Peripherally Inserted Central Catheter Tip Position Research Articles

Ultrasound vs. standard radiography to determine peripherally-inserted central catheter tip location

Background The use of a peripherally-inserted central catheter (PICC) has increased in preterm neonates to facilitate the administration of total parenteral nutrition. Standard radiography (thoracoabdominal X-ray) is the gold standard for determining the position of the PICC tip. However, radiography is not always accurate, influenced by the position of the extremities and anatomic variations, time-consuming procedural process, involves radiation, and is costly. Ultrasonography (USG) may serve as an easier, safer, less costly, and more real-time alternative in the neonatal intensive care unit (NICU) patients. Objective To assess the accuracy of USG use in determining PICC tip position compared to that of standard radiography. Methods This diagnostic study was conducted in the NICU at Dr. Cipto Mangunkusumo Hospital, Jakarta. The PICCs were placed using standard NICU procedure, then the tip position was evaluated using the USG immediately before standard radiography was performed. A 2x2 table was constructed to compare the diagnostic accuracy of the two modalities. Results A total of 29 neonates were included in our study. Subjects’ mean gestational age and weight were 31.7 weeks and 1,618.9 g respectively. Concordance of PICC tip positioning between standard radiography and USG occurred in 27 neonates (93.1%). USG had 88.89% sensitivity, 95% specificity, and 93.1% diagnostic accuracy. Conclusion USG has excellent diagnostic accuracy for confirmation of the PICC tip position.

No Critical Ultrasound, No Life: The Value of Point-of Care Critical Ultrasound in the Rescue of Critically Ill Infants.

Point-of-care critical ultrasound (POC-CUS) screening plays an increasingly important role in the treatment of critically ill infants. Without POC-CUS, the lives of many infants would not be saved in time and correctly. A premature infant with systemic multiple organ system dysfunction caused by fungal sepsis was treated and nursed under the guidance of POC-CUS monitoring, and the infant was ultimately cured. This premature infant had systemic multiple organ system dysfunction and disseminated intravascular coagulation (DIC) caused by fungal sepsis. In the hypercoagulable state of early-stage DIC, cardiac thrombosis could be found using ultrasound screening. For this case, right renal artery thrombosis was found via renal artery Doppler ultrasound examination. Due to the severity of this disease, ultrasound-guided peripherally inserted central catheter (PICC) insertion and ultrasound checks of the PICC tip's position were performed, which ensured the success of this one-time catheterization and shortened the catheterization time. Lung ultrasound is used for the diagnosis and differential diagnosis of pulmonary diseases, and to guide the application of mechanical ventilation. Because the abdominal circumference of the patient's markedly enlarged abdominal circumference, bloody stool, and absence of bowel sounds, abdominal ultrasonography was performed, which revealed a markedly enlarged liver, significant peritoneal effusion, and necrotizing enterocolitis. Guided by POC-CUS monitoring, we had the opportunity to implement timely and effective treatment that ultimately saved this critically ill patient's life. The successful treatment of this newborn infant fully reflects the importance of carrying out POC-CUS screening.

Role of a radiopaque agent and surveillance radiographs for peripherally inserted central catheters in newborn infants

BackgroundControversy exists regarding the use of a radiopaque agent to identify peripherally inserted central catheter (PICC) tip positions in newborn infants and of serial radiography to monitor PICC tip migration.ObjectiveTo investigate the roles of (1) the injection of a radiopaque agent to identify PICC tip position and (2) the performance of weekly radiography to monitor PICC migration.Materials and methodsThis retrospective single-centre cohort study included newborn infants who received a PICC between 1 January 2016 and 31 December 2020. A radiopaque agent was injected to identify PICC tip position and radiographs were performed weekly to detect PICC migration.ResultsWe identified 676 PICC episodes in 601 infants. A radiopaque agent was used for 590 of these episodes. There was no difference in the proportion of central PICC tip positions based on radiopaque agent use status (490/590, 83% for the radiopaque agent used group versus 73/85, 85.8% for the radiopaque agent not used group, P=0.51). Irrespective of the site of PICC insertion, outward migration was observed for most centrally placed PICCs over their entire in situ duration. Inward migration was identified in 23 out of 643 PICC episodes (3.6%) only on radiographs obtained on or before day 7. Based on serial radiographs, the odds for PICC tips remaining in a central position were lower the longer the PICC remained in situ (adjusted odds ratio-OR 0.93; 95% confidence interval 0.92–0.95). There was no difference in PICC migration between side and limb of insertion.ConclusionPICC tips can be identified without injection of a radiopaque agent. Serial radiographs identified PICC migration over the in situ duration. This study has implications for reducing exposure to a radiopaque agent and ongoing migration surveillance practices.Graphical abstract

