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COMMENTARY
Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 248-249  

Real-time localization of central venous catheter depth: Time to step out of the comfort zone


1 Department of Onco-Anesthesiology and Palliative Medicine, Dr. BRA-IRCH, AIIMS, Ansari Nagar, New Delhi, India
2 Department of Anaesthesiology, Pain Medicine and Critical care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Date of Submission03-Sep-2019
Date of Decision03-Sep-2019
Date of Acceptance09-Oct-2019
Date of Web Publication3-Jun-2020

Correspondence Address:
Nishkarsh Gupta
437, Pocket A, Sarita Vihar, New Delhi - 110 076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_249_19

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How to cite this article:
Gupta N, Samra R, Gupta A. Real-time localization of central venous catheter depth: Time to step out of the comfort zone. Med J DY Patil Vidyapeeth 2020;13:248-9

How to cite this URL:
Gupta N, Samra R, Gupta A. Real-time localization of central venous catheter depth: Time to step out of the comfort zone. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Jul 4];13:248-9. Available from: http://www.mjdrdypv.org/text.asp?2020/13/3/248/285767



Central venous catheter (CVC) placement is a commonly performed procedure both in the operation theaters and in the intensive care units.

Due to its predictable anatomic location, the internal jugular vein is the more preferred vein for central venous cannulation. The correct position of a CVC should be just above or at the junction of superior vena cava (SVC)–right atrium (RA) to avoid complications such as cardiac tamponade, arrhythmias, and valvular damage.[1]

A standard anterior posterior X-ray view of the chest (CXR) is done traditionally to ensure that the CVC tip is placed correctly. Other method includes transesophageal echocardiography (TEE), electrocardiography (ECG)-guided CVC insertion, and height- and anatomical landmark-based formulas.[2],[3] There are various limitations to the use of CXR for interpretation of CVC placement including delayed reading and risk of radiation exposure. Hence, several studies have been done in the recent past in search for an appropriate technique for CVC placement.

Peres investigated the successful placement of CVC tip in SVC while correlating the length of catheter inserted with patient's height which subsequently came to be known as the Peres formula.[2] Gebhard et al. reported more accurate CVC placement under ECG guidance and suggested its routine use to increase patient safety and reduce costs.[4]

The ECG-guided insertion of CVC monitors continuous changes in thePwave in the ECG as the tip of CVC catheter is advanced. As the catheter tip approaches the desired position (distal segment of the SVC), theP wave amplitude will peak and when its tip crosses SVC to enter the right ventricle then thePwaveform will become negative. Chu et al. compared the accuracy of the ECG technique with landmark-based approach for CVC insertion by confirming the position of CVC tip on a TEE as it approaches SVC–RA junction.[5] They concluded that ECG-guided CVC catheter placement was more accurate than the surface landmark-based technique.

Out of the millions of CVCs inserted worldwide, CVC insertion in pediatric population is increasing substantially. Similarly, there has been an increase in the number of studies done in pediatric population to find out the methods for localization of CVC tip.

Serafini et al. first reported the ECG positioning technique in children.[6] Hoffman et al. applied this technique on fifty patients based on a method originally described for ventriculo-atrial shunt placement in children with hydrocephalous and reported 100% accuracy.[7] Watters and Grant compared the efficacy of fluoroscopy and ECG guidance, defining the ECG guidance as a good alternative to fluoroscopy [8] and found it more accurate for CVC tip placement closer to carina. The incidence of complications was also found to be more in landmark-guided group in the study conducted by Barnwal et al.[9]

In this issue of journal, have investigated the accuracy of ECG guidance for depth of insertion of CVCs in children <12 years of age. Here, once the central vein was identified, a sterile alligator clip was clamped to the guidewire so as to connect it to a universal adaptor, which allowed to change over from surface to an intracardiac ECG. The CVC along with the guide wire was advanced till it was placed in the right atrium which was seen by increase in the amplitude ofPwave on the intracardiac ECG. The CVC was then gradually withdrawn until thePwave morphology normalized and CVC secured at this point. Out of 68 patients, appropriate position of CVC tip was seen in 65 patients. This method of CVC placement is quicker, needs a smaller learning curve, and also reduces the need for repositioning. The disadvantage of using this method is the difficulty in recognizing the serialP wave on a surface ECG, the requirement of a specific monitor for the same. In addition, this technique cannot be relied on patients with arrhythmias.

TEE can confirm the correct location of CVC tip in the RA–SVC junction and actively illustrate the angle of the catheter tip to the vascular wall, but it requires skill and is not always available. Use of ECG-guided insertion of central line catheter is a real-time method and is a step toward our pursuit to offer safer medical care. This study by Shah et al.[10] unsettles the traditional view and paves the way for improved patient care.



 
  References Top

1.
Chaskar V, Karnik PP, Dave NM, Garasia M. Comparative study of three methods for depth of central venous catheter placement in children: An observational pilot study. Turk J Anaesthesiol Reanim 2018;46:116-20.  Back to cited text no. 1
    
2.
Peres PW. Positioning central venous catheters: A prospective survey. Anesth Intensive Care 1990;18:536-9.  Back to cited text no. 2
    
3.
Murali BH, Srividya GS, Reshmavathi V. Appropriate length of the central venous catheter insertion via right internal jugular vein in children using external anatomical. Curr Pediatr Res 2016;20:20-3.  Back to cited text no. 3
    
4.
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. 4
    
5.
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. 5
    
6.
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. 6
    
7.
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. 7
    
8.
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. 8
    
9.
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. 9
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10.
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 2019;13:249–52.  Back to cited text no. 10
    




 

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