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CARDIOVASCULAR ANESTHESIA

The Accuracy of Electrocardiogram-Controlled Central Line Placement

Ralf E. Gebhard, MD^*, Peter Szmuk, MD, Evan G. Pivalizza, MBChB, FFASA, Vladimir Melnikov, MD, Christianne Vogt, MD, and Robert D. Warters, MD

From the *Department of Anesthesiology, University of Miami-Miller School of Medicine, Miami, Florida; Department of Anesthesiology, The University of Texas Southwestern Medical School at Dallas and Children's Medical Center Dallas, Dallas; and Department of Anesthesiology, The University of Texas Medical School at Houston, Houston, Texas.

	Abstract

Top Abstract Introduction METHODS RESULTS DISCUSSION REFERENCES

 
BACKGROUND: Electrocardiogram (ECG) guidance to confirm accurate positioning of central venous catheters (CVC), placed before surgery in the operating room, is rarely used in the United States. We designed this randomized, controlled trial to investigate whether the use of this technique impacts the accuracy of CVC placement.

METHODS: Patients in group ECG (n = 147) had a CVC placed using right-atrial ECG to guide catheter tip positioning. CVCs in group NO-ECG (n = 143) were positioned without this technique.

RESULTS: Overall, guidewire-ECG control resulted in more correctly positioned CVCs (96% vs 76%, P 0.001) without increasing placement time. Significantly more CVCs were placed in the middle of the superior vena cava in group ECG (P 0.001), although placement into the right atrium or right ventricle and into other vessels occurred significantly more often in group NO-ECG (P 0.001). Twenty patients in group NO-ECG required repositioning of their CVC after surgery, whereas this maneuver was necessary only in three patients in group ECG (P 0.001).

CONCLUSIONS: ECG guidance allows for more accurate CVC placement, and should be considered to increase patient safety and reduce costs associated with repositioning procedures.

	Introduction

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Anesthesiologists frequently place central venous catheters (CVCs) preoperatively in the operating room (OR) for fluid management and hemodynamic monitoring. These lines are usually used intraoperatively without prior confirmation of correct position, and only a chest radiograph (CXR) is usually performed postoperatively, several hours later. Because incorrect CVC position can be associated with serious adverse effects such as cardiac tamponade (1,2), it would be not only desirable, but also beneficial for patient safety to confirm, in the OR, correct CVC position immediately after placement. In addition, guidelines for CVC positioning issued by the United States Food and Drug Administration and other experts, emphasize that CVCs should not be placed into the right atrium (RA) in order to avoid the potential for cardiac complications (3,4). Previous studies have indicated the usefulness of electrocardiogram (ECG)-guided positioning (RA ECG) for CVC placement (5,6) and the routine use of CXRs to verify CVC position has been questioned (7). However, these studies were either not controlled or only included relatively small sample sizes. Consequently, ECG-guided CVC positioning has not yet become standard of care in the United States, and this method was not mentioned in a recent review published in The New England Journal of Medicine regarding the prevention of CVC-associated complications (8). This randomized, controlled study was designed to evaluate the influence of ECG-guided CVC placement on correct CVC positioning in a large sample size.

	METHODS

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This study was approved by the Committee for the Protection of Human Subjects at The University of Texas Medical School at Houston. All patients undergoing elective surgery during daytime hours (7 am–5 pm) and scheduled to receive a CVC as part of their anesthetic management were screened for enrollment in this prospective controlled trial. Individuals with known atrial fibrillation or pacemakers in place were excluded from participation. After patient informed consent, 300 patients were successfully enrolled. Patients were randomized using an internet-based computer program (http://www.randomizer.org) either to group ECG (CVC placement using ECG-guidance) or group NO-ECG (CVC placement without ECG-guided positioning). In group ECG, the CVC was placed by the individual anesthesia care team assigned to the case (resident under faculty supervision) according to the following technique: After induction of general anesthesia in the OR using ASA standard monitoring, either the right internal jugular vein (RIJ) or left internal jugular vein (LIJ) or the right subclavian (RS) or left subclavian (LS) vein was cannulated under sterile conditions. Using a Seldinger technique, a 20-cm triple-lumen CVC (Certofix®, B. Braun Medical, Bethlehem, PA) was then inserted over a 60-cm guidewire until the 20-cm mark was at skin level. The guidewire was then withdrawn through the catheter until a mark on the guidewire indicated the tip to be exactly positioned at the tip of the catheter. A connection between the guidewire and an ECG-adapter (Certodyn®, B.Braun Medical) was then established in the following fashion (Fig. 1): The ECG adapter was connected in-line between the ECG monitor and the right arm electrode. An alligator clip attached to a cable leading to the ECG adapter was then placed on the metal guidewire just above the catheter hub. Using a switch function in the adapter, ECG conduction was then transferred from a regular 3-lead surface ECG to a right intraatrial ECG. At this point, the principal investigator or one of the co-investigators supervised the further positioning of the CVC.