A Risk Score for Single-Lumen Peripherally Inserted Central Catheter (PICC)-Related Venous Thrombosis in Cancer Patients Undergoing Ambulatory Chemotherapy

Introduction The extended use of peripherally inserted central catheters (PICCs) in cancer patients have simplified the management of the treatment, but also represent an important risk factor of upper limbs thrombosis in a population specially predisposed to thrombotic events. Given the clinical significance of PICC-related venous thrombosis (VT) in cancer patients, a predictive risk model could be helpful. Methods Retrospective unicentric study in which patients with single-lumen PICCs, placed by using ultrasound guidance by a trained nursing team at our centre from January 2015 to May 2019 were included. Inclusion criteria were age ≥18 years-old, histologically confirmed diagnosis of cancer and treatment with ambulatory chemotherapy regimen. The presence of symptomatic PICC-related VT confirmed by ultrasounds, variables regarding PICC (placement, use and removal) and the main clinical and biological characteristics of the patients were recorded. For further analysis, sites of cancer were categorized into "very high risk", those with VT rates of 2-fold or higher than the median risk of the group (lung, testicular, bladder), "high risk", those with rates higher than average (gastric, pancreatic, breast, head and neck), and low risk, those with rates at or below average (colorectal, prostate, lymphoma, gynecologic, and others). The predictive accuracy of the model was assessed: discrimination was evaluated using the c-statistic representing the AUC (area under the receiver-operating characteristic), the Hosmer-Lemeshow test was used to assess model calibration and a bootstrap internal validation procedure with 1000 bootstrap resamples was performed. Results Seventy (6%) of 1170 patients who received PICCs, with a median time of use of 108.5 days [2-525], developed symptomatic, image-confirmed PICC-related VT. Moreover, 10 of the 70 had associated pulmonary embolism. The main characteristics of the patients with and without PICC-VT are summarized in table 1. The median time between PICC placement and thrombosis was 25.5 [1-458] days and VT was more probable on the first 100 days after placement (p=0.002). In univariable analyses, the following variables were significantly associated with the development of symptomatic PICC-VT: primary site of cancer, pre-chemotherapy platelet count ≥350 x109/L and supradiaphragmatic radiotherapy concomitant to PICC use. In addition, PICC tip placement next to the right atrium (in the right atrium or at the lower third of the superior vena cava) is associated with a lower incidence of VT. PICC tip position only could be checked in 447 patients by chest radiography. In the final multivariable logistic regression model (table 2), three variables emerged as risk factors independently associated with PICC-VT: primary site of cancer (very high risk or high risk), pre-chemotherapy platelet count ≥350 x109/L and supradiaphragmatic radiotherapy concomitant to PICC use. PICC tip placement was not considered in the multivariable analysis, since it is a correctable variable. To create the risk score, we assigned points to each of the three variables based on their regression coefficients (table 2). Patients were assigned to one of three risk groups based on cumulative total points: low (score 0), intermediate (score 1), and high (score ≥2). Observed PICC-related VT rates were 3.1% for the low-risk group, 6.4% for the intermediate-risk group and 12.4% for the high-risk group. In a logistic regression model with risk group as a categorical predictor, the risk classification rule was significantly associated with PICC-VT (p <0.001), with odds ratios of 2.136 (95% CI, 1.137-4.011) and 4.456 (95% CI, 2.387-8.320) for intermediate-risk and high-risk groups vs. low-risk group, respectively. C statistic was 0.662 (95%CI 0.598-0.727). Conclusions Primary site of cancer, pre-chemotherapy platelet count and supradiaphragmatic radiotherapy concomitant to the PICC use are independent risk factors for single-lumen PICC-related venous thrombosis in cancer patients undergoing ambulatory chemotherapy. The score proposed herein could be a helpful tool to predict the risk of PICC-related VT. PICC tip placement proximal to the right atrium could reduce the risk of VT. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Electrocardiographic localization of peripherally inserted central catheter tip position in critically ill patients with advanced cancer: An application study.

