Correct positioning of the venous port-a-cath catheter: comparison of intravascular electrocardiography signal from guidewire and sodium bicarbonate flushed catheter

A prospective study comparing the efficacy of wire-conducted intravascular ECG (IVECG) signal and signal from the port with a sodium bicarbonate (NaHCO3) flushed catheter to correctly place a catheter tip was carried out in 100 patients. The correct position of the catheter tip was confirmed as follows: with technique G, the IVECG signal was conducted from a guide wire to identify the tip position. With technique P, the IVECG signal was conducted from the port with a NaHCO3 (0.8 mmol/ml) flushed catheter to ascertain the tip position. Each patient received both technique G and technique P in a randomized sequence. The quality of IV-ECG signals, which included baseline drift, P wave pattern and QRS wave pattern, were assessed for ten seconds. Satisfactory quality of these IVECG signals was observed in all of the patients with technique P and 90 of the 100 patients with technique G, and this difference was significant (P=0.001). There was no obvious difference between the techniques in catheter tip placement time or the measured optimal catheter length. The incidence of atrial premature contractions was higher with technique G than with technique P (13% vs 2%; P=0.003). Therefore, technique P is a practical alternative for correctly placing the catheter tip of a Port-A-Cath.     

Central venous catheter placement using the ECG-guided cavafix-certodyn SD catheter

Study Objective: To evaluate the clinical use of a new ECG-guided central venous catheter with regard to positioning in the superior vena caves (SVC).

Design: Prospective study.

Setting: Operating rooms of a university hospital and a general hospital.

Patients: 89 elective and emergency adult surgical patients requiring central venous catheterization perioperatively.

Interventions: We performed ECG-guided placement of the central venous catheter from several insertion sites. After we observed an intra-atrial p-wave (p-atriale), the catheter was withdrawn 3 cm back into the SVC. Postoperative anterior-posterior chest radiographs were performed for verification of tip localization.

Measurements and Main Results: In all 81 patients who exhibited a p-atriale that reverted to a normal-size p-wave (p-SVC) after withdrawal of the catheter 3 cm, the tip was located in the SVC or the SVC-right atrial junction on the chest radiograph. In 7 of the 8 cases without a p-atriale, the catheter tip was shown to be located at an incorrect position on the chest radiograph. The size of the p-atriale was always at least twice that of the p-SVC.

Conclusions: Use of this wire-conducted intravascularECG signal is a reliable tool for positioning the central venous catheter via various insertion sites. The technique proved to be an inexpensive, easy, and clear method. When a p-atriale is seen, uncomplicated insertions do not require radiologic guidance to control catheter tip position.     

Central venous catheter placement in patients with disorders of hemostasis

BACKGROUND: Patients requiring central venous access frequently have disorders of hemostasis. The aim of this study was to identify factors predictive of bleeding complications after central venous catheterization in this group of patients. METHODS: A retrospective analysis of all central venous catheters placed over a 2-year period (1997 to 1999) at our institution were performed. The age, sex, clinical diagnosis, most recent platelet count, prothrombin international normalized ratio (INR), activated partial thromboplastin time (aPTT), catheter type, the number of passes to complete the procedure, and bleeding complications were retrieved from the medical records. RESULTS: In a 2-year period, 2,010 central venous catheters were placed in 1,825 patients. Three hundred and thirty placements were in patients with disorders of hemostasis. In 88 of the 330 patients, the underlying coagulopathy was not corrected before catheter placement. In these patients, there were 3 bleeding complications requiring placement of a purse string suture at the catheter entry site. In the remaining 242 patients, there was 1 bleeding complication. Of the variables analyzed, only a low platelet count (<50 x 10(9)/L) was significantly associated with bleeding complications. CONCLUSION: Central venous access procedures can be safely performed in patients with underlying disorders of hemostasis. Even patients with low platelet counts have infrequent (3 of 88) bleeding complications, and these problems are easily managed.     

Central venous catheter placement in children: evaluation of electrocardiography using J-wire

Misplacement of a central venous catheter may lead to myocardial perforation and dysrhythmia. Atrial electrocardiography (ECG) through a saline column is an effective but complex method to determine the accurate location of catheters. We evaluated a simplified variant of this technique using the guidewire as an internal electrode in 23 children (5-16 years old) undergoing spinal surgery. Catheters were placed using a Seldinger technique after jugular or subclavian venous puncture. Each time the operator recognized the atrial signal, the catheter was found to be correctly placed on the chest radiograph (20/23). In three patients, the atrial signal was not obtained. A technical error was responsible in one case whereas the two others were related to aberrant migrations of the catheter either into a subclavian vein or into the pleura. In this latter case, the complication was unrecognized on the first radiograph despite malposition having been predicted by atrial ECG. We conclude that a method using atrial ECG guidance is sensitive and specific, and may be an alternative to the classical chest radiograph to detect accurate placement of central venous catheters in children.     

Central venous catheter placement in hemodialysis: evaluation of electrocardiography using a guide-wire

Internal jugular vein cannulation has become a routine and clinically important aspect of medical care in hemodialysis patients. Mismanagement in the location of a central venous catheter may occur in up to 20% of cases. The aim of the study was to evaluate the utility of endocavitary electrocardiography in right internal jugu-lar vein placement of central venous catheters. We examined 327 central venous catheterizations performed in two Dialysis Units; all catheters were positioned using intra-atrial ECG monitoring by guide-wire and after, by catheter filled with NaCl solution. EC-ECG via guide-wire was successful on 321 occasions (98.1%). Correct placement of the catheter was confirmed by EC-ECG via catheter in each case, and by plain chest-X-ray only in the first hundred cases. In 314 patients (98.1%), insertion of the catheter was successful at the first attempt. In 6 catheterizations, no atrial trace was obtained due to atrial fibrillation in 4 cases, and in 2 cases technical error and guide-wire looping into a right jugular vein. Complications as a direct result of guide-wire or catheter placement were not observed. In our opinion this method can be used safely and makes radiological control usually unnecessary. (The Journal of Vascular Access 2001; 2: 45-50).     

