Optimierte Positionierung zentraler Venenkatheter durch eine modifizierte Anwendung der intravasalen Elektrokardiographie

BACKGROUND: Intraatrial electrocardiography (ECG) is a well-established method for central-venous catheter (CVC) placement and an intraatrial position is assumed, when a significantly increased P-wave is registered. However, an increase in P-wave amplitude also occurs in other positions. Therefore we evaluated CVC tip positioning by means of transesophageal echocardiography (TEE) at a maximum P-wave amplitude. PATIENTS AND METHODS: In this prospective randomized study the right or left internal jugular vein was cannulated with 100 patients in each group and catheter tip positioning was guided by means of ECG. The catheter was fixed at the position of maximum P-wave amplitude and the insertion depth was registered. The relationship of the CVC tip position to the superior edge of the crista terminalis was demonstrated with the help of TEE. RESULTS: In all patients the catheter tip was found +/- 0.5 cm from the superior edge of the crista terminalis at the transition from the superior vena cava to the right atrium. On x-ray control, all catheters ran along the length of the vessel wall of the superior vena cava. CONCLUSIONS: A maximum P-wave is derived even at the entrance to the right atrium. This explains why ECG-guided CVC placement -- based on the largest P-wave amplitude -- consistently resulted in correct positioning of the CVC tip at the transition from the superior vena cava to the right atrium.     

ECG-controlled placement of central venous catheters in patients with atrial fibrillation

Some workers state that sinus rhythm is essential for electrocardiographic placement of central venous catheters. We performed a prospective study to compare location control by ECG and by chest X-ray in 40 patients with absolute arrhythmia and atrial fibrillation. The criteria accepted as allowing the assumption of an intracardiac position of the catheter tip were: (1) Abrupt appearance of high-voltage P-waves when the right atrium (RA) was entered and their brisk disappearance when pulling the catheter back into the vena cava superior (VCS) and/or (2) a change in configuration and voltage of the QRS complex on withdrawal of the catheter from the right ventricle (RV). After establishment of an intracardiac position, the catheter was withdrawn until the ECG changed to show a trace identical to that seen before it had entered the heart. Then, in this study, the correct central venous position was confirmed by chest X-ray. The intravascular ECG revealed a correct placement of the catheter tip in the VCS in all patients but one. In this patient who had severe dysrhythmia, an intracardiac ECG could not be obtained, although the chest X-ray showed a correct position of the catheter in the VCS. While false-negative results (where an intracardiac catheter position cannot be documented although the catheter is in a central venous position) occasionally do occur, false-positive results (with ECG suggesting an intracardiac location read, though the catheter tip is actually in a peripheral vein) are virtually impossible.(ABSTRACT TRUNCATED AT 250 WORDS)     

The intracavitary ECG method for positioning the tip of central venous catheters: results of an Italian multicenter study

Purpose: The aim of this multicenter study was to assess the feasibility, safety, and accuracy of the intracavitary ECG method for real-time positioning of the tip of different types of central venous catheters. Methods: A total of 1444 catheter insertions in adult patients were studied in eight Italian centers (539 ports, 245 PICCs, 325 tunneled CVCs, 335 non-tunneled CVCs). Patients with no visible P wave at the standard baseline ECG were excluded. Depending on the type of catheter and its purpose, the target was to position the tip either (a) at the cavo-atrial junction, or (b) in the lower third of the superior vena cava, or (c) in the upper part of the atrium. The final position was verified by a post-procedural chest x-ray. Results: The method was feasible in 99.3% of all cases. There were no complications potentially related to the method itself. At the final x-ray control, 83% of all tips were positioned exactly at the target; 12.4% were positioned within 1-2 cm from the target, but still in a correct central position; only 3.8% were malpositioned. The mismatch between intra-procedural ECG method and post-procedural x-ray was significantly lower when the x-ray was taken in supine position.Conclusions: Our multicenter study confirms that the intracavitary ECG method for real time verification of tip position is accurate, safe, feasible in all adult patients and applicable to any type of short-term or long-term central venous access device.     