BackgroundWe compared the methods of electrocardiogram (ECG) and X‐ray localization of the peripherally inserted central catheter (PICC) tip position, in order to find a more convenient, practical, and safe method.ObjectiveTo investigate the value of applying electrocardiographic localization of the PICC tip position in critically ill patients with advanced cancer in Hebei Province, China.MethodEnrolled 137 advanced cancers requiring PICC placement. The position of the catheter tip was localized with the bedside electrocardiogram in real time. Then, the localization was performed using a chest X‐ray (the gold standard). The accuracy of electrocardiographic location was checked.ResultsSpecific P waves were observed in 130 patients. No change in the P waves was observed for the remaining seven patients. The age of the latter group of patients was more advanced (87.29 [5.15] years), a significant difference to that of the 130 patients with specific P waves (71.58 [14.84] years) (t = −6.704, p < .001). Specific P waves not only involve ascendance in P waves but also ascendance in QRS waves.ConclusionsThe use of an ECG to localize the PICC tip in critically ill patients with advanced cancer may replace the unnecessary use of chest X‐rays. Specific P waves not only involve an increase in P waves but also an increase in QRS waves. If there is no change in the P wave, a chest X‐ray film must be obtained. In elderly patients, because there is a possibility of catheter tip malposition, a comprehensive evaluation should be performed before surgery.

A comparative study on the tip position of peripherally inserted central catheter inserted at two forward P-wave amplitudes by intracavitary electrocardiogram in cancer patients.

This study aimed to compare the tip location of peripherally inserted central catheter (PICC) under two forward P-wave amplitudes (P-wave amplitude is the autonomous peak or P-wave amplitude is 50-80% of the QRS main wave) by intracavitary electrocardiogram (IC-EKG) to determine the PICC tip in optimal location thus avoiding catheter-related complications. The data of 300 cancer patients with PICC insertion were collected retrospectively. For the observation group, the position of the catheter tip was left at the level when P wave amplitude was its autonomous peak (168 patients catheterized in 2018). While for the control group, the catheter tip was left at the level when the P wave amplitude was 50-80% of the QRS main wave (132 patients catheterized in 2017). Both groups of patients underwent the chest X-ray examination (CXR) after catheterization. The total compliance rate [PICC tip was located in the lower third of the Superior Vena Cava (SVC) and the Cavo-Atrial Junction (CAJ)], the optimal position compliance rate (PICC tip was located in the CAJ), and the incidence of the catheter tip malposition were compared between the two groups. The complications after catheterization including arrhythmia after catheterization within 24 hours, catheter-related thrombosis, catheter dysfunction, and catheter infection within 90 days were also compared. There was no difference in the total compliance rate of PICC tip position and the incidence of the catheter malposition in the two groups (P>0.05). But the optimal position compliance rate of the observation group was higher than that of the control group (P<0.05). There was no difference in the incidence of arrhythmia after catheterization within 24 hours of the two groups (P>0.05). The incidence of catheter-related thrombosis, catheter dysfunction, and catheter infection within 90 days in the observation group was lower than those in the control group (P<0.05). The PICC tip position at the autonomous peak of the P wave is significantly better than that at the P wave amplitude being 50-80% of the QRS main wave under the IC-EKG guidance for PICC insertion.

Interference of a ventricular assist device with magnetic navigation during insertion of Sherlock 3CG™, a bedside peripherally inserted central catheter.

