Peripherally Inserted Central Catheters Tip Research Articles

Automated precision localization of peripherally inserted central catheter tip through model-agnostic multi-stage networks

Background:Peripherally inserted central catheters (PICCs) have been widely used as one of the representative central venous lines (CVCs) due to their long-term intravascular access with low infectivity. However, PICCs have a fatal drawback of a high frequency of tip mispositions, increasing the risk of puncture, embolism, and complications such as cardiac arrhythmias. To automatically and precisely detect it, various attempts have been made by using the latest deep learning (DL) technologies. However, even with these approaches, it is still practically difficult to determine the tip location because the multiple fragments phenomenon (MFP) occurs in the process of predicting and extracting the PICC line required before predicting the tip. Objective:This study aimed to develop a system generally applied to existing models and to restore the PICC line more exactly by removing the MFs of the model output, thereby precisely localizing the actual tip position for detecting its misposition. Methods:To achieve this, we proposed a multi-stage DL-based framework post-processing the PICC line extraction result of the existing technology. Our method consists of the following three stages: 1. Existing PICC line segmentation network for a baseline, 2. Patch-based PICC line refinement network, 3. PICC line reconnection network. The proposed second and third-stage models address MFs caused by the sparseness of the PICC line and the line disconnection due to confusion with anatomical structures respectively, thereby enhancing tip detection. Results:To verify the objective performance of the proposed MFCN, internal validation and external validation were conducted. For internal validation, learning (130 samples) and verification (150 samples) were performed with 280 data, including PICC among Chest X-ray (CXR) images taken at our institution. External validation was conducted using a public dataset called the Royal Australian and New Zealand College of Radiologists (RANZCR), and training (130 samples) and validation (150 samples) were performed with 280 data of CXR images, including PICC, which has the same number as that for internal validation. The performance was compared by root mean squared error (RMSE) and the ratio of single fragment images (RatioSFI) (i.e., the rate at which model predicts PICC as multiple sub-lines) according to whether or not MFCN is applied to seven conventional models (i.e., FCDN, UNET, AUNET, TUNET, FCDN-HT, UNET-ELL, and UNET-RPN). In internal validation, when MFCN was applied to the existing single model, MFP was improved by an average of 45 %. The RMSE improved over 63% from an average of 27.54 mm (17.16 to 35.80 mm) to 9.77 mm (9.11 to 10.98 mm). In external validation, when MFCN was applied, the MFP incidence rate decreased by an average of 32% and the RMSE decreased by an average of 65%. Therefore, by applying the proposed MFCN, we observed the consistent detection performance improvement of PICC tip location compared to the existing model. Conclusion:In this study, we applied the proposed technique to the existing technique and demonstrated that it provides high tip detection performance, proving its high versatility and superiority. Therefore, we believe, in countries and regions where radiologists are scarce, that the proposed DL approach will be able to effectively detect PICC misposition on behalf of radiologists.

Effects of indwelling centrally inserted central catheter on tip location of peripherally inserted central catheter with intracavitary electrocardiogram guidance: A retrospective case-control study.

Intracavity electrocardiogram (IC-ECG) guidance is an effective technology for monitoring the tip locations of centrally inserted central catheters (CICCs) and peripherally inserted central catheters (PICCs). However, for patients with an indwelling CICC, there has been no study on whether the CICC affects PICC tip positioning with IC-ECG guidance. Thirty people with a CICC requiring PICC insertion, matched with age to controls without a CICC. The stability of IC-ECG waveforms, the amplitude of P-waves, and the accuracy of PICC tip location were compared. There was no significant difference in the stability of the IC-ECG waveforms (χ2 = 0.22, p = 0.64). The amplitudes of baseline P-waves and ideal P-waves also showed no significant difference (t1 = 0.06, p1 = 0.96, t2 = 0.80, p2 = 0.43). Neither the accuracy of tip location (χ2 = 1.40, p = 0.50) nor the distance of PICC tip (t = -0.03, p = 0.98) were significantly different. For patients with an indwelling CICC, the position of PICC tip can be accurately determined by the dynamic changes in the P-wave amplitude.

