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Year : 2018  |  Volume : 14  |  Issue : 4  |  Page : 887-891

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

1 Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, Ji'nan, 250021 Shandong, China
2 Department of Healthcare Oncology, Shandong Provincial Hospital Affiliated to Shandong University, Ji'nan, 250021 Shandong, China
3 Department of Intensive Care, Shandong Provincial Hospital Affiliated to Shandong University, Ji'nan, 250021 Shandong, China

Date of Web Publication27-Jun-2018

Correspondence Address:
Dong Fan
Department of Intensive Care, Shandong Provincial Hospital Affiliated to Shandong University, Ji'nan, 250021 Shandong
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_46_18

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 > Abstract 

Objective: 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.
Methods: 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.
Results: 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%.
Conclusion: 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.

Keywords: Electrocardiogram-guided positioning, peripherally inserted central catheter, tip positioning

How to cite this article:
Li W, Xu R, Fan D. Clinical application of electrocardiogram-guided tip positioning in peripheral inserted central catheters placement. J Can Res Ther 2018;14:887-91

How to cite this URL:
Li W, Xu R, Fan D. Clinical application of electrocardiogram-guided tip positioning in peripheral inserted central catheters placement. J Can Res Ther [serial online] 2018 [cited 2020 Jul 15];14:887-91. Available from: http://www.cancerjournal.net/text.asp?2018/14/4/887/235086

 > Introduction Top

Peripherally inserted central catheter (PICC) is a kind of deep vein catheterization, which is inserted through peripheral vein. The tip of PICC is in the central vein, which could be visualized under X-ray. Currently, the best position of tip has been recognized as the middle and lower one-third of the superior vena cava (SVC), or 2–4 cm above the SVC/right atrium junction (SVC/AR), without entering the right atrium or right ventricle.[1],[2] If the catheter was located too shallow in the veins above the SVC (such as jugular vein or axillary vein), the complications would be significantly increased, such as phlebitis and PICC-related venous thrombosis.[2],[3],[4],[5],[6] If the catheter was placed too deep (enter right atrium, right ventricle, and inferior vena cava), there would be some serious complications such as arrhythmia, valve damage, and atrial thrombosis.[7]

The X-ray-guided positioning method has been called gold standard for positioning the tip of PICC. However, the current practice of performing a chest X-ray postinsertion of PICC can be fraught with complications regarding accurately placing the PICC. There were still some defects, such as its hysteresis and relevant complications. In addition, it was difficult to conduct X-ray positioning in special populations, including patients with critical illness, pregnant women, infants, and young children.[8]

Electrocardiogram (ECG)-guided method has been an innovative method for PICC tip positioning. The principal of ECG-guided positioning is based on the P-wave fluctuations. This method has been recognized effective and facile. Many developed countries have applied ECG-guided method in performing PICC placement. The Italian Group for Venous Access Devices has performed a multicenter study investigating the safety and accuracy of intracavitary electrocardiography (IC-ECG) in 309 pediatric patients (age 1 month–18 years).[9] P-wave was detected in finally included 307 cases. They concluded that the IC-ECG method was safe and accurate, with the applicability of 99.4% and feasibility of 99.4%. No ECG-related complication was reported. Another study reported that ECG guidance achieved a malposition rate of 20.5% (95% CI 16-26%) without complications, which was significantly lower than their historical data.[10] More studies have focused on the manipulation of ECG-guided PICC placement.[11],[12],[13] Argoti-Velasco et al. have reviewed the procedure for correctly placing the catheter.[11] All these efforts have enabled the further improved accuracy and efficiency of ECG-guided PICC placement. However, this technology has not been widely applied in China.

In this study, the control study was performed between the ECG-guided tip positioning and traditional radiological confirmation method in PICC placement. The patients with tumor were involved in this study. First, the PICC placement was performed under the guidance of ECG. Then, the results were confirmed with X-ray imaging. Finally, the accuracy, applicability, and complications of ECG-guided tip positioning were investigated.

 > Methods Top

General information

The patients with long-term infusion or tumor chemotherapy received PICC catheterization in Shandong Provincial Hospital Affiliated to Shandong University were included in this study. Inclusion criteria are as follows (1) no confirmed evidence of bloodstream infection or serious systemic infection before PICC placement; (2) no SVC compression syndrome; (3) no serious cardiovascular diseases with abnormal P-wave (such as pulmonary heart disease or atrial fibrillation), nor severe heart blockage; (4) aged 18 years or above; (5) without a pacemaker or implantable defibrillator; and (6) signed informed consent form by patients or relatives. Exclusion criteria are as follows (1) refused to sign informed consent form; (2) patient carried with infection source; (3) being allergic to the tubing material; and (4) patient with pregnancy or unable to receive X-rays. From March 2016 to August 2017, a total of 101 patients were enrolled in this study: 49 males and 52 females, with a mean age of 47.3 ± 7.6 years. There were four cases reported previous thromboses and three cases with central venous catheterization, five cases with PICC placement history.

