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"Therefore, the main objective of this study was to evaluate the ratios of different waves in ivECG and body external ECG (exECG) when the correct tip location was confirmed by chest X-ray (CXR)" Lee et al (2022).

Optimal PICC tip position using ECG

Abstract:

Background: Correct tip location of a peripherally inserted central catheter (PICC) is crucial to ensure optimal drug delivery and avoid creating potential complications. P-wave amplitude changes in the intravascular electrogram (ivECG) can guide the PICC tip to the optimal location during the catheter placement procedure, but its accuracy is limited. Therefore, the main objective of this study was to evaluate the ratios of different waves in ivECG and body external ECG (exECG) when the correct tip location was confirmed by chest X-ray (CXR).

Methods: In this retrospective study, we analyzed the ivECG, exECG, and CXR of 146 patients who underwent a PICC placement procedure. The optimal location of the PICC tip was defined in the lower 1/3 of the superior vena cava (SVC) to the junction of the SVC and right atrium, known as the cavo-atrial junction (CAJ). The catheter tip to carina distance (TCD) was also measured using vertebral body units (VBU). The PICC tip location was categorized as follows: Zone 1, malposition with TCD < 1.2 VBU; Zone 2, suboptimal with 1.2 VBU ≤ TCD < 1.8 VBU; Zone 3, optimal with 1.8 VBU ≤ TCD < 2.8 VBU; Zone 4 deep with TCD > 2.8 VBU. The amplitude ratios between/within the ivECG and the exECG of the corresponding waves were calculated and compared.

Results: The external/internal ratio of the amplitude of uprising P-wave (Psp) and declining P-wave (Ppe) in Zone 3 was significantly higher than in Zone 1 (p < 0.001) and Zone 2 (p = 0.004). The amplitude ratio in the ivECG of uprising P and QR (Pspiv /QRiv ), uprising P and RS (Pspiv /RSiv ), declining P and QR (Ppeiv /QRiv ), and declining P and RS (Ppeiv /RSiv ) were significantly lower in Zone 3 compared to Zone 1 (p < 0.001, respectively). There was a moderate correlation between TCD using VBU and ECG height ratios such as Pspiv , Ppeiv , Pspiv /QRiv , and Pspiv /RSiv (p < 0.001, respectively).

Conclusions: The height ratios of ECG waves such as Pspiv , Ppeiv , Pspiv /QRiv , and Pspiv /RSiv can help determine the catheter tip location during the catheter insertion procedure; however, caution is required for accurate positioning of the PICC tip.


Reference:

Lee K, Kelly L, Sabouri AS, Jung KT. Optimal tip position of peripherally inserted central catheter (PICC) using electrocardiogram-a retrospective analysis. FASEB J. 2022 May;36 Suppl 1. doi: 10.1096/fasebj.2022.36.S1.R3067. PMID: 35553143.