Yufang Gao,1,* Yuxiu Liu,1,2,* Hui Zhang,1,* Fang Fang,3 Lei Song4 1 Hospital Management Office, Affiliated Hospital of Qingdao University, Qingdao, China; 2 Department of Community Nursing, School of Nursing, Weifang Medical University, Weifang; 3 Department of Hematology, Affiliated Hospital of Qingdao University, Qingdao, People’s Republic of China; 4 Intensive Care Unit, Affiliated Hospital of Qingdao University, Qingdao, People’s Republic of China It is essential for the use of catheters. Postoperative chest X-rays, which are the “gold standard” practices recognized by the PICC tip, can cause significant delays in IV treatment for patients, higher costs, and lead to radiation exposure for patients and staff. Intracavitary electrocardiogram (IC-ECG) guided PICC placement provides real-time prompts during the insertion process to confirm that it has been widely used. However, for patients with abnormal body surface ECG, such as patients with atrial fibrillation (AF), the safety and accuracy of ECG have not been reported. Objective: To determine the safety and accuracy of IC-ECG technology in the verification of the PICC tip position of AF patients. Patients and methods: A prospective cohort study was conducted in a 3,600-bed teaching and tertiary referral hospital in Qingdao, People’s Republic of China. The study recruited adult patients with AF who required PICC infusion from June 2015 to May 2017. For each AF patient included, ECG was used to detect the tip position of the PICC during catheterization, and X-rays were performed to confirm that the tip position was the “gold standard” after PICC insertion. Compare the effectiveness and accuracy of ECG-guided catheter tip positioning and chest X-ray confirmation. Results: A total of 118 PICCs were enrolled in 118 patients with atrial fibrillation (58 males and 60 females, aged 50-89 years). There are no complications related to catheterization. When the catheter enters the lower 1/3 of the superior vena cava, the amplitude of the f wave reaches its maximum. There was no statistical difference between the X-ray PICC tip position verification and IC-ECG PICC tip position verification in AF patients (χ2=1.31, P=0.232). Using the cut-off point of f wave change ≥ 0.5 cm, it was observed that the sensitivity was 0.94, the specificity was 0.71, the positive predictive value was 0.98, and the negative predictive value was 0.42. The area under the receiver operating characteristic curve was 0.909 (95% CI: 0.810–1.000). Conclusion: ECG-guided technology is a safe and accurate technology that can be used to verify the position of the PICC tip of AF patients, and may eliminate the need for postoperative chest X-rays in AF patients. Keywords: peripheral central venous catheter, PICC, tip position, electrocardiogram, electrocardiogram, patients with atrial fibrillation
The correct tip positioning of the peripherally inserted central catheter (PICC) is essential to avoid catheter-related complications such as displacement, venous thrombosis, or arrhythmia. 1 PICC tip positioning, postoperative chest X-ray, electrocardiogram (ECG), and some reported new technologies, such as Sherlock 3CG® Tip Confirmation System (Bard Access Systems, Inc., Salt Lake City, UT, USA), which integrates Magnetic tracking and ECG-based PICC tip confirmation technology 2 and electrical conduction wire system. 3
Chest X-ray is the most commonly used method to verify the position of the PICC tip and is recommended as the gold standard. 4 One of the limitations of X-rays is that postoperative confirmation may lead to intravenous (IV) treatment. 5 In addition, if the position of the PICC tip is detected incorrectly by X-rays after surgery, catheter operations and chest X-rays need to be repeated, which will cause delays in patient treatment and further time usage, and increase costs. In addition, since the integrity of the dressing is interrupted, complications may occur, including catheter-related bloodstream infections. 6,7 The additional time, cost, and radiation exposure involved in radiological assessments have resulted in PICCs that can only be placed in hospitals.1
The ECG technique for central venous catheter (CVC) tip positioning was first reported in 1949. 8 Intracavitary ECG-guided PICC placement provides real-time tip confirmation during insertion. There is increasing evidence that ECG-guided PICC tip positioning can be as accurate as X-ray methods. 5,9-11 Walker’s systematic review indicated that ECG-based positioning may eliminate the need for postoperative chest X-rays, especially during PICC line insertion. 6 ECG-guided
PICC tip position is clarified in real time during catheterization, without postoperative adjustment or repositioning. PICC can be used immediately after placement without delaying patient treatment. 9
The current standard for PICC tip location is one third of the superior vena cava (SVC) and the inferior vena cava-atrial junction (CAJ). 10,11 As the tip of the PICC approaches the sinus node at CAJ, the P wave begins to rise and reaches its maximum amplitude at CAJ. As it passes through the right atrium, the P wave begins to invert, indicating that the PICC is inserted too far. The ideal PICC tip position is the position where ECG shows the largest P amplitude. Since the positioning of the PICC tip under ECG guidance is considered a safe, reliable, and reproducible method, can it be used in patients with atrial fibrillation (AF) without P waves in the ECG? Our research team comes from the Affiliated Hospital of Qingdao University and inserts approximately 5,000 PICCs every year. The research team has been committed to the study of PICCs. During our research, we found that the f wave of AF patients during the PICC tip positioning process also has some obvious changes. The team therefore explored this.