Study methods

Equipment and instruments

ECG – Mindray PM 9000 monitor. ECG-positioned PICC catheter package was purchased from Hao Long Company (model: PB-B 4F, the United States).


A convenient sampling method was involved in this study. Self-designed case report form was referred to expert consultants and literature review. PICC process was guided with electrocardiography. Then, the X-ray imaging was applied for examining and confirming.

Operation procedure

(1) Three ECG (Mindray PM 9000 monitor) leads were placed on the patient's left and right clavicle near the shoulder, left lower abdomen, respectively. The P-wave of normal sinus rhythm should be clearly distinguished to perform the ECG-guided positioning. Waveform of ECG was printed out [Figure 1]a. (2) The length of catheter required was measured: The span from the puncture point to the right sternal lock joint was measured, adding 5–7 cm or reflexed to the patient's third intercostal space, and 2 cm was added (Note: Biphasic P-wave would not appear with too short catheter length. Hence, the ideal position of the catheter tip could be affected). Sterile ECG lead clip and sterile protective sleeve were equipped within the largest sterile barrier. Then, normal sinus rhythm ECG was printed [Figure 1]a. Lead located at the right side of the clavicle was removed. Immediately, the right-side lead and ultrasound probe were wrapped in a sterile protective sleeve, and lead tip was clipped with the sterile EKG lead clip (Note: To make sure the lead tip passed through the protective sleeve. At the same time, the leads were well contacted with the lead clips). When the PICC catheter was inserted at an expected length, the sterile ECG lead clip was clamped with the PICC guide wire (Note: Do not extend more than 1 cm from the tip of the catheter during withdrawing the PICC guide wire). The catheter was slowly delivered, and the change of P-wave amplitude was carefully observed. When the “biphasic” amplitude of P-wave was displayed, the ECG waveform was printed [Figure 1]b. The catheter was slowly retracted by 2–3 cm and change of P-wave amplitude was carefully observed. When the P-wave amplitude was around 50%–80% of QRS-wave amplitude, the ECG waveform was printed [Figure 1]c. When the P-wave amplitude height is shown to be 50% of the QRS, print the ECG waveform [Figure 1]d. The X-ray imaging was taken for a second confirmation.
Figure 1: The electrocardiogram waveform of P-wave for catheter tip locating in different positions. (a) Normal sinus rhythm; (b) catheter located in the right atrium; (c) catheter located at the junction of the superior vena cava with the right atrium; (d) catheter located in the lower one-third of the superior vena cava

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Many indicators were observed and recorded, including the puncture success rate in different placement sites, incidence of ectopic catheter, average catheterization time, punctures number, incidence of complications, and positioning accuracy of different body surface length measurement methods.

Statistical analysis

The SPSS18.0 (IBM) was applied for analyzing the parameters such as patient's puncture success rate, incidence of ectopic catheter, average catheterization time, punctures number, incidence of complications and so on. Measurement data were expressed as mean ± standard deviation. Data were tested with Chi-square test. When P < 0.05, the difference was considered as statistically significant

 > Results Top

Peripheral inserted central catheters catheterization

The PICC catheterizing of all patients were performed and recorded [Table 1]. Many indicators were provided, including the placement sites, placement vein, puncture approach, puncture times, and the success rate of catheterization. From the results summarized in [Table 1], we could observe that 59 cases of catheterization were located at upper left elbow (58.4%) and 39 cases were placed at upper right elbow (38.6%). Most of the PICCs were placed at basilic vein (89 cases, 88.1%) and brachial vein (10 cases, 9.9%). Most of the catheterizations were completed under the ultrasonic guidance (96 cases, 95.1%). Most of the punctures succeeded at the first time (91 cases, 90.1%), without further adjustment (87 cases, 86.1%).
Table 1: Peripheral inserted central catheters catheterization of all patients (n=101)

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The tip position of peripherally inserted central catheters and success rate without adjustment

The 101 cases of patients received the ECG-guided PICC placement. The tip position of the PICC was located at the optimal position, which was confirmed with the X-ray imaging. The success rate of ECG-guided PICC placement was 100%. During the catheterization, there was one case (1%) of malposition with catheter located in jugular vein. After adjustment, the P-wave was changed. The total success rate of catheterization without adjustment was 99% (100/101) [Table 2].
Table 2: The tip position and success rate of peripheral inserted central catheters (n=101)

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Peripheral inserted central catheters catheterization time

In this study, the average PICC catheterization time was (49.59 ± 21.45) min.