Accurate central venous port-A catheter placement: intravenous electrocardiography and surface landmark techniques compared by using transesophageal echocardiography

Using transesophageal echocardiography (TEE) to locate the tip of central venous catheters inserted via the right subclavian vein, we compared IV electrocardiography (IV-ECG)-guided catheter tip placement with the conventional surface landmark technique. Sixty patients were randomly assigned into two groups. In Group E, the IV-ECG signal was conducted along an NaHCO(3)-filled catheter to facilitate catheter placement. In Group S, surface landmarks on the chest wall were used to determine the appropriate catheter length. The goal was to visualize the catheter tip with TEE at the superior edge of the crista terminalis, which is the junction of the superior vena cava (SVC) and right atrium (RA). The catheter tip position was considered to be satisfactory, as the tip was within 1.0 cm of the upper crista terminalis edge. All 30 Group E patients had satisfactory catheter tip placement when the ECG P wave was at its maximum. In contrast, 16 of the 30 patients in Group S had satisfactory tip positions (P < 0.001). All catheters were repositioned under TEE guidance to adjust the tip to the SVC-RA junction. After the catheter tips were confirmed to be located at the SVC-RA junction, the catheter tips were still visualized in the mid portion of RA in 12 of 60 patients on supine chest radiographs. We concluded that IV-ECG guidance to position a catheter resulted in satisfactory catheter tip placement that is in accordance with TEE views. Catheter placement at the SVC-RA junction with the surface landmark technique was unreliable. IMPLICATIONS: Intravenous electrocardiography guidance to position catheters obtains a satisfactory catheter tip placement that is in accordance with transesophageal echocardiography views. The surface landmark technique does not result in reliable placement at the superior vena cava-right atrium junction.     

Central venous catheter placement: comparison of the intravascular guidewire and the fluid column electrocardiograms

BACKGROUND AND OBJECTIVE: Placement of central venous catheters in patients is associated with several risks including endocardial lesions and dysrhythmias. Correct positioning of central venous catheters in the superior vena cava is essential for immediate use. The objective of a first study was to evaluate the signal quality of an intravascular electrocardiogram (ECG) during position control using a guidewire compared with the customary fluid column-based ECG system, and to assess its efficacy of correct placement of the central venous catheter. A second study tested if dysrhythmias can be avoided by intravascular ECG monitoring during catheter and guidewire advancement. METHODS: The jugular or subclavian vein of 40 patients undergoing heart surgery or who were being treated in the intensive care unit was cannulated. Intravascular ECGs were recorded during position control, and guidewire and water column lead were compared in the same patient with regard to the quality of the ECG reading and P-wave enhancement. In another 40 patients, the guidewire was inserted only 10 cm and the central venous catheter advanced under guidewire ECG control. Correct position of all the central venous catheters was confirmed by chest radiography. RESULTS: All central venous catheters were correctly positioned in the superior vena cava. For the same catheter position, the P-wave was significantly larger in the guidewire ECG than in the fluid column system. No changes in the quality of the ECG were detected when the guidewire was advanced or withdrawn by 1 cm relative to the catheter tip. Cardiac dysrhythmias were not seen during ECG-monitored advancement of the guidewire. CONCLUSIONS: ECG quality using a guidewire lead is superior to the water column-based system. Furthermore, it is independent from the exact position of the guidewire as related to the tip of the catheter. Using intravascular guidewire ECG during advancement can prevent induction of dysrhythmias.     

Intra-atrial ECG is not a reliable method for positioning left internal jugular vein catheters