Detection of intravascular epidural catheter placement: a review

Intravascular placement of an epidural catheter is recognised as a potentially fatal complication of epidural anaesthesia and analgesia. Up to 10% of epidural catheters may be inserted into an epidural vessel, the majority of which will be recognised; however, a proportion (1% of all epidural catheters inserted) may not be identified as lying intravascularly. Opinions differ on the optimal method for identifying intravascular catheters and no perfect method exists. Some debate the need for a test of correct location, as a lack of specificity may mean that a proportion of correctly located catheters are withdrawn and resited. This review outlines the incidence and risk factors associated with intravascular placement and aims to evaluate the detection methods that have been described, in an attempt to answer the question: "What is the optimal way of detecting intravascular placement of an epidural catheter?"     

Detection of subarachnoid and intravascular epidural catheter placement

PURPOSE: To report the detection of subarachnoid and intravascular catheter placement using nerve stimulation through an epidural catheter. CLINICAL FEATURES: Electrical stimulation (1-10 mA) was applied through the catheter. A positive motor response (truncal or limb movement) indicated that the catheter was in the epidural space. Absence of a motor response indicated that it was not. A low milliamperage (<1 mA) with bilateral response indicated subarachnoid placement. Intravascular catheter placement was indicated by a positive response to the test, which remains at or returns to the baseline levels (i.e. prior to any local anesthetic injection), despite the administration of local anesthetics. In the first patient, the test confirmed subarachnoid catheter placement during attempts at continuous spinal anaesthesia even though CSF could not be aspirated. Bilateral motor response in the legs was observed at 0.2 mA. In the second patient, inadvertent subarachnoid placement was detected during attempted lumbar epidural block by observing bilateral motor response in the legs at 0.3 mA. In the third patient, intravascular placement was suspected and confirmed by failure to obliterate the motor response despite repeated local anesthetic injection. CONCLUSION: The new test provides objective information in managing epidural catheters when their position is uncertain.     

Central venous catheter placement utilizing common facial vein. A technic useful in hyperalimentation and venous pressure monitoring

Catheter placement utilizing the common facial vein is recommended for parenteral hyperalimentation and is also useful for central venous pressure monitoring. The presence of chest wall sepsis is a specific indication for using the common facial vein as an entry point. The technical details of catheter placement are described.     

Stuck guidewire in the right atrium: an emergent situation in central vein catheter placement

Objective To investigate the emergency treatment and clinical effect when the guidewire stuck in the right atrium during central vein catheter placement for hemodialysis. Methods Five cases with guidewire stuck in the right atrium during central vein catheter placement for hemodialysis from January 2011 to July 2018 admitted into the First Affiliated Hospital of Zhejiang University were retrospectively analyzed. In two cases, the guidewires were found completely stuck when the insert depth was about 20 cm. The guidewires were not able to move forward nor backward. In the other three cases, the guidewires could be moved forward but not backward with the insert depth at about 18 cm. All patients received emergent computed tomography angiography (CTA) or digital subtraction angiography (DSA) imaging. Images showed that the guidewires were stuck in the right atrium near the ventricular valve. The guidewire core drawing method, the multipurpose angiography (MPA) catheter capturing method and the manual guidewire adjusting method were used for emergent treatment. Results One patient with completely stuck guidewire was successfully treated with guidewire core drawing method and the temporary central vein catheter catheterization through the internal jugular vein was performed under DSA. In a completely stuck case and a retrogradely stuck case, the J-shaped ends of the warped guidewires were captured into the MPA catheter, and the guidewires were then withdrawn from right atriums along with the contrast catheter. In the other 2 retrogradely stuck cases, under DSA, the guidewires were repeatedly pushed, the direction of J-shaped ends was manually adjusted, and then the guidewires were repeatedly pushed and pulled until catheters can be pulled out of the right atriums. The later 4 cases had permanent central vein catheter placement with the same guidewire after the stuck guidewires were withdrawn from the right atrium and readjusted. Conclusions All three methods can successfully solve the emergent situation of the stuck guidewire in the right atrium. For patients with completely stuck guidewires, the MPA catheter capturing method can be simpler, safer, and more effective.     

Influence of orientations of guidewire tip on the placement of subclavian venous catheters

BACKGROUND: The role of a J-type guidewire tip has been known to prevent vascular or cardiac wall damage. We hypothesized that the course of the guidewire may be influenced by the initial orientations of the J-type guidewire tip during the subclavian approach. The purpose of this study was to investigate the influence of the direction of the needle bevel and J-wire tip on successful placement of subclavian catheters. METHODS: A total of 140 adult patients of either sex were studied. Patients were randomly divided by the direction of the needle bevel (neutral vs. downward) and the direction of the J-wire tip (upward vs. downward). Under general anesthesia, right infraclavicular subclavian catheterization was attempted using the Seldinger technique. RESULTS: There was no statistically significant difference among the successful and unsuccessful placements in relation to factors including sex, body mass index, and needle bevel direction. The success rate was high when the J-wire tip was directed downward (P = 0.001). CONCLUSION: These data suggest that the orientation of the J-wire tip downward can increase successful placement rates of right subclavian venous catheterization.