Analysis on P Wave Morphology for PICC Placement Guided by Intracardiacelectrogram in Chinese Elderly Patients

Abstract

Objective: PICC can effectively protect upper extremity veins. It can reduce repetitive puncture and the incidence of phlebitis, relieve the pain, and improve the quality of life for those with long-term intravenous infusion, repeated infusion of stimulant drugs and blood products, and poor peripheral superficial vein conditions etc.. Successful PICC tip positioning can effectively avoid catheter-related complications during clinical care. If the catheter tip is misplaced, it may cause malfunction and related complications, such as venous thrombosis, bacteremia, arrhythmia, and heart valve injury etc. To investigate the correlation and clinical significance of monitoring P-wave characteristics, especially the occurrence of double peaks for precise tip positioning of peripherally inserted central catheter (PICC) guided by intracardiacelectrogram (IEGM). Methods: Enrolled 116 PICC patients (age≥60, no heart diseases) in our hospital. Conducted retrospective analysis on patients’ medical records, PICC catheterization data, IEGM-guided positioning records and nursing records. Observed and recorded patients’ P-wave changes (peaked P wave, bi-directional P wave and double-peaked P wave) at different catheter tip positions by real-time IEGM, and then analyzed the case number and positioning accuracy. Used chest X-ray to determine whether the catheter tip had reached the ideal position, the tracheal carina to the cavo-atrial junction (CAJ). Results: Among 116 patients (63 males, 53 females), bidirectional P waves were detected in 112 of them (96.55%) in ECG Lead II; 63 with peaked P waves (53.3%); 49 with double-peaked P waves but no peaked P waves (42.2%), meaning bidirectional P waves were seen when fed in the catheter and returned to double peaks when the catheter was withdrawn; 4 with no significant changes (3.4%). Chest X-ray proved that 49 of 49 cases with double-peaked P waves reached the ideal catheterization position (100% in accuracy), and 43 of 69 cases with peaked P waves succeeded as well (68.2% in accuracy). Conclusions: Double-peaked P waves in IEGM-guided PICC positioning for elderly patients can be considered as an indicator of the catheter tip entering the CAJ and supplementary support of peaked P wave and bidirectional P wave guidance for catheterization.