Appropriateness of Replacing Fluoroscopic Guidance With ECG-Electromagnetic Guidance for PICC Insertion: A Randomized Controlled Trial.

OBJECTIVE. Coupled ECG-electromagnetic (EM) guidance shows promise for use in placement of peripherally inserted central catheters (PICCs) when compared with the classic blind technique. However, ECG-EM guidance has not been appropriately compared with the reference standard of fluoroscopy (FX) guidance. Here, we aimed to compare ECG-EM guidance with FX guidance with regard to the final tip position of PICCs. SUBJECTS AND METHODS. A total of 120 patients (age range, 19-94 years) referred for PICC placement were randomized to the ECG-EM or FX group. All interventions were performed by PICC team members who had the same standardized training and experience. Final tip position was assessed using chest radiography and was classified as optimal, suboptimal, or inadequate requiring repositioning on the basis of the distance from the PICC tip to the cavoatrial junction (CAJ). Statistical analyses were performed using the Mann-Whitney U test for final catheter tip position (mean distance from CAJ) and Fisher and chi-square tests for proportions. RESULTS. PICCs were successfully inserted in 118 patients (53 men and 65 women). Catheter tip positions were optimal or suboptimal in 100% of the FX group and 77.2% of the ECG-EM group. Furthermore, precision of placement was significantly better (p = .004) in the FX group (mean distance from the PICC tip to the CAJ = 0.83 cm) than in the ECGEM group (mean distance from the PICC tip to the CAJ = 1.37 cm). Thirteen (22.8%) of the PICCs placed using ECG-EM guidance, all of which were inserted from the left side, were qualified as inadequate requiring repositioning and required another intervention. CONCLUSION. Our results revealed significant differences in final tip position between the ECG-EM and FX guidance techniques and indicate that ECG-EM guidance cannot appropriately replace FX guidance among unselected patients. However, ECGEM guidance could be considered as an acceptable technique for patients in whom the PICC could be inserted from the right side. TRIAL REGISTRATION. ClinicalTrials.gov NCT03652727.

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.

Ultrasound and Radiography Evaluation of the Tips of Peripherally Inserted Central Catheters in Neonates Admitted to the NICU

Background: Appropriate and accurate easy access tools are necessary to overcome complications from malpositioned line tips of peripherally inserted central catheters (PICCs) in critically ill neonates. Ultrasound is a radiationless, cost-beneficial, and time-saving method that allows medical personnel to manipulate the line and correct possible malposition of this tip. In addition, it reduces the need for a second radiography. Objectives: We compared the effectiveness of sonography with radiography for confirmation of the line tip placement. Methods: This prospective descriptive-analytical study was conducted in the Neonatal Intensive Care Unit (NICU) in Tehran Children’s Medical Center (tertiary level), Tehran, Iran. Neonates who were candidates for PICC implantation according to the ward’s protocol were enrolled in the study. Radiography and sonography were performed after catheter insertion by a radiologist blinded to the preliminary radiographic reports. The results of both methods were compared and interpreted by statistical analysis using the chi-square and Pearson correlation tests. Results: A total of 90 infants, 45 (50%) males and 45 (50%) females, were assessed. We noted that 17 (18.8%) cases had malpositioned tips according to the radiographs. Malpositioning of the line tips were identified in 21.1% of cases by sonography (P ≤ 0.05), which indicated a higher accuracy for sonography compared to radiography. Both methods were appropriately correlated regardless of the underlying variables. Sonography had a sensitivity of 100% and specificity of 89.5%, a positive predictive value (PPV) of 97.3%, and a negative predictive value (NPV) of 100%. Conclusions: Our findings show that sonography can be a more accurate, safer bedside tool, with fewer complications compared to radiography in PICC tip placement determination in neonates. Multi-center studies with increased sample sizes should be performed to confirm replacement of radiography by sonography as the gold standard test for confirmation of PICC tip positioning.