View larger version (17K): [in this window] [in a new window]   Figure 1. ECG lead connection for right-atrial ECG conduction. ECG = electrocardiogram.

The catheter was slowly withdrawn, while lead II was observed on the ECG monitor. After the intraatrial ECG indicated CVC position in the RA (elevated P-wave), the CVC was withdrawn until the P-wave returned to normal configuration. After further withdrawal of the CVC for another 2 cm, the CVC was secured at the skin with suture and dressed with tegaderm^TM (3M Health Care, St. Paul, MN). If an intraatrial ECG could not be obtained, the CVC and guidewire were withdrawn together to an insertion depth of approximately 8 cm. The guidewire and CVC were then re-advanced and another attempt was made to obtain an intraatrial ECG. If an intraatrial ECG could not be obtained after the second CVC repositioning attempt, the CVC was inserted to a depth determined by the attending anesthesiologist.

Patients randomized to group NO-ECG had their CVC placed by the individual anesthesia care team assigned to the case (resident under faculty supervision), according to the following technique: After induction of general anesthesia in the OR using ASA standard monitoring, and successful puncture of either the RIJ or LIJ vein or the RS or LS vein under sterile conditions, a 20-cm triple-lumen CVC (Certofix®, B. Braun Medical) was inserted over a guidewire. The decision regarding the final insertion depth was made by the attending anesthesiologist. Before the initiation of this study, the entire anesthesiology department was educated in Grand Rounds regarding the recommended depths for CVC insertion in the literature.

Ultrasound as a method to facilitate initial vessel cannulation was not used in either group because it was not the standard of care in our facility at the time of study conduction.

A CXR was taken in all patients immediately after the conclusion of surgery in either the Postanesthesia Recovery Unit or in the Intensive Care Unit. Before CXR performance, it was assured that patients were positioned completely flat in their beds with the patient's neck in neutral position. CXRs were read by one of three attending radiologists, who were aware of the study protocol but blinded to group assignment. A standardized method was used to describe the position of the CVC tip. CVC position was judged correct if the tip was positioned either in the proximal portion of the superior vena cava (SVC), the middle portion of the SVC, or the atriocaval-junction. Position in the RA or right ventricle (RV) and all other positions were judged incorrect. In both groups, final insertion depth, number of venous puncture attempts, incidence of premature ventricular contractions (PVCs) during CVC placement, placement time, and complications (arterial puncture, hematoma, pneumothorax) were recorded.

Lucey et al. (9) reported correct placement of CVCs in 85% of cases (n = 621). We considered a 10% difference in correct CVC placement to be of clinical significance. Assuming a two-sided Type-1 error protection of 0.05 and a power of 0.80, 132 patients were needed in each group to detect a 10% difference in correct placement rate.

Demographic data are presented as mean ± sd and times as median (25th–75th percentile). Correct CVC position, incidence of PVCs, and incidence of complications (arterial puncture and hematoma development) are presented as percentages. Data were analyzed using Student's t-test for normally distributed data and ² test when indicated. P levels below 0.05 were considered statistically significant.

	RESULTS

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Between November 2003 and January 2005, 300 patients were enrolled in this trial. Ten patients were excluded from the statistical analysis for the following reasons: The radiologist's report could not be obtained in three individuals, the CVC was accidentally removed before the CXR in four patients, and the anesthesia care team abandoned placement of a CVC in two cases because of multiple unsuccessful attempts of vascular puncture in one patient and two consecutive arterial punctures in the other patient. The remaining 290 patients (147 in group ECG and 143 in group NO-ECG) were included in statistical analysis. Demographics in both groups were similar (Table 1). The RIJ was chosen as the access vessel to the SVC in 134 patients in group ECG and in 125 patients in group NO-ECG (P 1). The LIJ, the right subclavian vein (RS), and the left subclavian vein (LS) were used in 4, 5, and 4 individuals in group ECG and in 8, 5, and 5 individuals in group NO-ECG, respectively. Overall, CVCs were positioned correctly in 142 patients (96%) in group ECG and in 108 patients (76%) in group NO-ECG (P 0.001) (Fig. 2). CVCs were significantly more often positioned in the middle of the SVC in group ECG versus group NO-ECG (P 0.001, Fig. 3).

View larger version (7K): [in this window] [in a new window]   Figure 2. Correct CVC positions overall. CVC = central venous catheter.

View larger version (9K): [in this window] [in a new window]   Figure 3. Correct CVC positions. CVC = central venous catheter.