Background. ECG guidance is widely used for positioning centralvenous catheters (CVCs) in the superior vena cava. We noticeda higher incidence of a more perpendicular angle between thecatheter tip and the vessel wall after left-sided ECG-guidedcatheter positioning. To investigate the value of left-sidedECG guidance, we performed this prospective study. Methods. Of 114 patients, 53 were randomized to right and 61to left internal jugular vein catheterization using a triplelumen catheter. Three methods to ascertain catheter tip positionwere sequentially applied in each patient, and the insertiondepths (ID) obtained using each of the three methods were recorded:(i) ECG guidance with a Seldinger guide wire (ID-A); (ii) ECGguidance with saline 10% used as an exploring electrode (ID-B);(iii) from position ID-B, the catheter was rotated and advanceduntil all three lumina could be aspirated easily. The catheterwas fixed in that position (ID-C). To determine final cathetertip position, intraoperative transoesophageal echocardiography(TOE) and a postoperative chest X-ray (CXR) were performed. Results. The depth of insertion of a catheter using the threemethods varied significantly in left-sided (P<0.001), butnot in right-sided catheters. Forty-eight of 57 (84%) left-sidedCVCs, correctly positioned according to ECG guidance, had tobe advanced further to achieve free aspiration through all threelumina. By this stage, five of the catheter tips had been positionedin the upper right atrium as demonstrated by TOE. There were13 malpositions (23%) after left-sided insertion. In nine cathetermalpositions, undetected by ECG guidance, the angle betweenthe catheter tip and the lateral wall of the superior vena cavaexceeded 40° on CXR. Conclusions. Intra-atrial ECG does not detect the junction betweenthe superior vena cava and right atrium. It is not a reliablemethod for confirming position of left-sided CVCs. Post-proceduralCXRs are recommended for left-sided, but not right-sided CVCs. Br J Anaesth 2003; 91: 481–6     

Use of electrocardiogram to position right atrial catheters during surgery.

OBJECTIVE: This study evaluated the accuracy of placing right atrial catheters using an electrocardiographic (ECG) technique. SUMMARY BACKGROUND DATA: Placement of right atrial catheters for vascular access is a common operative procedure. Accurate placement is essential for proper function. Previous placement techniques have used fluoroscopy, which is both time consuming and hazardous. METHODS: The accuracy of placement of 1236 right atrial catheters using an ECG technique was compared to placement of 586 catheters using fluoroscopy between March 1991 and November 1995. In the ECG technique, the catheter was flushed with sodium bicarbonate. A sterile left-leg ECG lead was attached to the catheter with the other ECG leads applied normally. On advancing the catheter through the superior vena cava, the P-wave amplitude (lead II) increased in negative deflection until greater than the QRS complex. Passing the sinoatrial node, the P-wave developed an initial positive then negative deflection. The catheter was positioned so the P-wave was biphasic, representing a position midway between the sinoatrial and atrioventricular nodes. For the fluoroscopic technique, catheters were positioned under direct observation just within the atrium estimated from cardiac contour. Use of contrast was optional if atrial anatomy was unclear. RESULTS: Postoperative portable chest x-rays showed the ECG method to position the catheter tip within the right atrium just as accurately (average, 1.9 +/- 1.3 cm) as with the use of fluoroscopy (average, 1.1 +/- 1.6 cm). The ECG method eliminated an average of 20 seconds of radiation exposure, an average of 3.0 minutes operating room time (p < 0.04), avoided all risks of contrast dye, and saved $279.10 per case. CONCLUSIONS: The ECG method is a satisfactory alternative to that of fluoroscopy for placement of long-term central venous catheters into the right atrium.     

Internal jugular vein occlusion test for rapid diagnosis of misplaced subclavian vein catheter into the internal jugular vein.

BACKGROUND: During subclavian vein catheterization, the most common misplacement of the catheter is cephalad, into the ipsilateral internal jugular vein (IJV). This can be detected by chest radiography. However, after any repositioning of the catheter, subsequent chest radiography is required. In an effort to simplify the detection of a misplaced subclavian vein catheter, the authors assessed a previously published detection method. METHODS: One hundred adult patients scheduled for subclavian vein cannulation were included in this study. After placement of subclavian vein catheter, chest radiography was performed. While the x-ray film was being processed, the authors performed an IJV occlusion test by applying external pressure on the IJV for approximately 10 s in the supraclavicular area and observed the change in central venous pressure and its waveform pattern. The observations thus obtained were compared with the position of catheter in chest radiographs, and the sensitivity and specificity of this method were evaluated using a 2 x 2 table. RESULTS: In 96 patients, subclavian vein cannulation was successfully performed. In four patients, cannulation was unsuccessful; therefore, these patients were excluded from the study. There were six misplacements of venous catheters as detected by radiography. In five (5.2%) patients, the catheter tip was located in the ipsilateral IJV, and in one (1.02%), the catheter tip was located in the contralateral subclavian vein. In the patients who had a misplaced catheter into the IJV, IJV occlusion test results were positive, with an increase of 3-5 mmHg in central venous pressure, whereas the test results were negative in patients who had normally placed catheters or misplacement of a catheter other than in the IJV. There were no false-positive or false-negative test results. CONCLUSION: The IJV occlusion test successfully detects the misplacement of subclavian vein catheter into the IJV. However, it does not detect any other misplacement. The test may allow avoidance of repeated exposure to x-rays after catheter insertion and repositioning.     