Arrhythmias in Children with Peripherally Inserted Central Catheters (PICCs).

To analyze the prevalence, types, and risk factors for cardiac arrhythmias associated with peripherally inserted central catheters (PICCs) in children. This is a case-control single center retrospective study. From 3180 PICCs inserted in children (< 18years old) between 2009 and 2013, cases with new onset arrhythmias were identified. Demographics, type and timing of arrhythmias, and possible risk factors were analyzed. ECGs, rhythm strips, physicians' records, and anti-arrhythmic management were confirmatory. The level of the PICC's tip in the superior vena cava (SVC) or right atrium (RA) was ascertained from chest X-rays and counted in rib units (RU) and vertebra units (VU). Cases were matched (1:1 ratio) to controls by weight and date of insertion. Descriptive statistics were performed. A two-sided p value < 0.05 was considered significant. Thirty-one children (1%) developed arrhythmias, 16/31 (56%) were males, and 24/31 (77%) were < 1-year age. Arrhythmias were atrial 22 (71%), ventricular 4 (13%), and undetermined 5 (16%). Median PICC dwell time was 16days. 14/31 (45%) cases and 9/31 (29%) controls had underlying structural heart disease. PICCs central tip position was lower among cases than controls (RU 6 vs 5). Odds Ratio for developing arrhythmia was 4.5 (95% CI 0.98-20.83) if the tip lays below 6.25RU. Arrhythmias were resolved with anti-arrhythmic agents in 52% (16/31) and with PICC exchange/manipulation in 32% (10/31) cases. Two children died unrelated to arrhythmia. Prevalence of arrhythmias associated with PICCs in children is low (1%). Arrhythmias are 4.5 times more likely when PICC's central tip position is deeper than 6.25RU.

Intracavitary electrocardiogram guidance for placement of peripherally inserted central catheters in premature infants.

This study evaluated the accuracy of intracavitary electrocardiogram (IC-ECG) guidance for placement of peripherally inserted central catheters (PICCs) in premature infants, relative to chest X-ray.Premature infants (n = 173) underwent placement of a PICC monitored by ECG, and a stable heart rhythm was shown. Changes in the P wave of the ECG reflected the position of the catheter tip, and a characterized P wave indicated the correct position. The P wave results were compared with a chest X-ray.P wave changes were observed in 157 (90.75%) of the premature infants on the ECG. Among them, the catheter tips of 148 (85.55%) and nine (5.20%) patients were in the correct and non-correct position, respectively, which was confirmed by chest X-ray. No characteristic P wave changes were observed in 16 (9.32%) patients on ECG, in which the catheter tips of eight (4.62%) patients each were in the correct and non-correct position, according to the chest X-ray. The accuracy of IC-ECG guidance for placement of the PICC was 90.17%. The PICC tip location results of the IC-ECGs were statistically similar to that of the chest X-rays.IC-ECG guidance is accurate for placement of PICC in premature infants, and provides an economical assessment without radiation.

Influence of guide wire removal on tip location in peripherally inserted central catheters (PICCs): a retrospective cross-sectional study

ObjectivesThe aim of this study was to identify the prevalence of peripherally inserted central catheter (PICC) malposition and the influence of guide wire removal on tip location in PICCs and...

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.

Clinical application of electrocardiogram-guided tip positioning in peripheral inserted central catheters placement.

The objective of the study was to perform the control study between the electrocardiogram (ECG)-guided tip positioning and traditional radiological confirmation method in peripherally inserted central catheters (PICC) placement; the accuracy and applicability of ECG-guided tip positioning were investigated. It aimed to expand the scope of PICC applications. From March 2016 to August 2017, 101 cases of patient with tumor admitted to the hospital were included in this study. The control study was performed before and after PICC placement. The tip positioning of PICC placement was performed under the guidance of bedside ECG system. The X-ray confirmation was applied for confirmation. Several parameters were observed, including positioning accuracy, success rate of primary catheterization, incidence of ectopic catheter, average catheterization time, and incidence of complications. Position accuracy was 100%. The success rate of primary catheterization was 99%. The incidence of ectopic catheter was 1%. Average catheterization time was (49.59 ± 21.45) min. Incidence of postoperative complications within 1 week was 4%. ECG-guided PICC tip positioning was safe and accurate. Success rate of catheterization could be improved. ECG-guided PICC tip positioning can be applied as an alternative approach for patients with P-wave fluctuations.