Although no CVC in group ECG was placed into the RA or the RV, 14 CVCs (10%) were positioned into the RA or the RV in group NO-ECG (P 0.001, Fig. 4). Additionally, significantly more CVCs were positioned into other locations than the SVC, the RA, or the RV in group NO-ECG (15% vs 3%, P 0.001, Fig. 4). These incorrect positions included placement of the CVC tip into the subclavian, axillary, and internal jugular veins. The final position of the CVC had to be corrected postoperatively, according to the CXR, in 20 patients (14%) in group NO-ECG and in three patients (2%) in group ECG (P 0.001), in which catheter tips were positioned in the subclavian veins. PVCs during CVC placement were observed in 48 patients in group ECG (33%) and 51 patients in group NO-ECG (36%). Although 15 patients (10%) required a second attempt of CVC positioning before an intraatrial ECG could be recorded and three attempts were necessary in one individual, intraatrial ECGs could eventually be obtained in all patients in group ECG. The average final insertion depth for CVCs placed through the RIJ was 14 ± 1.3 cm in group ECG and 15 ± 1.4 cm in group NO-ECG. The average final insertion depth for CVCs placed in either the RA or the RV using the RIJ was 16.5 cm. Insertion time was 7 min (6–8) in group ECG and 6 (6,7) min in group NO-ECG. Overall, arterial punctures occurred in 33 patients (11%) and small hematomas, requiring no further intervention, developed in eight of these patients. No CVC was placed into the arterial system and no pneumothorax was observed during CVC placements by the anesthesia care team. One patient, whose CVC was accidentally removed during transport from the OR table to his bed, developed a pneumothorax after receiving a new CVC postoperatively in the Intensive Care Unit.

View larger version (8K): [in this window] [in a new window]   Figure 4. Incorrect CVC positions. CVC = central venous catheter.

When patients who received CVCs via other vessels than the RIJ were excluded from the statistical analysis, catheter placement by using ECG guidance through the RIJ (group ECG-RIJ, n = 134) was 97% vs 78% (P 0.001) more accurate than catheter placement without this technique through the same vessel (group NO-ECG-RIJ, n = 125). In addition, significantly more individuals (14 vs 3, P 0.01) required CVC repositioning in group NO-ECG-RIJ.

	DISCUSSION

Top Abstract Introduction METHODS RESULTS DISCUSSION REFERENCES

 
In this randomized, controlled study, Certofix®–CVC placement using guidewire-ECG control resulted in a significantly higher percentage of correctly positioned CVCs without increasing placement time. Furthermore, we observed a significantly reduced need for postoperative correction maneuvers and consequently repeat CXR with this technique. In our opinion, these represent important advantages over conventionally placed CVCs, and ECG guidance should be considered during CVC insertion.

Although ECG guidance for CVC positioning was suggested as early as 1949 (10), this method is not widely used in the United States. This could be explained, at least in part, by the lack of conclusive evidence. In a prospective, controlled, randomized trial comparing ECG guidance to conventional placement, Francis et al. (6) reported a significantly higher success rate (96% vs 59%) using a continuous column of normal saline for ECG-guided CVC placement. However, part of the methods in their investigation was to insert CVCs in the control group to at least 18 cm from the RIJ and 22 cm from the LIJ. This is in contrast to the findings by McGee et al. (11), who reported the safe insertion depth to be 16.5 cm for most adults, and could explain the extremely low percentage of correctly positioned CVCs in the control group. In our investigation, anesthesia care teams were aware of McGee's results and insertion depth in the control group was left to their discretion. Consequently, average insertion depths are similar between the study and control group in our investigation (14 cm vs 15 cm, respectively). CVC placement in the RA or RV occurred only in the control group and was associated with an average insertion depth of 16.5 cm. While this appears to be in contrast to McGee et al.'s initial report, the same group later found a 16% incidence of intracardiac placement when 16-cm CVCs were placed via the RIJ (12). Based on the average insertion depth in group ECG in our investigation, we recommend inserting CVCs via the RIJ no deeper than 14 cm if ECG guidance cannot be used.

Good quality intraatrial ECG and clear display of the P-wave on the ECG monitor are essential for successful guidance and positioning of CVCs. Consequently, a limitation of ECG guidance is the fact that it cannot be reliably used in patients with atrial fibrillation or other supraventricular arrhythmias. Koscielniak-Nielsen et al. (7) reported a rate of 96% of satisfactory and good quality ECGs in a study that used both available techniques, ECG conduction via a saline column and via a guidewire. However, guidewire-conducted ECGs were of significantly better quality than those using the saline column.