Recently, the Sherlock 3CG™ Tip Confirmation System, including a magnetic tracking system and an intracavitary electrocardiography guidance system, has been introduced for bedside peripherally inserted central catheter (PICC) insertion. Magnetic field sources interfere with the magnetic tracking system. Electromagnetic interference of the ventricular assist device (VAD) has already been reported with various devices but not on Sherlock 3CG™. We assessed the availability of the magnetic tracking system in patients with and without a VAD during Sherlock 3CG™ insertion and evaluated the rate of optimal PICC tip position. We retrospectively reviewed 99 patients who had undergone PICC insertion using Sherlock 3CG™ on the bedside at our institutional intensive care unit from February 2018 to December 2020. Patients were divided into groups with and without a VAD. The availability of magnetic navigation and the success rate of optimal catheter tip position in each group were assessed. Among 87 cases analyzed, there were 12 and 75 cases with a VAD and without a VAD, respectively. The availability of magnetic navigation during Sherlock 3CG™ insertion was significantly lower in the group with a VAD [4/12 (33%) with VAD vs. 72/75 (96%) without VAD, P < 0.001]. In addition, the rate of optimal PICC tip position was also significantly lower in the group with a VAD [6/12 (50%) vs. 63/75 (84%), P = 0.015] The VAD significantly led to magnetic tracking system failure due to its electromagnetic interference during Sherlock 3CG™ insertion and significantly reduced the success rate of PICC insertions in the optimal position.

Machine Learning for Detection of Correct Peripherally Inserted Central Catheter Tip Position from Radiology Reports in Infants.

In critically ill infants, the position of a peripherally inserted central catheter (PICC) must be confirmed frequently, as the tip may move from its original position and run the risk of hyperosmolar vascular damage or extravasation into surrounding spaces. Automated detection of PICC tip position holds great promise for alerting bedside clinicians to noncentral PICCs. This research seeks to use natural language processing (NLP) and supervised machine learning (ML) techniques to predict PICC tip position based primarily on text analysis of radiograph reports from infants with an upper extremity PICC. Radiographs, containing a PICC line in infants under 6 months of age, were manually classified into 12 anatomical locations based on the radiologist's textual report of the PICC line's tip. After categorization, we performed a 70/30 train/test split and benchmarked the performance of seven different (neural network, support vector machine, the naïve Bayes, decision tree, random forest, AdaBoost, and K-nearest neighbors) supervised ML algorithms. After optimization, we calculated accuracy, precision, and recall of each algorithm's ability to correctly categorize the stated location of the PICC tip. A total of 17,337 radiographs met criteria for inclusion and were labeled manually. Interrater agreement was 99.1%. Support vector machines and neural networks yielded accuracies as high as 98% in identifying PICC tips in central versus noncentral position (binary outcome) and accuracies as high as 95% when attempting to categorize the individual anatomical location (12-category outcome). Our study shows that ML classifiers can automatically extract the anatomical location of PICC tips from radiology reports. Two ML classifiers, support vector machine (SVM) and a neural network, obtained top accuracies in both binary and multiple category predictions. Implementing these algorithms in a neonatal intensive care unit as a clinical decision support system may help clinicians address PICC line position.

Neonatal Anthropometric Measures and Peripherally Inserted Central Catheter Depth.

Peripherally inserted central catheters (PICCs) are used routinely in neonatal care. Measures of surface anatomy have been used to estimate appropriate PICC depth in neonates since 1973. However, prior PICC research using anthropometric measures to estimate proper PICC insertion depth has been limited to pediatric and adult literature. The purpose of this study was to explore the relationships among a neonate's anthropometric measures and the appropriate PICC insertion depth. Neonates requiring PICC insertion at Nationwide Children's Hospital were enrolled between January and September 2018. Standard PICC procedures were followed. The research group corroborated appropriate PICC tip position of enrolled infants. Multivariable linear regression with robust standard errors was used to evaluate linear relationships between PICC insertion depth and current weight, current length, and PICC insertion site. Demographics of enrolled infants included gestational ages of 23 to 39 weeks, weights of 510 to 3870 g, and lengths of 31 to 54 cm. Of the 56 infants considered, final statistical analysis included 49 neonates (14 ankle, 16 knee, and 19 antecubital insertions). Current neonatal weight was associated with PICC depth at all sites (all Ps < .0001). Current neonatal length was associated with PICC depth at all sites (all Ps < .0001). Preprocedure surface measurement was also strongly associated with PICC insertion depth (P < .0001). This investigation demonstrated a relationship for both neonatal weight and length that may be an anthropometric model for neonatal PICC insertion depth. A more robust sample size could more precisely define the anthropometric model.

