-based device for tip navigation and tip location during central venous catheterization: A prospective clinical study on a cohort of 136 adult patients

INTRODUCTION

According to current guidelines, tip location of peripherally inserted central catheters (PICCs) should be verified during insertion, preferably using non-invasive methods such as intracavitary ECG (IC-ECG) or echocardiography. An interesting new option is represented by a new pressure-based device, the CatFinder System (CFS), which might be theoretically useful also for tip navigation.

METHODS

We planned a single-center, prospective, non-randomized trial on adult patients requiring PICC insertion, using simultaneously CFS and IC-ECG, with the purpose of verifying the applicability, feasibility, safety, and accuracy of CFS for intra-procedural tip location. Patients with known ECG abnormalities or cardiac diseases of any type were excluded. The ability of CFS to assess wrong directions of the catheter during insertion (tip navigation) was evaluated by comparison with ultrasound scan.

RESULTS

Out of 136 enrolled adult patients, CFS was found to be applicable in 131 cases (five cases were excluded because of ECG abnormalities) and feasible in 111 cases (in 20 cases, tip location by CFS could not be carried out because of technical issues). There were no complications directly or indirectly related to the CFS maneuvers. Using IC-ECG as a comparison, 87 tips placed by CFS were within 2 cm from the target, 17 were >2 cm from target. In seven cases, CFS was able to detect a wrong direction (to the ipsilateral internal jugular vein), as confirmed by ultrasound.

CONCLUSION

Applicability of CFS in patients with sinus rhythm was 96.3%, feasibility was 84.7%, and safety was 100%. If compared to IC-ECG, accuracy was 83.6% (accepting an error <2 cm) and 96.1% (for an error <3 cm). Unacceptable tip positions (>3 cm) were 3.8% (the tip was too high inside the SVC). This study confirms a possible future role of CFS for intra-procedural tip location and tip navigation, though its use cannot be currently recommended.

A GAVeCeLT bundle for central venous catheterization in neonates and children: A prospective clinical study on 729 cases

BACKGROUND

In the pediatric patient, central venous catheterization may be associated with relevant complications. Though, most of them may be prevented by a wise choice of materials, methods, and techniques. Evidence-based insertion bundles for central venous catheterization have been developed in the adult patient, but not in neonates and children.

METHODS

The Italian Group for Long Term Venous Access Devices (GAVeCeLT) has developed an insertion bundle for central venous catheterization in neonates, infants, and children, which includes seven evidence-based strategies: (1) preprocedural ultrasound evaluation, (2) appropriate aseptic technique, (3) ultrasound guided venipuncture, (4) intraprocedural tip location by non-radiological methods, (5) proper choice of the exit site by tunneling, (6) sutureless securement, and (7) protection of the exit site using glue and transparent membranes. The effectiveness and safety of this bundle has been tested in a prospective study.

RESULTS

All neonates, infants and children requiring a non-emergency central line (except for umbilical venous catheters and epicutaneo-cava catheters) were included in the study. Out of 729 central line insertions, there were no immediate complications (no pneumothorax, no arterial puncture, no malposition); the incidence of early and late complications (local ecchymosis, dislodgment, local pain, exit site infection) was 3.7%; in the first 2 weeks after insertion, no catheter-related bacterial infection or catheter-related thrombosis was recorded.

CONCLUSION

The results of this prospective study strongly validate the hypothesis that an insertion bundle is highly effective in optimizing the safety of the maneuver, reducing immediate, early, and late complications.

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.

The intracavitary ECG method for tip location of ultrasound-guided centrally inserted central catheter in neonates

BACKGROUND

The correct position of the tip of a central venous access device is important in all patients, and especially in neonates. The traditional method of tip location (approximated intra-procedural length estimation + post procedural chest X-ray) is currently considered inaccurate and not cost-effective by most recent guidelines, which recommend the adoption of tip location by intracavitary electrocardiography (IC-ECG) whenever possible.

METHODS

This study prospectively investigated the applicability, the feasibility, the accuracy, and the safety IC-ECG for tip location in neonates requiring insertion of ultrasound-guided centrally inserted central venous catheters (CICCs) with caliber 3Fr or more. All catheter tip locations were verified using simultaneously both IC-ECG and ultrasound-based tip location, using the Neo-ECHOTIP protocol.

RESULTS

A total of 105 neonates were enrolled. The applicability of IC-ECG was 100% since a P wave was evident on the surface ECG of all neonates recruited for the study. The feasibility was also 100% since an increase of the P-wave was detected in all cases. The accuracy was also 100%, since a perfect match between IC-ECG based tip location and ultrasound-based tip location was found. There were no adverse events directly or indirectly related to the IC-ECG technique; no arrhythmias occurred.

CONCLUSIONS

When applied to ultrasound guided CICCs, tip location by IC-ECG is applicable and feasible in neonates, and it is safe and accurate.

Ultrasound-guided cannulation of the brachiocephalic vein in newborns: A novel approach with a supraclavicular view for tip navigation and tip location

PURPOSE

Central vascular catheters (CVCs) are frequently used in newborns in NICU. Ultrasound (US) guided supraclavicular venipuncture of the brachiocephalic vein (BCV) is usually performed with a 12 MHz linear probe and then a catheter tip location is verified with an 8 MHz micro-convex probe or intracavitary ECG (IC-ECG). We explored the feasibility of an US guided puncture using a 7 MHz sector probe, positioned on the clavicular sternal joint. We also explored the opportunity of performing it with a probe tilting tip navigation and tip location.

DESIGN

This is a monocentric retrospective observational study made in the neonatal intensive care unit L. Vanvitelli University Hospital of Naples, Italy.

PATIENTS

Forty newborns in NICU scheduled for an ultrasound guided CVC.

INTERVENTIONS

US guided brachiocephalic vein catheterization. We used A long axis in plane supraclavicular approach to the BCV for real time puncture, for tip navigation and tip location, using a 7 MHz sector transducer. We executed an ultrasound pre-scan of the Y-shape (right and left BCV, superior vena cava (SVC)) and of the right pulmonary artery (RPA), and then we performed a guided sterile puncture on middle third of supraclavicular fossa next to clavicular sternal joint with a 7 MHz. We used the same probe for tip navigation by this supraclavicular short axis of ascending aorta view. Tip location was confirmed with the ultrasound and IC-ECG.

RESULTS

In all infants the ultrasound tip navigation and tip location were successful and were confirmed by IC-ECG. No misplacement, arterial puncture or pneumothorax occurred.

CONCLUSIONS

The supraclavicular view performed with a 7 MHz sector probe has proved to be completely safe and to be a method with 100% feasibility.