A potential weakness of our study is the fact that it was left to the discretion of the individual anesthesia faculty, which approach for initial vessel cannulation was used in both groups and to what depth CVCs were inserted in group NO-ECG. Although the ECG guidance system is currently only available with the 20-cm CVC used in this trial, application of a standardized approach, limiting insertion depth to 12–14 cm, or using shorter (16 cm) catheters may have been sufficient to prevent CVC positioning into the RA or RV without the need for ECG guidance. However, the frequent incidence of CVCs placed into other locations (15%) in group NO-ECG could not have been prevented by a standardized approach or by limiting insertion depth. We speculate that the initial lack of an intraatrial ECG (10%) in group ECG allowed identifying those patients in whom the CVC was first advanced into other vessels than the SVC and that the following repositioning maneuvers allowed correction of this misplacement in most cases. We did not observe any adverse events due to the malpositioned CVCs in group NO-ECG, and recording of suspicious intraoperative central venous pressure readings was not part of the study protocol. Therefore, it is speculation as to how many cases of misplaced CVCs' inaccurate central venous pressure readings may have negatively impacted fluid management. However, the fact that these lines had to be repositioned or replaced with the need for repeat CXRs in 20 patients in group NO-ECG versus only three cases in group ECG represents a clear advantage of ECG guidance in our opinion. Although CVCs equipped with the ECG guidance system are offered by the manufacturer without additional cost when compared with a conventional CVC, the cost for a portable CXR in our institution is approximately $120, which resulted in a saving of more than $2000 in group ECG.

Another limitation of this investigation is that the majority of CVCs were placed through the RIJ. Therefore, based on the presented data, no conclusion can be drawn concerning whether ECG guidance results in more accurate positioning when either the LIJ or one of the subclavian veins is chosen as access to the SVC. Schummer et al.(13), suggested that ECG guidance does not improve the accuracy of the CVC position when CVCs are placed through the LIJ. In their investigation, one of the criteria for correctly positioned CVCs was the angle of the CVC tip in relation to the wall of the SVC. This angle may be of importance to avoid erosion to the SVC (14), but other risk factors, such as CVC size and site of insertion, have also been described (15). For obvious reasons, ECG guidance is not capable of providing information regarding this angle. Although this may be a disadvantage, there is no consensus whether the angle should be considered an important criterion when evaluating whether a CVC is positioned correctly. Furthermore, it appears that the RIJ is used more frequently than the LIJ as the access vessel for CVC placement. This is supported, not only by the choice of the anesthesia care teams in the present study, but also throughout literature (6,16). Additionally, there is evidence that CVCs placed from the left side are associated with a higher complication rate (15), and most anesthesiologists avoid these vessels whenever possible.

In another study, Schummer et al. (17) demonstrate that intraatrial ECG is not reliable for detecting whether a central catheter is positioned IV or intraarterially. According to their data, it is questionable whether the elevation in the P-wave (P-atriale) is caused by the RA or rather by the pericardial reflection. However, the authors conclude that ECG guidance is efficient in positioning CVCs into a major vessel just proximal to the heart. Although arterial punctures occurred frequently in our study, no catheters were placed into the arterial system. In addition, the literature describes effective methods to distinguish whether an arterial or venous vessel is accessed before CVC insertion (18). These techniques are recommended and should be applied whenever the operator is uncertain which type of vessel has been cannulated. Therefore, the failure of the intraatrial ECG to differentiate between arterial and venous CVC position just outside the heart appears to be only a hypothetical disadvantage.

This study was not designed to investigate different methods to prevent accidental arterial puncture during CVC placement. However, other investigators (18) have reported a high incidence of this complication as well, especially in junior operators (19). We believe that this observation supports the potential benefit of methods to visualize the chosen vessel before puncture.

In conclusion, our data indicate that ECG-guided CVC placement can improve the accuracy of CVC positioning. This may be especially important if other means of verifying correct CVC position are not immediately available. As indicated by the significantly less frequent need for CVC repositioning and repeat CXRs postoperatively, ECG-guided CVC positioning may also have the potential to save resources. Whether this method can be used to completely replace CXR verification of CVC position as advocated and practiced in some European countries, cannot be concluded based on our investigation alone. We believe that such a recommendation should be left to the discretion of a multidisciplinary panel of experts, reviewing all available data and discussing potential risks and benefits.

	Footnotes

 
Accepted for publication September 28, 2006.

Supported by B. Braun Medical, Bethlehem, Pennsylvania and by the Department of Anesthesiology, The University of Texas Medical School at Houston.

Author for correspondence and reprint requests to Ralf E. Gebhard, MD, Department of Anesthesiology, Ryder Trauma Center T-239, The University of Miami-Miller School of Medicine, 1800 NW 10th Ave., Miami, FL 33136-1018. Address e-mail to rgebhard{at}med.miami.edu.

	REFERENCES

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999