The right supraclavicular fossa ultrasound view for correct catheter tip positioning in right subclavian vein catheterisation: a prospective observational study

Central venous catheter misplacement is common (approximately 7%) after right subclavian vein catheterisation. To avoid it, ultrasound-guided tip navigation may be used during the catheterisation procedure to help direct the guidewire towards the lower superior vena cava. We aimed to determine the number of central venous catheter misplacements when using the right supraclavicular fossa ultrasound view to aid guidewire positioning in right infraclavicular subclavian vein catheterisation. We hypothesised that the incidence of catheter misplacements could be reduced to 1% when using this ultrasound technique. One -hundred and three adult patients were prospectively included. After vein puncture and guidewire insertion, we used the right supraclavicular fossa ultrasound view to confirm correct guidewire J-tip position in the lower superior vena cava and corrected the position of misplaced guidewires using real-time ultrasound guidance. Successful catheterisation of the right subclavian vein was achieved in all patients. The guidewire J-tip was initially misplaced in 15 patients, either in the ipsilateral internal jugular vein (n = 8) or in the left brachiocephalic vein (n = 7). In 12 patients it was possible to adjust the guidewire J-tip to a correct position in the lower superior vena cava. All ultrasound-determined final guidewire J-tip positions were consistent with the central venous catheter tip positions on chest X-ray. Three out of 103 catheters were misplaced, corresponding to an incidence (95%CI) of 2.9 (0.6–8.3) %. Although the hypothesis could not be confirmed, this study demonstrated the usefulness of the right supraclavicular fossa ultrasound view for real-time confirmation and correction of the guidewire position in right infraclavicular subclavian vein catheterisation.     

Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access?

Purpose: The aim of this study was to determine in a pediatric population whether a routine chest x-ray after central venous access is necessary when the central venous catheter is placed with intraoperative fluoroscopy.Methods: This was a retrospective review of the charts of all patients at Children’s Hospital in Denver, Colorado who underwent subclavian or internal jugular central venous catheter placement from January 1, 1998 through December 31, 2001. Age, sex, primary reason for access, access site, number of venipuncture attempts, type of catheter, intraoperative fluoroscopy results, chest x-ray results, location of the tip of the catheter, and complications were analyzed.Results: There were 1,039 central venous catheters placed in 824 patients, 92.6% in the subclavian vein and 7.4% in the internal jugular vein. There were 604 (58.1%) children who had both fluoroscopy and a postprocedure chest x-ray, there were 308 (29.6%) who had only fluoroscopy, there were 117 (11.3%) who had only a postprocedure chest x-ray, and there were 10 (1.0%) who had neither fluoroscopy nor chest x-ray. On completion of the procedure, there were 12 (1.1%) children with misplaced central venous catheters, only 1 (0.1%) when intraoperative fluoroscopy was used. There were 17 (1.6%) complications; 9 (0.9%) were pulmonary (pneumothorax, hemothorax, or an effusion). All children with pulmonary complications experienced clinical signs and symptoms suggestive of the complication after their central venous catheter insertion but before their postprocedure chest x-ray.Conclusions: The number of complications encountered in children who had central venous access of the subclavian vein or internal jugular central vein with intraoperative fluoroscopy was infrequent, the number of misplaced catheters was minimized with intraoperative fluoroscopy, and all children with pulmonary complications showed clinical signs suggestive of pulmonary complications before postoperative chest x-ray. Therefore, children who have had central venous access of the subclavian and internal jugular vein with intraoperative fluoroscopy do not appear to require a routine chest x-ray after catheter placement unless clinical suspicion of a complication exists.     

