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| Year : 2009 | Volume
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| Issue : 5 | Page : 794-797 |
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| Application of intravenous electrocardiography for insertion of central veins dialysis catheters |
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Ali Akbar Beigi1, Farzad Parvizian2, Hassan Masoudpour2
1 Department of Vascular Surgery, Alzahra Hospital, Isfahan, Iran
2 Department of General Surgery, Alzahra Hospital, Isfahan, Iran
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| Date of Web Publication | 2-Sep-2009 |
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 Abstract | | |
One fifth of the inserted dialysis catheters in the internal jugular or subclavian veins may be misplaced. Appropriate positioning of the catheter tip is sometimes difficult. We attempted to use intravenous electrocardiography (ECG) to guide catheter tip positioning in 30 hemodialysis patients (17 (57%) were men, and the mean age was 43 ± 12 years). who required vascular accesses for dialysis by insertion of double lumen temporary catheters via the jugular veins. Before catheterization, standard ECG on the long lead D II was performed and P-wave height was recorded. Pwave voltage was also measured via the blue (venous) and red (arterial) lumens, using the guide wire as an electrical conductor. After confirmation of the appropriate position of the catheter tip at the superior vena cava (SVC)-right atrial junction using chest radiography, the ECG lead corresponding to the right hand was connected to the guide wire lodged inside the lumen of the blue catheter. P-wave height in the long lead D II was recorded. The guide wire was withdrawn so as to bring its tip tangent to the tip of the red catheter. ECG was performed on the long lead D II in a similar manner, and the P-wave height was recorded. The mean P-wave voltage in normal ECG and intravenous ECG (red and blue catheter tips) measured 1.27 ± 0.38 mm, 3.10 ± 0.95 mm, and 5.42 ± 1.76 mm, respectively. The difference between the mean P-wave voltages measured in standard and intravenous ECG (blue and red catheter tips) was statistically significant (P< 0.05). We conclude that the dialysis catheter tip can be positioned appropriately via the measurement of the P-wave height by intravenous ECG and using the sinoatrial node as an accurate landmark. This method can complement the chest radiography in the appropriate placement of the central vein catheters.
How to cite this article:
Beigi AA, Parvizian F, Masoudpour H. Application of intravenous electrocardiography for insertion of central veins dialysis catheters. Saudi J Kidney Dis Transpl 2009;20:794-7 |
How to cite this URL:
Beigi AA, Parvizian F, Masoudpour H. Application of intravenous electrocardiography for insertion of central veins dialysis catheters. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2020 Dec 2];20:794-7. Available from: https://www.sjkdt.org/text.asp?2009/20/5/794/55363 |
| Introduction | |  |
Large bore double lumen dialysis catheters are commonly used as a temporary access for hemodialysis. Catheters placed via the femoral vein increase the risk of deep vein thrombosis (DVT) in the lower limb and cannot be used for more than 1 week. [1],[2] The internal jugular vein is a more common route of access placement, but can potentially result in a serious morbidity due to trauma to the adjacent structures (e.g. arterial rupture, pneumothorax, neuronal damage, etc.) or damage caused by the catheter itself (cardiac rupture, cardiac arrest, thrombosis, infection and tamponade). [1],[2],[3],[4],[5],[6],[7] Accurate placement of the catheter tip at the junction of the superior vena cava (SVC) and the right atrium can not be overemphasized in order to minimize these complications. [6],[7],[8],[9] The sinoatrial (SA) node is located at approximately at the junction of SVC and the right atrium and can be precisely located by intravenous electrocardiography (ECG). [10],[11],[12],[13] Assurance of An appropriate catheter tip insertion can be obtained by locating the SA and positioning the catheter tip in its close vicinity. Inaccurate positioning of the catheter tip results in sluggishness or cessation of blood flow in the access. Generally, chest X-ray (CXR) is routinely performed to verify the correct positioning of the catheter. [1],[2] The position of the catheter can be ascertained by a complementary intravenous ECG.
Our study aims at the evaluation of the efficacy of using the intravenous ECG in guiding the position of the tips of the dialysis catheters during the procedure of insertion in the jugular veins.
| Materials and methods | | |
This prospective study was conducted on 30 dialysis patients presenting to Alzahra University Hospital. The patients required access placement to undergo dialysis for different reasons. The patients with electrolyte imbalance and/or cardiac arrhythmia were excluded.