Improving Quality of Chest Radiographs After Placement of Peripherally Inserted Central Catheters.

The goal of this study was to determine the best method for localizing peripherally inserted central catheters (PICCs) in postplacement portable chest radiographs. A retrospective analysis showed no significant difference in visualization of the PICC tip between different chest radiograph projections. Modifications were made to an institutional PICC protocol to obtain anteroposterior chest views with the guidewire present only. Repeat analysis demonstrated statistically significant increases in the frequency of anteroposterior radiographs performed, the number of chest radiographs with guidewire, and the localization of the catheter. By standardizing the acquisition of PICC placement chest radiographs, fewer variant projection radiographs were performed and the catheter tip was confidently localized in more examinations.

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.

Non-central peripherally inserted central catheters in neonatal intensive care: complication rates and longevity of catheters relative to tip position.

Peripherally inserted central catheters (PICCs) represent a mainstay of intravascular access in the neonatal intensive care setting when long-term vascular access is needed. Ideally, PICCs should be inserted and maintained in a central position with the tip ending in the superior or inferior vena cava. This is not always achievable, and sometimes the tip remains in a peripheral location. Higher complication rates have been reported with non-central PICCs; however these findings have not been confirmed in a solely neonatal series and PICCs with tips in peripheral veins have not been studied. To compare complication rates and length of catheter duration related to PICC position in neonates. We conducted a retrospective analysis of all PICCs inserted in term and preterm infants in a tertiary neonatal intensive care unit between May 2007 and December 2009. A single pediatric radiologist reinterpreted the catheter tip site on initial anteroposterior (AP) chest radiographs and categorized sites as central (superior vena cava, inferior vena cava, brachiocephalic vein), intermediate (subclavian, axillary, common or external iliac veins), or peripheral (veins peripheral to axillary or external iliac veins). We analyzed complication rates and length of catheter duration among the three categories. We collected data on a total of 176 PICCs. Infants with PICCs in a central location had a significantly lower complication rate (18/97, 19%) than those with the PICC tip in an intermediate (24/64, 38%) or peripheral (9/15, 60%) locations (P=0.0003). Length of catheter duration was noted to be longest with central, intermediate with intermediate, and shortest with peripheral PICC tip locations (17.7±14.8days for central vs. 11.4±10.7days for intermediate vs. 5.4±2.5days for peripheral, P=0.0003). A central location is ideal for the tip of a PICC. When this is not achievable, an intermediate location is preferable to a more peripheral position.

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.

Peripherally Inserted Central Venous Catheter Complications in Children Receiving Outpatient Parenteral Antibiotic Therapy (OPAT).

OBJECTIVE To identify the frequency of and risk factors associated with complications necessitating removal of the peripherally inserted central catheters (PICCs) in patients receiving outpatient parenteral antibiotic therapy (OPAT) and to determine the appropriateness of OPAT in children with OPAT-related complications. METHODS A retrospective cohort of children who had a PICC inserted at the Johns Hopkins Children's Center between January 1, 2003, and December 31, 2013, and were discharged from the hospital on OPAT was assembled. RESULTS A total of 1,465 PICCs were used to provide antibiotic therapy for 955 children after hospital discharge. Among these, 117 PICCs (8%) required removal due to a complication (4.6 of 1,000 catheter days). Children discharged to a long-term care facility were at increased risk of adverse PICC events (incidence risk ratio [IRR], 3.32; 95% confidence interval [CI], 1.79-6.17). For children receiving OPAT, age of the child (adjusted IRR [aIRR], 0.95; 95% CI, 0.92-0.98), noncentral PICC tip location (aIRR, 2.82; 95% CI, 1.66-4.82), and public insurance (aIRR, 1.63; 95% CI, 1.10-2.40) were associated with adverse PICC events. In addition, 34 patients (32%) with adverse events may not have required intravenous antibiotics at the time of hospital discharge. CONCLUSIONS Of children discharged with PICCs on OPAT during the study period, 8% developed a complication necessitating PICC removal. Children discharged to a long-term care facility had an increased rate of complication compared with children who were discharged home. With improved education regarding appropriate duration of antibiotic therapy and situations in which early conversion to enteral therapy should be considered, PICC-related complications may have been avoided in 32% of children. Infect.