Catheter malplacement during central venous cannulation through arm veins in pediatric patients

For successful catheter placement, central venous cannulation (CVC) through internal jugular vein and subclavian vein has been recommended in both adult and pediatric patients. But it carries a risk of serious complications, such as pneumothorax, carotid, or subclavian artery puncture, which can be life-threatening, particularly in critically ill children. So a prospective study was carried out to determine the success rate of correct catheter tip placement during CVC through antecubital veins in pediatric neurosurgical patients. A total of 200 pediatric patients (age 1-15 years) of either sex were studied. Basilic or cephalic veins of either arm were selected. All the patients were cannulated in the operation room under general anesthesia. Single lumen, proper size catheters (with stillete) were used for cannulation. The catheter was inserted in supine position with the arm abducted at right angle to the body and neck turned ipsilaterally. The length of insertion was determined from cubital fossa to the right second intercostal space. The exact position of the tip of the catheter was confirmed radiologically in ICU. Correct catheter tip placement was achieved in 98 (49%) patients. Multivariate logistic regression analysis of data shows that there was no statistically significant difference among correct and incorrect catheter tip placement in relation to factors including sex, side of cannulation (left or right), and type of vein (basilic or cephalic). The analysis of correct catheter tip placement in relation to age showed that the highest success rate was achieved in children of age group 6 to 10 years (60.2%) followed by 30.6% in the 11 to 15 year group. The lowest success rate of tip placement of only 9.2% was observed in younger children of age 1 to 5 years, which is statistically significant (P = 0.001). Of 102 incorrect placements reported, 37% were in 1 to 5 year age group versus 9.2% correct tip placements. The most common unsatisfactory placements were either in the ipsilateral internal jugular vein (N = 38, 37.2%) or in the ipsilateral subclavian vein (N = 27, 26.4%). In 10 patients the catheter crossed over to the opposite subclavian vein, in 16 patients the catheter tips were found in the axillary vein, and in 10 patients each the catheter tip was observed in right atrium and right ventricle. No major complication during and following CVC was observed. To conclude, CVC using single orifice catheter through arm veins in pediatric patients is easy to perform, but the proper catheter tip placement is highly unreliable, particularly in younger children 1 to 5 years of age.     

Secondary migration of a central venous catheter. A case report

A case of central venous catheter (CVC) secondary migration in a patient with Hodgkin's lymphoma is reported. The catheter was inserted in the right internal jugular vein with anterior approach. The correct position of the catheter tip in the superior vena cava was confirmed by X-ray. Secondary migration to the right subclavian vein, without displacement at the point of insertion, was reported 8 days later by a chest X-ray performed for worsening of the respiratory condition. CVC was removed and reinserted with the same procedure. The correct position of the catheter tip was confirmed by thoracic radiography till 10 days later. Epidemiological data present in the literature and secondary migration predisposing factors are reported.     

Internal Jugular Vein Occlusion Test for Rapid Diagnosis of Misplaced Subclavian Vein Catheter into the Internal Jugular Vein

Background : During subclavian vein catheterization, the most common misplacement of the catheter is cephalad, into the ipsilateral internal jugular vein (IJV). This can be detected by chest radiography. However, after any repositioning of the catheter, subsequent chest radiography is required. In an effort to simplify the detection of a misplaced subclavian vein catheter, the authors assessed a previously published detection method.

Methods : One hundred adult patients scheduled for subclavian vein cannulation were included in this study. After placement of subclavian vein catheter, chest radiography was performed. While the x-ray film was being processed, the authors performed an IJV occlusion test by applying external pressure on the IJV for approximately 10 s in the supraclavicular area and observed the change in central venous pressure and its waveform pattern. The observations thus obtained were compared with the position of catheter in chest radiographs, and the sensitivity and specificity of this method were evaluated using a 2 x 2 table.

