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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 244-247  

Accuracy of electrocardiography guidance for depth of insertion of central venous catheters in children: A prospective observational study


Department of Pediatric Anesthesia, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission15-May-2019
Date of Decision15-Aug-2019
Date of Acceptance16-Oct-2019
Date of Web Publication3-Jun-2020

Correspondence Address:
Harick Shah
14/Peace Bird Society, T.H. Kataria Marg, Matunga (W), Mumbai - 400 016, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_131_19

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  Abstract 


Context: Central venous catheters (CVCs) have become integral in the pediatric intensive care setting as well as in the operating room (OR). In the OR, these lines are usually used without prior confirmation of correct position, and a chest radiograph is performed postoperatively, several hours later. Hence, it is desirable to confirm the correct CVC position immediately after placement. Aim: This observational study was designed to evaluate the accuracy of electrocardiography (ECG) guidance on correct CVC positioning in pediatric population. Settings and Design: This was a prospective observational study. Subjects and Methods: Patients till 12 years of age were included in the study. Ultrasound was used to guide initial cannulation of the vessel. Certodyn® universal adaptor was connected to the guidewire via a sterile alligator clip. The CVC along with the guidewire was advanced till it lies in the right atrium which was seen by an increase in the amplitude of P-wave on the intracardiac ECG. The CVC was then withdrawn slowly until the P-wave morphology returned to normal or preprocedural configuration. Statistical Analysis Used: Data were expressed as percentage. Results: Out of the 68 patients, the percentage of patients having appropriate position of CVC tip was 95.5% (65 patients). Out of the three patients with incorrect tip position, in two patients, the tip was distal to the appropriate position and in one case, the ECG changes could not be appreciated. Conclusions: ECG-guided CVC placement has high accuracy of correct positioning in infants and children.

Keywords: Carina, central venous catheter, electrocardiogram, pediatric


How to cite this article:
Shah H, Dave N, Karnik P. Accuracy of electrocardiography guidance for depth of insertion of central venous catheters in children: A prospective observational study. Med J DY Patil Vidyapeeth 2020;13:244-7

How to cite this URL:
Shah H, Dave N, Karnik P. Accuracy of electrocardiography guidance for depth of insertion of central venous catheters in children: A prospective observational study. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Jul 4];13:244-7. Available from: http://www.mjdrdypv.org/text.asp?2020/13/3/244/285752




  Introduction Top


Central venous catheters (CVCs) have become integral in the pediatric intensive care setting as well as in the operating room (OR). Central venous catheterization is indicated in shock, severe dehydration, for long-term parenteral nutrition, central venous pressure monitoring, difficult peripheral venous cannulation, and surgeries where major blood loss or fluid shifts are anticipated.

In the OR, these lines are usually used intraoperatively without prior confirmation of correct position, and a chest radiograph (CXR) is performed postoperatively, several hours later. Because incorrect CVC position can be associated with various complications ranging from incorrect central venous pressure measurements to life-threating complications such as thrombosis of great vessels, cardiac perforation, cardiac tamponade, and arrhythmias,[1] it is desirable to confirm correct CVC position immediately after placement in the OR.[2] It is recommended to place the CVC so that its tip lies at the lower third of the superior vena cava (SVC) or the junction between the SVC and the right atrium (SVC–RA junction).[3]

There are various methods that have been recommended to decide the proper depth of CVC placement based on patient characteristics, anatomical landmarks, electrocardiogram (ECG) -guidance and transesophageal echocardiography guidance, and CXR.[4] However, different physicians may interpret CXR differently and may not give similar results. In addition, using CXR for confirmation is a delayed process and does not provide immediate confirmation of the correct placement of CVC. Avoiding CXR helps prevent radiation exposure to children and medical staff.

This observational study was designed to evaluate the accuracy of ECG guidance on correct CVC positioning in the pediatric population.


  Subjects and Methods Top


The study was approved by the institutional ethics committee. Informed consent for the study was obtained from parents along with assent from children >7 years old. The study was conducted over a period of 1 year. All patients between the ages of 1 and 12 years requiring central venous cannulation, over a period of 1 year, were enrolled in the study.

