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      Therapeutics and Clinical Risk Management (submit here)

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      The safety and accuracy of ECG-guided PICC tip position verification applied in patients with atrial fibrillation


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          Tip position verification of peripherally inserted central catheters (PICCs) is essential to the use of the catheter. Postprocedural chest X-ray as the “gold standard” practice for PICC tip confirmation can lead to a significant delay for patient IV therapy, cost more, and lead to radiation exposure for both patients and staffs. Intracavitary electrocardiogram (IC-ECG)-guided PICC placement which provides real-time tip confirmation during the insertion procedure has been widely used. However, safety and accuracy of ECG for abnormal surface ECG patients, such as patients with atrial fibrillation (AF), have not been reported.


          To determine the safety and accuracy of IC-ECG technique for PICC tip position verification among the patients with AF.

          Patients and methods

          A prospective cohort study was conducted in a teaching and tertiary referral hospital with more than 3,600 beds in Qingdao, People’s Republic of China. Adult patients with diagnosis of AF who need a PICC for infusion from June 2015 to May 2017 were enrolled in the study. For every included patient with AF, ECG was used to detect the PICC tip position during catheterization and X-ray was done to confirm the tip position as the “gold standard” after PICC insertion. The effectiveness and accuracy of ECG-guided catheter tip positioning and chest X-ray confirmation were compared.


          Totally, 118 AF patients with 118 PICCs were enrolled (58 male and 60 female, age range 50–89 years old). There was no catheterization-related complication. When the catheter entered the lower 1/3 of superior vena cava, the amplitude of f wave reached the maximum. There was no statistical difference between X-ray PICC tip position verification and IC-ECG PICC tip position verification among patients with AF ( χ 2=1.31, P=0.232). Utilizing the cutoff point of f wave change ≥0.5 cm, a sensitivity of 0.94, a specificity of 0.71, a positive predictive value of 0.98, and a negative predictive value of 0.42 were observed. The area under the receiver operating characteristic curve was 0.909 (95% CI: 0.810–1.000).


          The ECG-guided technique represents a safe and accurate technique to verify the position of PICC tip in patients with AF and could potentially remove the requirement for postprocedural chest X-ray among the patients with AF.

          Most cited references21

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          Dressing disruption is a major risk factor for catheter-related infections.

          Major catheter-related infection includes catheter-related bloodstream infections and clinical sepsis without bloodstream infection resolving after catheter removal with a positive quantitative tip culture. Insertion site dressings are a major mean to reduce catheter infections by the extraluminal route. However, the importance of dressing disruptions in the occurrence of major catheter-related infection has never been studied in a large cohort of patients.
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            The electrocardiographic method for positioning the tip of central venous catheters.

            Tip position of a central venous access is of paramount importance and should be verified before starting infusion. Intra-procedural methods for verifying the location of the tip are to be preferred, since they avoid the risks, delays and costs of repositioning the tip. Among the intra-procedural methods, the electrocardiography (EKG) method has many advantages since it is as accurate as fluoroscopy, but simpler, more readily available, less expensive, safer and more cost-effective. The only contraindication to utilizing the EKG method is the difficulty in identifying the standard P-wave on a surface EKG (this happens - usually because of severe arrhythmias, such as atrial fibrillation - in only approximately 7% of cases: although such patients are easily identified before the procedure, and are referred to other methods for tip positioning). When dealing with the insertion of peripherally inserted central catheters (PICC), the EKG method (using the column of saline technique) virtually has no risk of false positives. The EKG method removes the need for the post-procedural chest x-ray, as long as there is no expected risk of pleuropulmonary damage to be ruled out (example: ultrasound guided central venipuncture for central venous catheter insertion or any kind of PICC insertion). In conclusion, evidence is mounting that the EKG method may be a valid and cost-effective alternative to the standard radiological control of the location of the tip of any central venous access device (VAD), and that will rapidly become the preferential method for confirming the tip position during PICC insertion.
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              The intracavitary ECG method for positioning the tip of central venous catheters: results of an Italian multicenter study.

              The aim of this multicenter study was to assess the feasibility, safety, and accuracy of the intracavitary ECG method for real-time positioning of the tip of different types of central venous catheters.

                Author and article information

                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                06 June 2018
                : 14
                : 1075-1081
                [1 ]Hospital Management Office, The Affiliated Hospital of Qingdao University, Qingdao, People’s Republic of China
                [2 ]Department of Community Nursing, School of Nursing, Weifang Medical University, Weifang, People’s Republic of China
                [3 ]Department of Hematology, The Affiliated Hospital of Qingdao University, Qingdao, People’s Republic of China
                [4 ]Intensive Care Unit, The Affiliated Hospital of Qingdao University, Qingdao, People’s Republic of China
                Author notes
                Correspondence: Yufang Gao, Hospital Management Office, The Affiliated Hospital of Qingdao University, No 16 Jiangsu Road, Shinan District, Qingdao, 266005, People’s Republic of China, Tel +86 186 6180 1800, Email gaoyufang0612@ 123456163.com

                These authors contributed equally to this work

                © 2018 Gao et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Original Research

                peripherally inserted central catheter,picc,tip position,electrocardiograph,ecg,patients with atrial fibrillation


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