Unique Cases of Intracavitary-Electrocardiogram Success in the Pediatric Intensive Care Unit: Jump Aboard, Innovators!

Highlights Abstract Proper peripherally inserted central catheter (PICC) placement has traditionally been confirmed by the use of a chest radiograph. With the innovation of the intracavitary electrocardiogram (IC-ECG), the use of a routine chest radiograph is not indicated. However, in many pediatric centers a chest radiograph is still required by policy. This article describes 4 cases in which PICC lines were properly placed using IC-ECG and the routine chest radiograph was unable to locate the PICC tip position.

A 1-Year Study on Association between Peripherally Inserted Central Catheter Tip Position and Complications in Neonates.

Aims:A peripherally inserted central catheter (PICC) is required in preterm neonates, especially those with low birth weight. However, PICC is associated with various complications resulting in increased morbidity and mortality. The objective of the study was to evaluate the association between PICC tip position and complications in neonates.Materials and Methods:One hundred neonates were recruited in a 1-year hospital-based, longitudinal, observational study. Radiographs were obtained to confirm the position of the catheter tip as central or noncentral in relation to vertebral level (T9–L5). The variables studied included site of insertion, duration of stay of PICC, time of removal, reason for removal, and associated complications. These were compared between the groups using SPSS version 20. Fisher's exact test was used to find the associations.Results:Most of the neonates were preterm (78%) and 81% were low birth weight. Catheter was placed in the right lower limb in most of the neonates (85%), and the catheter tip was central in position in 84% of neonates. The incidence of complications was observed in 29%. Noninfectious complications were common (26%) compared to infectious (3%). The most frequent PICC-induced complication was phlebitis (11%). Incidence of complications (P = 0.020), especially occlusion (P = 0.008), was significantly higher in neonates with noncentral catheter tip compared to the central tip.Conclusion:We observed a high incidence of PICC-induced complications in neonates, with phlebitis being most common. Further, the incidence of complications is influenced by noncentral tip position.

Ultrasound to Localize the Peripherally Inserted Central Catheter Tip Position in Newborn Infants.

This study aimed to evaluate the application of ultrasound for the localization of the tip position of peripherally inserted central catheters (PICCs) in newborn infants. This study was a retrospective analysis on ultrasonic localization for PICC placement conducted in our department over the past 2 years. Ultrasonic localization was performed immediately after PICC placement in all neonatal patients. Successful PICC placement was confirmed if the PICC tip position was located at the inferior/superior cavoatrial junction. Chest X-ray localization was performed on 32 infants immediately after ultrasound examination to compare the accuracy of ultrasound localization. Of the 186 patients, 174 (93.5%) had successful PICC placement on the first attempt. In 11 (5.9%) patients, the catheter tip was placed beyond the ideal location as follows: too deep (in the right atrium) in 4 patients, too shallow in 4 patients, and malpositioned in 3 patients. Both the sensitivity and the specificity of ultrasound for identifying PICC tip localization were 100%. Complications occurred in 2.7% of this group of patients. Ultrasonic localization of the PICC tip position is a timely, accurate, and reliable method and can identify the catheter tip with high accuracy. This method could be widely applied in neonatal wards.

The safety and accuracy of ECG-guided PICC tip position verification applied in patients with atrial fibrillation.