The study was conducted in a tertiary care government hospital. Pediatric patients from surgical and medical wards, intensive care unit (ICU), neonatal ICU, and operation theater who required central line were included in the study. Patients having coagulopathy, platelet count <50,000, patients with abnormal ECG rhythm, those with parent's refusal, and those with infection at the site of insertion were excluded from the study.

After induction of general anesthesia or after giving adequate sedation to the patient, the right internal jugular vein (RIJV) or left internal jugular vein (LIJV) or right subclavian vein (RSV) or left subclavian vein was cannulated under sterile conditions by Seldinger technique. Ultrasound was used to guide the initial cannulation of the vessel. Size of the CVC was determined depending on the weight of the patient: 3 Fr for <5 kg; 4 Fr or 4.5 Fr for 5–10 kg; 5 Fr or 5.5 Fr for 10–25 kg; and 7 Fr for >25 kg. The position of the patient was 30° Trendelenburg with a rolled towel under the scapula and the head rotated to the opposite side of the point of insertion of CVC. Once the central vein was identified, a sterile alligator clip was clamped to the guidewire so as to connect it to the Certodyn® universal adaptor, manufactured by B Braun Company., which allowed to change over from surface to an intracardiac ECG [Figure 1].
Figure 1: Assembly and circuit for intracardiac electrocardiography-guided central venous catheter placement

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The CVC along with the guidewire was advanced till it was placed in the RA which was seen by increase in the amplitude of P-wave on the intracardiac ECG [Figure 2]. The CVC was then withdrawn slowly until the P-wave morphology returned to normal or preprocedural configuration [Figure 3]. At this point, the guidewire was removed, and CVC was secured to the skin with suture and dressed with transparent dressing. When the intra-atrial ECG was not obtained during the procedure, the CVC was inserted till a depth determined by the attending anesthesiologist.
Figure 2: Intracardiac electrocardiography with central venous catheter tip in the right atrium

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Figure 3: Intracardiac electrocardiography with central venous catheter tip proximal to the right atrium

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After completion of the procedure, a CXR was taken in all patients. CXR was taken with the patient in supine position, completely flat in their bed with their neck in neutral position. The position of the tip was considered correct if it was at the level of carina on CXR. The catheter tip was repositioned if it was too in or too out, and it was recorded as inappropriate. This constituted the end of study. For all the procedures, final depth of insertion, number of attempts, and occurrence of any complication (arterial puncture, hematoma, ventricular ectopics, and pneumothorax) were recorded.


  Results Top


A total of 68 patients up to 12 years of age were enrolled in the study, out of which 38 were males and 30 were females. There were 12 infants between the age of 0 and 12 months, 27 toddlers between 1 and 3 years, and 29 children between 3 and 12 years of age. Forty-five cannulations were through the RIJV, 18 through the LIJV, and 5 through the RSV. Percentage of patients having appropriate position of CVC tip was 95.5% (65 patients). In two patients, the tip was distal to the appropriate position. In one patient, ECG changes could not be appreciated and the tip was found to be wrongly positioned. CXR showed CVC crossing over from the RSV to the LIJV. Small hematomas developed in nine (13%) of these patients, which did not require further intervention. There were no other complications during the study period.


  Discussion Top


In our study, CVC placement using ECG guidance resulted in a high percentage (95.5%) of correctly positioned CVCs without increasing the placement time. We also observed a reduced need for postprocedural repositioning and consequently repeat CXR imaging with this technique.

It is recommended that the best position of the tip of the catheter is in the distal SVC or at the SVC–RA junction. The carina as a landmark is easy to identify on CXR and can be taken as proxy for SVC–RA junction, for correct placement of the catheter tip.[5],[6]

Serafini et al.[7] first reported the ECG positioning technique in children. In a similar article from the same group, the authors reported that the ECG method, without subsequent CXR, did not result in a single false-positive or false-negative CVC position.[8] Hoffman et al.[9] applied this technique on fifty patients and reported 100% accuracy. They concluded that equipment required for this method found in most OR departments, is easily learned and taught and obviates the need for X-rays. Watters and Grant [10] compared the efficacy of fluoroscopy and ECG guidance, defining the ECG guidance as a good alternative to fluoroscopy; Chu et al.[11] compared the landmark technique with the ECG method, finding the ECG much more accurate.

