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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 5  |  Page : 794-797
Application of intravenous electrocardiography for insertion of central veins dialysis catheters

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 Publication2-Sep-2009


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 The guide wire was withdrawn so as to bring its tip tangent to the tip of the red catheter.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 2022 Jun 28];20:794-7. Available from: https://www.sjkdt.org/text.asp?2009/20/5/794/55363

   Introduction Top

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 Top

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 Top

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 Top

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 Top

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.

   References Top

1.Bernard Montreuil. Vascular and Peritoneal Access. ACS Surgery: Principles & Practice, 2007.  Back to cited text no. 1    
2.Miller RD. Cardiovascular Monitoring. In: Mark BJ, Slaughter TS,(eds). Anesthesia 5th ed. Vol 1. Cherchil - Livingstone, 2000:1117-207.  Back to cited text no. 2    
3.Work J. Hemodialysis catheters and ports. Semin Nephrol 2002;22:211.  Back to cited text no. 3    
4.Mansfield PF, Hohn DC, Fornage BD, et al. Complications and failures of subclavian vein catheterization. N Engl J Med 1994;331:1735.  Back to cited text no. 4    
5.Conces D, Holden R. Aberrants locations and complications in initial placement of subclavian vein catheters. Arch Surg 1984;119:293-5.  Back to cited text no. 5    
6.McGee D, Gould M. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.  Back to cited text no. 6    
7.Scott W. Complications associated with central venous catheters. A survey. Chest 1988;94: 1221-4.  Back to cited text no. 7    
8.Szanjder J, Zverbil F, Bitterman H, et al. Central vein catheterization, failure and complications by three percutaneous approaches. Arch Intern Med 1986;146:259-61.  Back to cited text no. 8    
9.Rippe JM, Irwin RS, Fink MP, et al. Procedures and techniques - Central venous catheters, In: Semeff MG. Intensive care Medicine, 3 rd . vol 1. Little Brown company, 1996:15-36.  Back to cited text no. 9    
10.Artea A, Colley P. The site of origin of the intravascular electrocardiogram recorded from multiorifice intravascular catheters. Anesthesio­logy 1988;69:44-8.  Back to cited text no. 10    
11.Taylor RW, Palagiri AV. Central venous catheterization. Crit Care Med 2007;35:1390-6.  Back to cited text no. 11    
12.Caruso LJ, Gravenstein N, Layon AJ. A better landmark for positioning a central venous catheter. J Clin Monit 2002;17:331-4.  Back to cited text no. 12    
13.Snell RS. The upper limb. In: Snell RS. Clinical Anatomy, 7th ed. Lippincott Williams & Wilkins, 2004:502-503.  Back to cited text no. 13    
14.Schummer W, Schummer C, Schelenz C, et al. Modified ECG-guidance for optimal central venous catheter tip positioning: A trans­esophageal echocardiography controlled study. Anaesthesist 2005;54:983-90.  Back to cited text no. 14    
15.McGee WT, Ackerman BL, Rouben LR, et al. Accurate placement of central venous catheters: A prospective, randomized, multicenter trial. Crit Care Med 1993;21:1118-23.  Back to cited text no. 15    
16.Gronert GA. Intra atrial ECG guidance for positioning. Br J Anaesth 2004;92:599-601.  Back to cited text no. 16    
17.Schuster M, Nave H, Piepenbrock S, Pabst R, Panning B. The carina as a landmark in central venous catheter placement. Br J Anaesth 2000; 85:192-4.  Back to cited text no. 17    
18.James L, Hadaway LC. A retrospective look at tip location and complication of peripherally inserted central catheter lines. J Intrav Nurs 1993;16(2):104-9.  Back to cited text no. 18    
19.Malatinsky J, Kadlic T, Majek M, et al. Mis­placement and loop formation of central venous catheters. Acta Anaesth Scand 1976;20(3):237­47.  Back to cited text no. 19    
20.David JS, Tazarourte K, et al. Is ECG-guidance a helpful method to correctly position a central venous catheter during pre-hospital emergency care? Acta Anaesth Scand 2005;49:1010-4.  Back to cited text no. 20    
21.Wilson R. JAG Right atrial electrocardiography in placement of central venous catheters. Lancet 1988;1:462-3.  Back to cited text no. 21    
22.Schummer W, Schummer C, Muller A, et al. ECG guided central venous catheter positioning: does it detect the pericardial reflection rather than the right atrium? Eur J Anaesthesiol 2004; 21:600-5.  Back to cited text no. 22    
23.Salmela L, Aromaa U. Verification of the position of a central venous catheter by intra atrial ECG. When does this method fail? Acta Anaesthesiol Scand 1993;37:26-8.  Back to cited text no. 23    

Correspondence Address:
Hassan Masoudpour
Department of General Surgery, Alzahra Hospital, Isfahan
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Source of Support: None, Conflict of Interest: None

PMID: 19736475

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