The placement of central venous catheters in hemodialysis: role of the endocavitary electrocardiographic trace. Case reports and literature review.

Abstract

At present, the placement of a central venous catheter is becoming more and more a routine procedure nevertheless it involves different operators in fields such as oncology, nutrition, nephrology, and emergency medicine. It is well known that complications in the placement of CVC may occur in up to 20% of cases. One fifth of the catheters may result to be misplaced either in the internal omolateral jugular vein or in the innominate vein or in the controlateral brachiocephalic veins and usually a chest radiogram is necessary to evaluate its location. On the basis of 10 years of experience including more than 1,000 CVC placements, we now believe that endocavitary electrocardiography EC-ECG, initially studied and applied by Dr. Serafini, constitutes the best technique, more secure and more comfortable for the patient, to verify the position of the tip of a CVC. The technique EC-ECG, very simple and secure, utilizes the CVC as an endocavitary electrode. This is connected to a standard electrocardiograph, the same one to which the patient is connected during the placement of the CVC, and provides, in derivation V 1 or D 3 , an electrocardiographic pattern extremely sensitive to the position of the catheter tip. From December 1991 to December 2000, this technique has been used successfully in our departments of nephrology and applied to 1,139 patients that needed a CVC for hemodialysis. EC-ECG and a standard chest radiogram controlled the first 100 CVC we placed and in the other 1,039 cases, the control was made by EC-ECG alone. Only in 31 patients (2.7% of all cases), due to arrhythmia, the technique EC-ECG was not utilized. According to our experience, the procedure EC-ECG is an extremely reliable technique, sensitive and specific in 100% of cases, easy for the operator to perform, comfortable for patient. It doesn't need additional time to be performed and eliminates the need of taking a chest radiogram that up to now was considered indispensable in order to verify the position of the catheter tip. In this manner serious complications such as pneumothorax, and haemothorax that can complicate the placement of a CVC can also be avoided. Based on our experience, we now believe that this technique, that today has a large application in nephrology, oncology, clinical nutrition and in various branches of general medicine whenever the placement of a CVC is required, should be considered as a possible new guide line in controlling the placement of a CVC together with a chest X-ray when it is necessary.