This technique offers many advantages. Technically, this approach provides a quick and reliable method to track the position of the catheter during the insertion procedure, potentially reducing the need for repositioning. It also has a relatively small learning curve, with proficiency achieved after eight insertions.[3] This procedure is less operator dependent, and the interpretation of the ECG record is immediate; provided that an adequate ECG monitor is available, it is widely applicable. All patients with a detectable P-wave at preoperative ECG could benefit from this technique. It may obviate the need for postprocedural CXR.

Good-quality intra-atrial ECG and clear visual of the P-wave on the ECG monitor are necessary for successful guidance and positioning of CVCs. There are certain limitations of ECG guidance which include an additional ECG cable with an alligator clip which may not be available with all CVC sets. It is monitor specific as it requires ECG cable with detachable red lead from the hub.[4] It may not be reliable in patients with atrial fibrillation or other supraventricular arrhythmias.[2]


  Conclusions Top


Our data indicate that ECG-guided CVC placement has high accuracy of correct positioning in infants and children. It may be especially important if other means of verifying correct CVC position are not immediately available.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Booth SA, Norton B, Mulvey DA. Central venous catheterization and fatal cardiac tamponade. Br J Anaesth 2001;87:298-302.  Back to cited text no. 1
    
2.
Gebhard RE, Szmuk P, Pivalizza EG, Melnikov V, Vogt C, Warters RD. The accuracy of electrocardiogram-controlled central line placement. Anesth Analg 2007;104:65-70.  Back to cited text no. 2
    
3.
Perin G, Scarpa MG. Defining central venous line position in children: Tips for the tip. J Vasc Access 2015;16:77-86.  Back to cited text no. 3
    
4.
Barnwal NK, Dave ST, Dias R. A comparative study of two techniques (electrocardiogram- and landmark-guided) for correct depth of the central venous catheter placement in paediatric patients undergoing elective cardiovascular surgery. Indian J Anaesth 2016;60:470-5.  Back to cited text no. 4
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5.
Yoon SZ, Shin JH, Hahn S, Oh AY, Kim HS, Kim SD, et al. Usefulness of the carina as a radiographic landmark for central venous catheter placement in paediatric patients. Br J Anaesth 2005;95:514-7.  Back to cited text no. 5
    
6.
Albrecht K, Breitmeier D, Panning B, Tröger HD, Nave H. The carina as a landmark for central venous catheter placement in small children. Eur J Pediatr 2006;165:264-6.  Back to cited text no. 6
    
7.
Serafini G, Pietrobono P, Cornara G. Location of central venous catheters in children by endocavitary ECG: A new technique. Clin Nutr 1985;4:201-2.  Back to cited text no. 7
    
8.
Parigi GB, VergaG. Accurate placement of central venous catheters in pediatric patients using endocavitary electrocardiography: Reassessment of a personal technique. J Pediatr Surg 1997;32:1226-8.  Back to cited text no. 8
    
9.
Hoffman MA, Langer JC, Pearl RH, Superina RA, Wesson DE, Ein SH, et al. Central venous catheters – No X-rays needed: A prospective study in 50 consecutive infants and children. J Pediatr Surg 1988;23:1201-3.  Back to cited text no. 9
    
10.
Watters VA, Grant JP. Use of electrocardiogram to position right atrial catheters during surgery. Ann Surg 1997;225:165-71.  Back to cited text no. 10
    
11.
Chu KS, Hsu JH, Wang SS, Tang CS, Cheng KI, Wang CK, et al. Accurate central venous port-A catheter placement: Intravenous electrocardiography and surface landmark techniques compared by using transesophageal echocardiography. Anesth Analg 2004;98:910-4.  Back to cited text no. 11
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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