BackgroundTip position verification of peripherally inserted central catheters (PICCs) is essential to the use of the catheter. Postprocedural chest X-ray as the “gold standard” practice for PICC tip confirmation can lead to a significant delay for patient IV therapy, cost more, and lead to radiation exposure for both patients and staffs. Intracavitary electrocardiogram (IC-ECG)-guided PICC placement which provides real-time tip confirmation during the insertion procedure has been widely used. However, safety and accuracy of ECG for abnormal surface ECG patients, such as patients with atrial fibrillation (AF), have not been reported.ObjectiveTo determine the safety and accuracy of IC-ECG technique for PICC tip position verification among the patients with AF.Patients and methodsA prospective cohort study was conducted in a teaching and tertiary referral hospital with more than 3,600 beds in Qingdao, People’s Republic of China. Adult patients with diagnosis of AF who need a PICC for infusion from June 2015 to May 2017 were enrolled in the study. For every included patient with AF, ECG was used to detect the PICC tip position during catheterization and X-ray was done to confirm the tip position as the “gold standard” after PICC insertion. The effectiveness and accuracy of ECG-guided catheter tip positioning and chest X-ray confirmation were compared.ResultsTotally, 118 AF patients with 118 PICCs were enrolled (58 male and 60 female, age range 50–89 years old). There was no catheterization-related complication. When the catheter entered the lower 1/3 of superior vena cava, the amplitude of f wave reached the maximum. There was no statistical difference between X-ray PICC tip position verification and IC-ECG PICC tip position verification among patients with AF (χ2=1.31, P=0.232). Utilizing the cutoff point of f wave change ≥0.5 cm, a sensitivity of 0.94, a specificity of 0.71, a positive predictive value of 0.98, and a negative predictive value of 0.42 were observed. The area under the receiver operating characteristic curve was 0.909 (95% CI: 0.810–1.000).ConclusionThe ECG-guided technique represents a safe and accurate technique to verify the position of PICC tip in patients with AF and could potentially remove the requirement for postprocedural chest X-ray among the patients with AF.

A randomized controlled study of bedside electrocardiograph-guided tip location technique & the traditional chest radiography tip location technique for peripherally inserted central venous catheter in cancer patients.

Background & objectives:The peripherally inserted central catheter (PICC) has the advantages of higher safety, lower infection rate and longer retention time than peripherally inserted catheter. This study was aimed to evaluate the accuracy and safety of bedside electrocardiograph (ECG)-guided tip location technique in PICC in cancer patients, and compared with traditional chest radiography tip location technique.Methods:Patients were randomly assigned into two groups: The ECG test group patients underwent PICC insertion with ECG-guided tip location, while the control group patients had PICC insertion by the conventional method. The precision of tip location was verified by chest radiography in both groups. The groups were compared with regard to the accuracy of tip placement, anxiety levels before and after the procedure; medical cost and incidence of complications at one week, three months and six months after PICC insertion.Results:Accurate tip location was achieved in 99.30 per cent in the ECG test group vs 92.30 per cent in the control group (P <0.001). At 24 h after the procedure, the anxiety level was significantly lower in the ECG test group. The presence of thrombogenesis was significantly lower in the ECG test group at both three months and six months after the procedure (P=0.04 and P=0.03, respectively).Interpretation & conclusions:The ECG-guided PICC tip location technique was accurate and caused fewer procedure-related complications and less anxiety in patients compared to chest radiography tip location technique. Radiographic confirmation of PICC tip position may not be needed when ECG guidance is used and thus it can help avoid radiation exposure.

Perforations associated with peripherally inserted central catheters in a neonatal population.

Peripherally inserted central catheters (PICCs) are increasingly used in neonates but perforations can result in devastating complications such as pericardial and pleural effusions. Identifying risk factors may guide surveillance and reduce morbidity and mortality. To determine the risk factors for PICC perforation in neonates. Retrospective case:control (1:2) study of neonates admitted between 2004-2014. Charts and imaging were reviewed for clinical and therapeutic risk factors. Among 3,454 PICCs, 15 cases of perforation (incidence 0.4%, 5 pericardial effusions, 10 pleural effusions) were matched to 30 controls, based on gestation and insertion date. Timing of perforations post-insertion was median 4days for pericardial effusions and 21.5days for pleural effusions. A risk factor for pericardial effusion was lower weight at PICC insertion compared with controls. There were no statistically significant differences between cases and controls in catheter material, insertion site, PICC size and lumen number. Among upper limb PICCs, pericardial effusions were associated with tip positions more proximal to the heart at insertion (P=0.005) and at perforation (P=0.008), compared with controls. Pleural effusions were associated with tip positions more distal from the heart at perforation (P=0.008). Within 48h before perforation, high/medium risk infusions included total parenteral nutrition (100% cases vs. 56.7% controls, P=0.002) and vancomycin (60% cases vs. 23.3% controls, P=0.02). PICC-associated pericardial effusions and pleural effusions are rare but inherent risks and can occur at any time after insertion. Risk factors and etiologies are multifactorial, but PICC tip position may be a modifiable risk factor. To mitigate this risk, we have developed and disseminated guidelines for target PICC positions and routinely do radiographs to monitor PICCs for migration and malposition in our NICU. The increased knowledge of risk profiles from this study has helped focus surveillance efforts and facilitate early recognition and treatment.