This prospective cohort study was conducted in the Affiliated Hospital of Qingdao University, a tertiary referral hospital with more than 3,600 beds from June 2015 to May 2017. The research plan was reviewed and approved by the Institutional Review Committee of the Affiliated Hospital of Qingdao University (approval number QDFYLL201422). All enrolled patients signed written informed consent.
The inclusion criteria are as follows: 1) Patients in need of PICC, whose ECG shows the AF wave before PICC insertion; 2) Over 18 years of age; 3) Patients can tolerate X-ray examination. The exclusion criteria are as follows: 1) Patients with mental or skin diseases; 2) Patients with pacemakers; 3) Patients using any other types of catheters 4) Patients allergic to alcohol and iodophor.
PICC is inserted under ultrasound guidance by professional PICC nurses under standard aseptic conditions. Four French (Fr) single-lumen distal valved silicone Bard Groshong® PICC (Bard Access Systems, Inc.) were used in the study. The Bard Site Rite 5 Ultrasound Machine Ultrasound System (Bard Access Systems, Inc.) is used to measure and evaluate the relevant veins at the insertion point. All PICCs are inserted using Groshong® NXT ClearVue through improved Seldinger technology. After inserting the tube, rinse all PICC with 10 mL of normal saline, and cover the entrance of the catheter with a dressing after skin disinfection. Check chest X-rays routinely to confirm the position of the catheter tip. 10
According to the Association of Infusion Nurses, the recommended tip location is located in the lower third of the SVC near the entrance of the right atrium. 11 According to reports, approximately 4 cm (95% CI: 3.8-4.3 cm) below the carina at the tip of the CVC will result in placement near the CAJ. The average length of the SVC is 7.1 cm. 12 In this study, we used the X-ray method as the “gold standard” for confirming the position of the PICC tip. During the X-ray examination, all patients were in a neutral supine position, with their arms straight to the body, and did not breathe hard to avoid possible tip dislocation due to posture or strong inhalation. We use the carina as an anatomical landmark from which to measure the PICC tip. In our study, the best position is estimated to be 1.6-4 cm below the carina. 12,13 X-ray data were evaluated by 2 radiologists separately. If the judgments are inconsistent, the third radiologist will further check the X-ray results and confirm the decision.
The ECG under study was obtained through the so-called “saline technique”, which uses a column of saline solution contained in a catheter as an intraluminal electrode. 13 Braun® transducers and a switch for switching from body surface ECG tracking to intracavity ECG (IC-ECG) tracking) were used in the research. Three surface electrodes (right arm [RA], left arm and left leg) are connected to lead II. When the tip of the catheter enters the SVC, connect the catheter to the connector of the transducer, and then continuously infuse normal saline through the PICC. The electrocardiogram of patients with atrial fibrillation shows f waves instead of P waves. With the deepening of the tip of the catheter, the f wave has also undergone a certain change. When the catheter enters the SVC, the f wave becomes higher, similar to the change of the P wave, that is, when the catheter enters the SVC, the amplitude of the f wave gradually increases. When the catheter enters the lower 1/3 of the SVC, the f-wave amplitude reaches its maximum value, and when the catheter enters the right atrium, the f-wave amplitude decreases.
For each PICC insertion, collect the following data: 1) Patient data, including age, gender, diagnosis, an
Post time: Dec-20-2021