Incidence of postoperative complications within 1 week

No complication was observed during the procedures. The incidence of complications was 4.0% within 1 week after placement, including 1 case (1.0%) of arrhythmia, 1 case (1.0%) of phlebitis, and 2 cases (2.0%) of blood return in catheter [Table 3].
Table 3: The incidence of complications within 1 week after peripheral inserted central catheters placement (n=101)

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 > Discussion Top

Many previous studies have introduced that the success rate of PICC placement could be improved with ECG-guided positioning. The improved success rate and reduced complications have made ECG-guided positioning a better approach than the traditional X-ray-based method, which was also the current “gold standard” for positioning PICC placement. The results obtained in our study were consistent with above conclusions.[10],[11],[12],[13],[14] With the guidance of ECG, the results of X-ray confirmed that the catheter tip was located in correct position, with an accuracy of 100%. The traditional X-ray method mainly depended on the prediction of required length before puncture. The catheterization was performed according to the predicted length and then it was confirmed with postoperative X-ray examination. The operation would be easily affected by the size of patients, the measurement method, changes of puncture point, and the subjective factors of operators. The catheter may be located too shallow or too deep. However, the catheterization was real-time monitored with ECG guidance, then the position of catheter tip could be adjusted at any time by operator according to the change of P-wave. Therefore, the puncture and positioning of catheter could be completed at the same time, with high success rate. In addition, suffering resulting from multiple times of puncture and the damage from multiple times of X-ray imaging could be avoided. Notably, except for the own pathological factors of patients, the malposition of catheter tip should be first considered if P-wave changes was not observed during catheterization. One case of malposition in jugular vein was observed in this study.

As an alternative method to the traditional chest X-ray positioning, ECG-guided PICC tip positioning has been proved to be safe and accurate with lower complication rate. A multicenter study has demonstrated that ECG-guided positioning was applicable to the majority of patients.[14] The Vein Therapy Practices Standard (2016) released by the American Infusion Nurses Society stated that: Postoperative radiographic imaging was not necessary if tip position was confirmed with an alternative method.[15] There is no ECG associated complication observed during catheterization, the incidence of postoperative complications within 1 week was about 4%, which was lower than the incidence of chest X-ray positioning related complications.[16] The result indicated that ECG-guided positioning technology would reduce the catheter-related complications. The reasons may be the hysteresis in traditional X-ray positioning, or repeated adjustments if necessary, leading to increased infection and complications, and the chance of adjustment was slim if the catheter was trimmed. In addition, the X-ray imaging was not applicable for real-time monitoring because of the potential radiation damage. There were several advantages of ECG-guided PICC positioning method: (1) it was a facile, simple and safe technique without large area exposure; (2) it was noninvasive examining enabling real-time monitoring, thus the catheter position can be adjusted at any time; (3) PICC catheterization and tip positioning was performed at the same time; and (4) the exposure from X-ray radiation could be avoided. Thus, the conventional postoperative X-ray confirmation is dispensable when there were characteristic P-wave changes.

The ECG-guided tip positioning could extend the application of PICC placement, since the less time-consuming and medical source-consuming, as well as the equipment requirement. In this study, the mean catheterization time was (49.59 ± 21.45) min. It was significantly lower than the traditional catheterization time (17 h, from examination to provide the written report by radiologists). Therefore, the time from catheterization to infusion treatment was greatly shortened. The patient would be accompanied by nurse in traditional postoperative chest radiograph confirm, the procedure would increase both the time and economic cost of catheterization, which was inefficient. With the ECG-guided positioning technique, postoperative chest radiography was only needed for a small percentage of patients without P-wave changes. Thus, the imaging resources could be saved, and be beneficial for effective utilization of limited medical resources. Especially, ECG positioning technology was even suitable for patients unable to receive X-ray examination, including patients with pregnancy,[17] intensive care or the patients in community medical units without radiology. With ECG positioning technology, the application of PICC could be expanded, and more patients will be benefited.

