Electrocardiogram (EKG) Guided Peripherally Inserted Central Catheter Placement and Tip Position: Results of a Trial to Replace Radiological Confirmation

Abstract Background The current standard of care for Peripherally Inserted Central Catheters (PICCs) is radiological confirmation of terminal tip location. Tip location practices in Europe have used electrocardiographic (EKG) guided positioning for central venous catheters for more than twenty years with tip positioning safely confirmed over thousands of insertions ( Madias, 2003 ). The goal of this group was to confirm the findings of a study performed by Pittiruti and his team; and to establish safe function in the use of EKG guidance for verification of terminal tip position with PICCs placed at McKenzie Willamette Medical Center. Methods In 2008/2009 McKenzie Willamette Medical Center conducted a study to determine whether or not EKG guidance can be used as a reliable means to accurately place and confirm terminal tip location of PICCs. A group of trained nurses performed PICC placement using EKG guidance followed by radiological confirmation of SVC position. All PICCs placed from October 2008 to December 2009 were included in the study. Tip location was confirmed using either radiological confirmation alone, EKG plus radiological confirmation, or EKG alone. Results A total of 417 PICCs were placed during the study period. EKG guidance alone was used in the placement and confirmation of 168 PICCs. Both EKG and chest x-ray confirmation were used in the placement of 82 of the PICCs; 240 of the PICCs were placed with the use of EKG and then position correlated using the traditional chest x-ray procedure. Discussion EKG guided PICC placement proved accurate in consistently guiding the terminal tip to the superior vena cava (SVC). The procedure was easily taught and duplicated by members of the PICC team. The study demonstrated a definite correlation between the height (size) of the P-wave and the location of the terminal tip within the SVC. With knowledge of this correlation, transition from placing PICCs using EKG guidance with chest x-ray confirmation to confirmation of tip placement using just EKG guidance without chest x-ray confirmation was attained. Application of EKG placement/ confirmation performed during insertion saves time previously spent waiting for x-ray confirmation readings, saves cost of chest x-ray, prevents patient exposure to radiation and saves time required for tip repositioning of malpositioned tips found after the end of the procedure.