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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 ,
C. Schummer ,
A. Müller ,
J. Steenbeck ,
J. Fuchs ,
D. Bredle  and
E. Hüttemann
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
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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.

Keywords

CENTRAL VENOUS CATHETERIZATION, instrumentationELECTROCARDIOGRAPHY, diagnostic useINTERNAL JUGULAR VEINSTRANSOESOPHAGEAL ECHOCARDIOGRAPHY
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 21 , Issue 8 , August 2004 , pp. 600 - 605
Copyright
2004 European Society of Anaesthesiology

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