Initially, standard ECG on the long lead D II was performed on each patient, and the P-wave height was recorded. Before placement, a guide wire was passed through the catheter, its tip was brought tangent to the catheter tip, and the guide wire was marked. Under cardiac monitoring and in sterile conditions, we inserted a 12 Fr 13 cm temporary dialysis catheter (ARROW®) in the internal jugular vein. CXR was performed using a portable X-ray or C-Arm device to accurately locate the tip of the access catheter. The standard location of the catheter tip is at the superior vena cava (SVC)-right atrial junction, which lies anterior to the T4-T5 thoracic vertebral bodies. [1],[2],[11] All the catheters were so adjusted as to have its tip at the T4-T5 level. [13] After injecting the catheter lumen with normal saline, we inserted the guide wire into the lumen of the blue catheter and brought its tip tangent to that of the catheter. With the limb leads connected, we used the ECG gel to connect the lead corresponding to the right hand to the guide wire lodged inside the catheter. Then we obtained a long lead D II ECG and recorded the P-wave height. Then we inserted the guide wire into the red catheter, or alternatively, since the tip of red catheter (ARROW®) is shorter than the blue one by 2 cm, the guide wire could be pulled out through the blue catheter by 2 cm.
With the tip of the guide wire tangent to that of the red catheter, we obtained a long lead D II ECG in a manner similar to before and recorded the P-wave height. After ECG, the guide wire was pulled out and the catheter was washed with normal saline. The catheter was then heparinized and the access was fixed using 3/0 nylon thread. With the catheter tip in the appropriate location, we measured the mean P-wave height via the blue and red catheter lumens.
We compared the P-wave heights corresponding to ECGs performed via the blue and red catheters lumens, and compared them with those measured by the standard ECG [Figure 1].
| Statistical analysis | | |
SPSS software package was used to analyze the data. The Pearson's correlation coefficient was used to assess the correlation between variables. The linear or logarithmic regression analysis was used to predict dependent variables based on independent ones. P values less than 0.05 were considered statistically significant.
| Results | | |
Thirty hemodialysis patients were included in the study (17 (57%) were men and the mean age of the patients was 43 ± 12 years). The means of the P-wave peaks measured by standard ECG and intravenous ECG conducted via the red and blue catheters lumens were 1.27 ± 0.38 mm, 3.10 ± 0.95 mm, and 5.42 ± 1.76 mm, respectively [Figure 1]. One way analysis of variance (ANOVA) showed statistically significant differences between the means of the Pwave peaks measured by standard and intravenous ECG (i.e. via blue and red catheters) (P < 0.05).
| Discussion | | |
We applied the intravenous ECG to find the efficacy of the peaks of the P-waves in guiding accurate insertion of the dialysis catheters tips and found it useful, since the P-waves can denote the location of the SA node at the junction of the SVC-R atrial junction. Considering the difficulties involved in reading the portable CXR and the occasional need for multiple radiographs, we found the intravenous ECG a good tool to complement the CXR in accurately locating the catheter tip relative to the SA as the accurate landmark. Our success rate was 100%. Similar studies on the application of ECG in the central venous catheterization have yielded varying results; however, thus far there have been no definite conclusions or guidelines as to how the mean P-wave peak may be used to guide dialysis catheterization. [14],[15],[16],[17],[18],[19],[20]
We measured P-wave voltage via the guide wire as an electrical conductor. The highest Pwave was recorded when the guide wire tip was closest to the SA, which lies at the SVC-right atrium junction. A biphasic P-wave was recorded when the catheter tip was advanced further ahead, passing the SA and entering the right atrium. The biphasic P-wave consisted of a small negative P-wave followed by a high-amplitude positive P-wave. As the catheter was pushed further into the atrium, the negative and positive P-waves gained and lost amplitude, respectively. Assuming that the SA is located at the SVC-right atrium junction and that the highest P-wave is recorded in the closest vicinity of the SA, the catheter's best location should corresponds to the point where the highest P-wave voltage is recorded. Although the absence of increasing the P-wave size may be interpreted as incorrect positioning of the CVCs in vessels other than the superior vena cava, [15],[16] it may also be observed in patients with myocardial pathology or pulmonary emphysema, or when the catheter is inserted in the left side of tall patients. [21]
We did not observe in our study incorrect positioning of the dialysis catheters inserted through the left internal jugular vein. However, it has been suggested by a few authors that ECG-guidance may fail, and catheters may advance through the left subclavian veins when insertion is attempted in the left jugular veins. [22],[23] Further more, we expect this method to be inapplicable in conditions such as left atrial enlargement (e.g. mitral stenosis), where the position of the SA cannot be estimated based on its typical anatomical location relative to the SVCright atrial junction.
In conclusion, ECG-guidance may be a reliable method to correctly position dialysis catheters in the superior vena cava during emergency care. It could allow a decreasing rate of hemodialysis catheters misplacement and the number of CXRs needed to check their positions.
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Correspondence Address:
Hassan Masoudpour
Department of General Surgery, Alzahra Hospital, Isfahan
Iran
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PMID: 19736475 
[Figure 1] |
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