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LETTER TO THE EDITOR

Can Electrocardiogram-Controlled Central Line Placement Decrease the Need for Routine Chest Radiographs After Central Venous Cannulation?

Department of Anesthesiology; Ryder Trauma Center, University of Miami-Miller School of Medicine; Miami, FL; rgebhard{at}med.miami.edu

In Response:

Dr. Farooq raises several issues regarding (1) our investigation of the accuracy of central venous catheter (CVC) placement utilizing ECG guidance (2).

First, the cable which is used to connect the guidewire to the ECG adapter is included in each CVC kit and therefore is sterile. The cable itself is equipped with an alligator clip at one end and a plug at the other end. During ECG guidance, the alligator clip is connected to the guidewire by the operator while the other end is dropped to an assistant, e.g., the circulating nurse. The assistant then establishes the connection to the non-sterile ECG adapter by plugging the cable in. Sterility of the CVC itself, the guidewire, and the operator is maintained at all times.

Second, our investigation was not designed to evaluate whether the requirements for initial routine chest X-rays (CXR) after CVC placement using ECG guidance can be modified. Consequently, we did not make such a statement. While some earlier investigations (3,4) based on their results have suggested that routine CXRs after CVC placement under ECG control may be eliminated altogether, we only reported a significantly reduced need for repeat CXRs in those patients who had their CVCs placed with ECG guidance. Furthermore, we clearly state in our last paragraph that recommendations regarding completely replacing CXR verification of CVC placement with ECG guidance should be left to a multidisciplinary panel of experts, reviewing all available data and discussing potential benefits and risks. I agree with Dr. Farooq that such risks would include missing serious complications such as a pneumothorax.

REFERENCES

1. Farooq M. Can electrocardiogram-controlled central line placement decrease the need for routine chest x-rays after central venous cannulation? Anesth Analg 2007;104:1614.[Free Full Text]
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.[Abstract/Free Full Text]
3. Koscielniak-Nielsen ZJ, Otkjaer S, Hansen OB, Hemmingsen C. CVP catheter electrocardiography: an alternative to radiographic control after cannulation of central veins? Acta Anesthesiol Scand 1991;35: 762–6.[Web of Science][Medline]
4. Hoffmann MA, Langer JC, Pearl RH, 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.[Web of Science][Medline]

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