Results : In 96 patients, subclavian vein cannulation was successfully performed. In four patients, cannulation was unsuccessful; therefore, these patients were excluded from the study. There were six misplacements of venous catheters as detected by radiography. In five (5.2%) patients, the catheter tip was located in the ipsilateral IJV, and in one (1.02%), the catheter tip was located in the contralateral subclavian vein. In the patients who had a misplaced catheter into the IJV, IJV occlusion test results were positive, with an increase of 3-5 mmHg in central venous pressure, whereas the test results were negative in patients who had normally placed catheters or misplacement of a catheter other than in the IJV. There were no false-positive or false-negative test results.     

Optimal placement of CVP catheter in paediatric cardiac patients

For correct monitoring of central venous pressure (CVP) the tip of the CVP catheter should be placed in the superior vena cava (SVC). Since there is no useful guide for the optimal depth of insertion of CVP catheter in children undergoing cardio-vascular surgery, we examined the relationship between the depth of the CVP catheter and easily measured body-size variables, such as age, weight and height, and then created a guide for the optimal placement of the paediatric population. The CVP catheterization was performed through the right internal jugular vein by the high approach. The position of the catheter tip was determined by the wave form of the CVP tracing and the depth of insertion was assessed by the external marking on the catheter at the cannulation site. The position of the catheter tip, determined by postoperative AP chest x-ray, was identified by the level of thoracic vertebra (T) corresponding to the position of the catheter tip. We analyzed the relationship between the depth of the catheter and patient’s age, weight and height by linear regression analysis. The position of tip was normally distributed from T₁ to T₇ and the tips were centralized at levels of T₃ T₄ and T₅ which anatomically correspond to SVC. The r values between the catheter depth and the three factors at each level were comparable, although the correlation between the depth of catheter and height was best. A simple guide for placement of the catheter tip at T₃, T₄ and T₅ levels as a function of patient’s height was created. Since height is a primary information variable which is available even in emergency cases, we believe that the guide is acceptable and valuable to anaesthetists.     

Control of the placement of a central venous catheter using Doppler ultrasound

Precise placement of central venous catheters is necessary to prevent complications and assure proper functioning. Chest X-ray is the current standard method of locating the catheter tip. This is usually not feasible in the operating room setting, particularly after the induction of anesthesia. Intravascular ECG registration using the catheter as a lead and identification of intra-atrial P-waves has been suggested as an alternative. In the present study we evaluated the use of Doppler sonography as a noninvasive method of locating the catheter tip and detecting faulty placement. Two hundred patients scheduled for insertion of a central venous catheter took part in this study. The catheters were inserted via standard routes (internal or external jugular vein, basilar or cephalic vein). A Doppler sonographic device with a 2 mHz probe was used (Parke Electronics 915L). The probe was applied to the right sternal border and affixed at the position where the characteristic venous flow sound was most distinct. The signals were displayed visually, subjected to spectral analysis, and also recorded for later evaluation. A rapid injection of 2-5 ml isotonic saline causes turbulences which can readily be heard and recognized without special training. The position of every catheter was later confirmed by radiography, and in 159 patients the intraatrial ECG method was subjected to direct comparison with the sonographic method. The turbulences due to the injected fluid were found to cause an increased amplitude at frequencies above 350 Hz. If the catheter tip was positioned correctly there was no discernable time lag between the start of the injection and perception of turbulences.(ABSTRACT TRUNCATED AT 250 WORDS)     

Depth of a central venous catheter tip: length of insertion guideline for pediatric patients

BACKGROUND: In pediatric patients, several studies have been undertaken to establish central venous catheter (CVC) tip optimal depth. Assessments of catheter tip position using chest radiographs may be misleading, whereas transesophageal echocardiography (TEE) has been shown to accurately monitor catheter tip placement at the superior vena cava-right atrial (SVC-RA) junction. The aim of this study was to issue a guideline for ideal catheter insertion depth, from the right internal jugular vein (IJV) using TEE to confirm the position of the catheter tip at the SVC-RA junction. METHODS: Over a 6-month period, we studied 60 right internal jugular vein catheterizations in infants and children undergoing surgery for congenital heart disease. Positions of CVC tips were confirmed to be at the SVC-RA junction by TEE. Distance from the skin puncture site to the SVC-RA junction, height, weight, and age were recorded. RESULTS: Distances measured were found to be highly correlated with patient height. The following guideline allows the CVC tip to be positioned above the RA in 97.5% of patients with an accuracy of 95%: optimal depth of insertion (cm) = 1.7 + (0.07 x height) in patients whose height is between 40 and 140 cm. CONCLUSION: The model proposed for the insertion of the CVC tip in pediatric patients could be used to prevent inadvertent catheter tip placement into the atrium.     