 > Conclusion Top

In summary, ECG-guided PICC tip positioning technology was facile, and the puncture and position could be completed at the same time. The process of PICC insertion could be real-time monitored and adjusted under a sterile state. The success rate of catheterization could be ensured, and the complications could be significantly reduced, including infection, thrombosis, catheter blockage, phlebitis, and atrial arrhythmia. In addition, the risk of X-ray radiographs could be avoided, especially for critically ill patients and pregnant patients. Therefore, the quality of life of the patients can be greatly improved.

Financial support and sponsorship

This study was supported by Key Research and Development Plan of Shandong Province (No. 2015GSF118137).

Conflicts of interest

There are no conflicts of interest.

 > References Top

Pittiruti M, La Greca A, Scoppettuolo G. The electrocardiographic method for positioning the tip of central venous catheters. J Vasc Access 2011;12:280-91.  Back to cited text no. 1
Chen W, Deng H, Shen L, Qin M, He L. A comprehensive intervention program on the long-term placement of peripherally inserted central venous catheters. J Cancer Res Ther 2014;10:359-62.  Back to cited text no. 2
Caers J, Fontaine C, Vinh-Hung V, De Mey J, Ponnet G, Oost C, et al. Catheter tip position as a risk factor for thrombosis associated with the use of subcutaneous infusion ports. Support Care Cancer 2005;13:325-31.  Back to cited text no. 3
Madabhavi I, Patel A, Anand A, Choudhary M, Revannasiddaiah S. Spontaneous deep venous thrombosis: An unrecognized entity with sorafenib. J Cancer Res Ther 2015;11:1029.  Back to cited text no. 4
Bhagat M, Kembhavi S, Qureshi SS. Fibrolamellar hepatocellular carcinoma with extensive vascular thrombosis. J Cancer Res Ther 2015;11:493-4.  Back to cited text no. 5
Zhu L, Liu B, Zhao Y, Liu L, Yang C, Yang Y, et al. High levels of D-dimer correlated with disease status and poor prognosis of inoperable metastatic colorectal cancer patients treated with bevacizumab. J Cancer Res Ther 2014;10 Suppl: 246-51.  Back to cited text no. 6
Taylor RW, Palagiri AV. Central venous catheterization. Crit Care Med 2007;35:1390-6.  Back to cited text no. 7
Oliver G, Jones M. ECG or X-ray as the 'gold standard' for establishing PICC-tip location? Br J Nurs 2014;23 Suppl 19:S10-6.  Back to cited text no. 8
Johnston AJ, Holder A, Bishop SM, See TC, Streater CT. Evaluation of the sherlock 3CG tip confirmation system on peripherally inserted central catheter malposition rates. Anaesthesia 2014;69:1322-30.  Back to cited text no. 9
Pittiruti M, Bertollo D, Briglia E, Buononato M, Capozzoli G, De Simone L, et al. The intracavitary ECG method for positioning the tip of central venous catheters: Results of an Italian multicenter study. J Vasc Access 2012;13:357-65.  Back to cited text no. 10
Argoti-Velasco YL, Carrillo-Torres O, Sandoval-Mendoza RA, Paez-Amaya WG, Cahuantzi-Caballero XY. Proper electrocardiography-guided placement of a central venous catheter. Rev Méd Del Hosp Gen De Méx 2016. Available from: http://dx.doi.org/10.1016/j.hgmx.2016.09.007.  Back to cited text no. 11
Smith B, Neuharth RM, Hendrix MA, McDonnall D, Michaels AD. Intravenous electrocardiographic guidance for placement of peripherally inserted central catheters. J Electrocardiol 2010;43:274-8.  Back to cited text no. 12
Madias JE. Intracardiac electrocardiography via a “saline-filled central venous catheter electrocardiographic lead”: A historical perspective. J Electrocardiol 2004;37:83-8.  Back to cited text no. 13
Rossetti F, Pittiruti M, Lamperti M, Graziano U, Celentano D, Capozzoli G, et al. The intracavitary ECG method for positioning the tip of central venous access devices in pediatric patients: Results of an Italian multicenter study. J Vasc Access 2015;16:137-43.  Back to cited text no. 14
Gorski L, Hadaway L, Hagle ME, Mcgoldrick M, Orr M, Doellman D, et al. Infusion therapy standands of practice. J Infusion Nurs 2016;39:1-132.  Back to cited text no. 15
Gabriel J. Preventing and managing complications of CVADs. Nurs Times 2013;109:20-3.  Back to cited text no. 16
Cape AV, Mogensen KM, Robinson MK, Carusi DA. Peripherally inserted central catheter (PICC) complications during pregnancy. JPEN J Parenter Enteral Nutr 2014;38:595-601.  Back to cited text no. 17


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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