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LETTER TO THE EDITOR

Don’t Abandon Martin’s Intravascular Electrocardiography Technique!

Western Anesthesiology Associates, Inc; St Louis, Missouri; tjohans{at}aol.com

To the Editor:

Kerr and Applegate’s (1) work on the accurate placement of right atrial air aspiration catheters resurrects Westheimer’s (2) 1982 intravascular electrocardiography (IVECG) technique using the J-wire as the intravascular ECG lead. On the basis of transesophageal echocardiographic (TEE) evidence, they concluded that the IVECG technique places the catheter tip "fairly close" (within 1–2 cm) of the optimal right atrial-superior vena caval junction (RA-SVCJx). They chose this technique over Martin’s (3) ionic-solution filled catheter IVECG technique, because it "was shown to produce superior IVECG tracings."

Martin’s technique, unlike the J-wire technique, allows for continuous intraoperative monitoring of the catheter’s tip position. This has taught us that common maneuvers during surgeries performed with the patient in the seated position cause changes in the IVECG p/r wave height ratio, suggestive of tip migration. For instance, catheter tip migration of 3–4 cm has been reported (4,5) with arm adduction, neck flexion, and diaphragmatic movement. Using data from previous work (6), the IVECG p/r wave ratios measured from the IVECG tracings in Figure 3 of Kerr and Applegate’s study (1) suggest movement of 1–2 cm toward the right atrium with respirations alone. Clinical experience further confirms that even though the tip may be placed in the ideal position, air is often not aspirated until the catheter is moved 1–3 cm around the RA-SVCJx, suggesting that the "ideal" position is not always ideal.

Therefore, no matter what technique is used to place the aspirating catheter tip in the optimal position, the tip moves. It is for this reason that Arrow included in its brachial central venous catheter kit a Seldinger introducer with sterile sheath, so that the catheter could be repositioned and an IVECG adaptor to aid in catheter insertion and to monitor tip location (Dr. Johans is the inventor of the Arrow-Johans IVECG adaptor). The 1–2 cm differences between IVECG and TEE as found by Kerr and Applegate is of little clinical consequence. Although it is arguable where the p wave is conducted through the multiorificed aspirating portion of the catheter (6–9), the Martin IVECG technique should not be abandoned.

REFERENCES

1. Kerr R, Applegate R. Accurate placement of the right atrial air aspiration catheter: a descriptive study and prospective trial of intravascular electrocardiography. Anesth Analg 2006;103:435–8.[Abstract/Free Full Text]
2. Westheimer D. Right atrial catheter placement: use of a wire guide as the intravascular ECG lead. Anesthesiology 1982;56:478–80.[Web of Science][Medline]
3. Martin JT. Neuroanesthetic adjuncts for patients in the sitting position: intravascular electrocardiography. Anesth Analg 1970;49:793–805.[Free Full Text]
4. Lee DS, Kuhn J, Shaffer MJ, Weintraub HD. Migration of tips of central venous catheters in seated patients. Anesth Analg 1984;63:949–52.[Free Full Text]
5. Kasten GW, Owens E, Kennedy D. Ventricular tachycardia resulting form central venous catheter tip migration due to arm position changes: report of two cases. Anesthesiology 1986;62:185–7.
6. Johans TG. Multiorificed catheter placement with an intravascular electrocardiographic technique. Anesthesiology 1986;64:411–13.[Web of Science][Medline]
7. Artu AA, Colley PS. The site of origin of the intravascular electrocardiogram recorded from multiorificed intravascular catheters. Anesthesiology 1988;69:44–8.[Web of Science][Medline]
8. Johans TG. Arrow brachial CVP air aspirating catheter placement with the IVECG technique. Anesthesiology 1988;69:140–1.[Web of Science][Medline]
9. Warner DO, Cucchiara RF. Position of proximal orifice determines electrocardiogram recorded from multiorificed catheter. Anesthesiology 1986;65:235–6.[Web of Science][Medline]

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