Effectiveness of Intracavitary Electrocardiogram Guidance in Peripherally Inserted Central Catheter Tip Placement in Neonates.

Correct tip location is crucial for a peripherally inserted central catheter (PICC) to maximize the effects of central venous infusion. However, it is difficult to place the tip in a correct location in neonates because of the unreliable estimated length by surface landmark. Therefore, we evaluated the feasibility and safety of an improved intracavitary electrocardiogram (IC-ECG) technique in guiding PICC placement in neonates based on the ratios of P/R wave amplitudes on IC-ECG. The results showed that all of the 32 neonates whose PICCs had been successfully placed and correct tip position verified by chest radiography acquired qualified P wave on IC-ECG. The average ratio of P/R wave amplitude was 0.6 ± 0.1, with a range of 0.4 to 0.8. The 49 neonates who received IC-ECG-guided PICC catheterization showed higher success rates of correct PICC tip position on the first attempt than traditional, predetermined length estimation on surface landmark (93.9% vs 62.5%, χ = 18.01, P < .001). No significant complications occurred in the studied neonates. Based on these findings, IC-ECG-guided tip placement appears to be a promising approach in improving the success rate of tip location when placing a PICC in neonates.

The application of Seldinger guidewire in PICC tip position under the guidance of intravenous ECG

Objective To explore the feasibility and security of micro-guidewire of Seldinger instead of EKG lead clip applied in the peripherally inserted central catheter(PICC) tip position under the guidance of intravenous electrocardiogram(ECG). Methods A total of 60 patients with the need of being inserted PICC because of various clinical conditions were chosen as the research objects.B ultrasound-guided Seldinger technology was adopted to insert PICC.The tip position was fixed by the change of P waves with the micro-guidewire of Seldinger as the boot medium and the micro-guidewire of PICC as the detective polar. Results The intravenous ECG can be extracted for all of the patients. Conclusion The stable intravenous ECG can be extracted with the micro-guidewire of Seldinger as the boot medium and the micro-guidewire of PICC as the detective polar to guide the PICC insertion and positioning. Key words: Catheterization; Central venous; Electrocardiography; Monitoring; Psychology; Veins

Evidence-Based Implementation of Peripherally Inserted Central Catheters (PICCs) Insertion at a Vascular Access Care Outpatient Clinic.

Evidence-Based Implementation of Peripherally Inserted Central Catheters (PICCs) Insertion at a Vascular Access Care Outpatient Clinic.

ECG-based PICC tip verification system: an evaluation 5 years on.

In 2011, the vascular access team at East Kent Hospitals University NHS Foundation Trust safely and successfully incorporated the use of electrocardiogram (ECG) guidance technology for verification of peripherally inserted central catheters (PICC) tip placement into their practice. This study, 5 years on, compared the strengths and limitations of using this ECG method with the previous gold-standard of post-procedural chest X-ray. The study was undertaken using an embedded case study approach, and the cost, accuracy and efficiency of both systems were evaluated and compared. Using ECG to confirm PICC tip position was found to be cheaper, quicker and more accurate than post-procedural chest X-ray.

Confirming PICC tip position during insertion with real-time information.

Peripherally inserted central catheters (PICCs) play a fundamental role in patient care in a variety of clinical and healthcare settings. Tip location is important for both safety and efficacy. New technologies may offer the possibility of safer, more efficient and more effective insertion. A prospective evaluation was carried out of a system providing real-time information on the tip's location, direction, and depth during insertion in a total of 488 patients at a single centre (65 patients in the initial study, plus follow-on case series reports in 423 patients). No tip malpositions were reported and, as a result, the institution has been able to waive the requirement for confirmatory chest X-ray after PICC insertion, thus minimising the delay before the PICC can be used and increasing staff and patient confidence in the procedure.