Application of intracavitary electrocardiography in the insertion of the groshong peripherally inserted central catheters

Objective To assess the application of intracavitary electrocardiography (IC-ECG) during the insertion of the Groshong peripherally inserted central catheters (PICC). Methods A total of 168 patients (aged 20-76 years) with gynecologic tumors who required the insertion of Groshong PICC because of various clinical conditions between January 2013 and December 2014 were selected into this study in Zhongnan Hospital of Wuhan University. During PICC insertion, the P-wave of IC-ECG helped general judgments about the position and direction of the tip of catheters, hence guiding the intubation. Precise position was determined by X-ray following the fastening of catheters, based on which the accuracy and sensitivity of IC-ECG in the insertion of Groshong PICC were evaluated. Results All the cases presented typical changes of P-wave. However, 15 cases exhibited no such alternations in the first placement however deep or shallow the catheters were, in whom the typical P-wave was induced after withdrawal and replacement of the catheters with adjustment of patient position. According to the X-ray (gold standard), the accuracy and sensitivity of IC-ECG in diagnosing position of tip in the superior vena cava (SVC) were 98.8% and 98.8%, respectively. The accuracy of diagnosing the position at the optimum location in the SVC reached 97.0%. Conclusions A high peaked P-wave of similar shape could be observed in IC-ECG in the insertion of Groshong PICC. IC-ECG could remarkably increase the positioning accuracy of PICC tip into the SVC; meanwhile, the optimal inserted length of the catheters could be determined by monitoring the changes of the P-wave with IC-ECG during insertion. Key words: Intracavitary electrocardiogram; Peripherally inserted central catheters; Tip position

CNS Led Implementation of ECG Guided PICC Placement Technology Decreases Patient Radiation Exposure, Nursing Time and Cost

Persistent left superior vena cava (PLSVC) occurs in approximately 1 in every 200 people, and with various malformations. Nurses who insert peripherally inserted central catheters (PICCs) may need to place a PICC line in this venous malformation.To review the literature and assess the safety of positioning a PICC line in a PLSVC, and to also assess the ideal placement of a PICC line in a PLSVC with reference to a chest radiograph and intravenous electrocardiogram (IVECG) navigation.Literature search across 5 main databases, alongside hand-searched articles.No literature was found that prohibits placement of a PICC line in a PLSVC, unless the PLSVC enters the left atrium, and no literature was found that identifies an ideal position for the PICC tip in a PLSVC. Two approximate positions were highlighted: high in the PLSVC or passed through a bridging brachiocephalic vein to a right superior vena cava. Placing a PICC line in a PLSVC using IVECG navigation is shown to produce abnormal electrocardiogram readings.A PICC line can be safely placed in a PLSVC as long as the PLSVC does not enter the left atrium, avoiding potential systemic embolization. Final positioning of the PICC tip on a chest radiograph is proposed to be in the midregion between the carina and the junction of the PLSVC/coronary sinus, with the aim of avoiding coronary sinus thrombosis and providing satisfactory dilution of infusate. If abnormal electrocardiogram readings during IVECG placement are seen, then PLSVC should be suspected. Further research and data are needed due to limited research in this area.