ECC Guidance for CVC Placement

Abstract

ECC Guidance for CVC Placement In Response: Dr. Schulz-Stubner reminds us of the method of ECG guidance for placement of central venous catheters (CVC). The studies he cites are of adult patients (1,2), with a failure rate of correct placement of 8.5 and 10% in a total of 439 patients. Simon et al. reported the use of this method in a series of 23 pediatric patients (3), with a failure rate of 13%. Our height and weight based formulae require no special equipment, and predict correct placement 97% and 98% of the time, respectively. Our 452 patients ranged in age from newborn to young adults and in weight from 2.5 to over 100 kg (4). The patients in our series all had congenital heart disease, and the majority had enlarged right atria. This gives rise to enlarged P waves on surface ECG (5), which could change the progression of P wave enlargement as the guide wire is advanced into the atrium, rendering ECG guidance less useful. In clinical practice we use the Seldinger technique and advance the guidewire into the right atrium carefully until premature atrial contractions are seen, confirming intracardiac passage of the guidewire. If no premature atrial contractions are observed, we remove the guidewire and make another attempt, or use transesophageal echocardiography, when available (6), to determine if the guidewire is in the atrium and then to place the catheter tip in the desired location under direct ultrasound guidance. Thus, although ECG guidance for CVC placement is a viable option for CVC placement, the uses of our formulae appear to be simpler and more accurate. We would also like to emphasize that radiographic confirmation of all CVC placements should be made as soon as practical. Every method has a failure rate, and the risk of severe complications is small, but these are often preventable with immediate correction of malposition. Dean B. Andropoulos, MD Stephen A. Stayer, MD