Hostname: page-component-cd9895bd7-dk4vv Total loading time: 0 Render date: 2024-12-25T21:00:12.086Z Has data issue: false hasContentIssue false

ECG-guided central venous catheter positioning: does it detect the pericardial reflection rather than the right atrium?

Published online by Cambridge University Press:  23 December 2004

W. Schummer
Affiliation:
Friedrich-Schiller-University of Jena, Department of Anaesthesia and Intensive Care Medicine, Jena, Germany
C. Schummer
Affiliation:
Friedrich-Schiller-University of Jena, Department of Anaesthesia and Intensive Care Medicine, Jena, Germany
A. Müller
Affiliation:
Friedrich-Schiller-University of Jena, Department of Otorhinolaryngology-Head and Neck Surgery, Jena, Germany
J. Steenbeck
Affiliation:
Friedrich-Schiller-University of Jena, Institute of Diagnostic and Interventional Radiology, Jena, Germany
J. Fuchs
Affiliation:
Friedrich-Schiller-University of Jena, Department of Anaesthesia and Intensive Care Medicine, Jena, Germany
D. Bredle
Affiliation:
University of Wisconsin-Eau Claire, Department of Kinesiology, WI, USA
E. Hüttemann
Affiliation:
Friedrich-Schiller-University of Jena, Department of Anaesthesia and Intensive Care Medicine, Jena, Germany
Get access

Abstract

Summary

Background and objective: Although electrocardiography (ECG) guidance of central venous catheters (CVCs) is traditionally thought to detect the entrance into the right atrium (RA), there is little evidence in the literature to confirm this. We previously observed a high incidence of left-sided CVCs abutting the wall of the superior vena cava (SVC), even when the catheters were advanced past the point of increased P-wave amplitude. Our hypothesis was that this ECG amplitude signal is actually detecting the pericardial reflection rather than the RA. The goal of the study was to position catheter tips under ECG guidance outside the RA.

Methods: One-hundred central venous triple-lumen catheters inserted either via the right or the left internal jugular veins, respectively, were analysed in cardiac surgical patients. The position of the catheter tip was ascertained by ECG. Method A: A Seldinger guide-wire in the distal lumen served as exploring electrode, the respective insertion depth was recorded. Method B: The middle lumen (port opening 2.5 cm from the catheter tip, thus the catheter was advanced more towards the atrium) filled with a saline 10% fluid column served as the exploring electrode, and the insertion depth was recorded again. Descriptive data are given as mean ± standard deviation.

Results: On average, the catheters were advanced by the expected 2 ± 0.3 cm using Method B beyond the initial insertion by Method A. All 100 CVCs were finally correctly positioned in the SVC and confirmed by transoesophageal echocardiography. When chest radiography was performed after surgery not a single catheter abutted the lateral wall of the SVC.

Conclusion: Since both methods detected the same structure, and catheters placed by Method B did not result in intra-atrial CVC tip position, the first increase in P-wave amplitude does correspond to a structure in the SVC, most likely the pericardial reflection.

Type
Original Article
Copyright
2004 European Society of Anaesthesiology

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Waghorn DJ. Intravascular device-associated systemic infections: a 2 year analysis of cases in a district general hospital. J Hosp Infect 1994; 28: 91101.Google Scholar
Collier PE, Blocker SH, Graff DM, Doyle P. Cardiac tamponade from central venous catheters. Am J Surg 1998; 176: 212214.Google Scholar
Fletcher SJ, Bodenham AR. Safe placement of central venous catheters: where should the tip of the catheter lie? Br J Anaesth 2000; 85: 188191.Google Scholar
Scott WL. Complications associated with central venous catheters. A survey. Chest 1988; 94: 12211224.Google Scholar
Schuster M, Nave H, Piepenbrock S, Pabst R, Panning B. The carina as a landmark in central venous catheter placement. Br J Anaesth 2000; 85: 192194.Google Scholar
Schummer W, Herrmann S, Schummer C, et al. Intra-atrial ECG is not a reliable method for positioning left internal jugular vein catheters. Br J Anaesth 2003; 91: 481486.Google Scholar
McGee WT, Ackerman BL, Rouben LR, Prasad VM, Bandi V, Mallory DL. Accurate placement of central venous catheters: a prospective, randomized, multicenter trial. Crit Care Med 1993; 21: 11181123.Google Scholar
Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 1999; 89: 870884.Google Scholar
Nanda NC, Domanski HJ. Normal anatomy.Atlas of Transoesophageal Echocardiography. Baltimore, USA: Lippincott Williams & Wilkins, 1998: 15.
Nanda NC, Domanski HJ. Superior vena cava and right atrium.Atlas of Transoesophageal Echocardiography. Baltimore, USA: Lippincott Williams & Wilkins, 1998: 3638.
Wunderbaldinger P. ‘Tubes and lines’ in thoracic radiography: malpositioning and complications. Wien Med Wochenschr 2001; 151: 524531.Google Scholar
Trigaux JP, Goncette L, Van Beers B, de Wispelaere JF, Pringot J. Radiologic findings of normal and compromised thoracic venous catheters. J Thorac Imaging 1994; 9: 246254.Google Scholar
Weissauer W. The cava-catheter from the medico-legal viewpoint. Anaesthesiol Intensivmed Notfallmed Schmerzther 1998; 33: 117118.Google Scholar
Jay AW, Aldridge HE. Perforation of the heart or vena cava by central venous catheters inserted for monitoring or infusion therapy. Can Med Assoc J 1986; 135: 11431144.Google Scholar
Blackshear RH, Gravenstein N. Critical angle of incidence for delayed vessel perforation by central venous catheter: a study of in vitro data. Ann Emerg Med 1991; 21: 659.Google Scholar
NKF–DOQI clinical practice guidelines for vascular access. National Kidney Foundation–Dialysis Outcomes Quality Initiative. Am J Kidney Dis 1997; 30: S150S191.
Barton BR, Hermann G, Weil III R. Cardiothoracic emergencies associated with subclavian hemodialysis catheters. JAMA 1983; 250: 26602662.Google Scholar
Kappes S, Towne J, Adams M, Kauffman HM, Maierhofer W. Perforation of the superior vena cava. A complication of subclavian dialysis. JAMA 1983; 249: 22322233.Google Scholar
Kielstein JT, Abou-Rebyeh F, Hafer C, Haller H, Fliser D. Right-sided chest pain at the onset of haemodialysis. Nephrol Dial Transplant 2001; 16: 14931495.Google Scholar
Twardowski ZJ. Advantages and limits of the jugular catheter approach. Nephrol Dial Transplant 1995; 10: 21782182.Google Scholar
Food and Drug Administration. Precautions necessary with central venous catheters. FDA Task Force. FDA Drug Bull 1989; July: 1516.