Accurate placement of central venous catheter--ECG-guided method vs patient height method

Correct positioning of central venous catheters (CVC) is important. We compared the positioning of CVCs by ECG-monitoring via the guidewire and that by method using patient height. "Certofix" triple-lumen CVCs were inserted in 60 cardiac surgical patients via right internal jugular puncture. Of these, 30 were placed with ECG guidance via the guidewire (Group ECG), and 30 with reference to patient height (modified Pere's method) (Group H). The distance from CVC tip to the superior vena cava/right atrial junction (C-J distance) was measured by postoperative chest X-ray. There was no difference in height between the two groups. The depth of insertion of CVC and C-J distance (cm) were 15.1 +/- 0.3 and 3.6 +/- 2.0 in group H and 14.3 +/- 1.5 and 4.9 +/- 1.2 in group ECG, respectively, with no statistically significant differences between the two groups. In one case of group H, the catheter tip was placed in the right atrium. In group ECG, there was a significant correlation between height and the depth of insertion of CVC. In conclusion, ECG guidance via the guidewire is useful for avoiding CVC displacement.     

Usefulness of Groshong catheters for central venous access via the external jugular vein.

This study was designed to evaluate the usefulness of central venous access via the external jugular vein (EJV) employing Groshong catheters, and to compare the complications with those of conventional internal jugular venous catheterization. Central venous access was achieved by insertion of a single-lumen 4.0 Fr Groshong catheter via the EJV or internal jugular vein (IJV) with a single puncture. Complications associated with insertion and central venous catheter-related bloodstream infection (CVC-RBSI) were evaluated from the database. Two hundred and twenty-five patients received 400 catheters for a total period of 5377 catheter-days. Ninety-six patients underwent 201 internal jugular venous catheter (IJV-C) procedures for 2381 catheter-days, and 129 patients underwent 199 external jugular venous catheter (EJV-C) procedures for 2996 catheter-days. Use of EJV-C was associated with a longer catheter insertion length (p < .01) and period (p < .01), a larger number of operations (p < .01), and more frequent use of total parenteral nutrition (TPN) (p < .01) and less frequent use of chemotherapy (p < .01) than for IJV-C. However, there were no significant differences (NS) in complications associated with insertion and CVC-RBSI between IJV-C and EJV-C. There were no significant differences such complications as malposition, oozing or hematoma formation of insertion site, arterial bleeding, nerve damage, pneumothorax, and phlebitis between IJV-C and EJV-C. Moreover, EJV-C was not associated with morbidities such as pneumothorax, arterial bleeding, and nerve damage. Thus the study concluded that EJV-C using Groshong catheters has no severe complications and has the same rates of CVC-RBSI as conventional IJV-C for central venous access.     

Defining peripherally inserted central catheter tip position and an evaluation of insertions in one unit

Peripherally inserted central catheters are increasingly used to provide access to the central venous circulation. They are commonly positioned ‘blind’ using a variety of anthropometric techniques and operator experience to direct insertion length. Malposition rates are poorly defined because of differing insertion techniques, difficulties defining anatomical tip position on chest radiographs, controversy over what constitutes an adequate catheter position and possible differences between patient groups. We have developed a reproducible method to define catheter positions on chest radiograph and have applied this in a retrospective analysis of 256 ICU and 243 non‐ICU catheter insertions over a 6‐month period. Two different definitions were used for adequate position. ‘Blind’ positioning of peripherally inserted central catheters was associated with a definition‐dependent malposition rate of 42–76%. Malposition rates were significantly higher in ICU patients. Emerging technologies may assist in reducing these high rates.