Liz Wilson, OPAT Lead NurseWythenshawe HospitalManchester University NHS FT

ECG directed PICC line insertion

What is ECG directed PICC line insertion?

• ECG monitoring, during PICC line insertion, to promote accurate central line placement.

• This method can be used for all central line insertions.

Hellerstein, Pritchard & Lewis, 1949

• Reported changes in the internal p-wave, measured from the tip of a central venous catheter, as it passes through the superior vena cava, cavo-atrial junction & into the right atrium

How does ECG placement work?

• During PICC placement an intravascular ECG waveform is detected

• As the catheter moves along the SVC towards the heart, ECG changes occur

• These changes are detected by a metal guidewire or saline column inside the PICC, which transmits the internal ECG waveform to the monitoring device

• Practitioner compares the 2 ECG traces to determine optimal PICC tip position

‘Optimal’ tip position

US guidelines:

‘The…..tip location with the greatest safety profile in adults and children is the cavo-atrial junction.’ (Infusion Nurses Society 2016)

European guidelines:

The distal tip of a CVAD should dwell in the mid or lower third of the SVC, CAJ or upper right atrium. (Pittiruti, 2009)

NICE consensus (2014):

Variation between definitions are less important than whether a PICC is so misplaced that a further procedure is needed to correct the position

• Furthest distance from the ‘high risk’ areas

• Largest vein diameter

• Highest blood flow capacity

• Minimal risk for catheter migration and looping

Too short - ↑ risk of DVT, phlebitis, CR-BSI

Too long - ↑ risk of arrhythmias, tricuspid valve dysfunction or atrial dysfunction

Benefits of ‘maximum-p’

Benefits of ECG technology:

• Provides ‘real-time’ feedback of PICC tip position• Promotes accuracy of PICC placement• Improves success rate

• Removes the need for fluroscopy or CXR to confirm PICC tip position• Less radiation exposure• Free-up radiology services• Avoids treatment delays

• Promotes bedside placement

• Free-up radiology services• Improves CVAD placement for

compromised patients• Can be used in hospital or community

setting

Challenges of ECG technology

• Cannot be used for patients without a p- wave

• Training & competency required

• Local organization needs to recognise/ ‘sanction’ the technology

• Cost of technology

• Cost of associated consumables

Cost comparison:

• ECG v fluoroscopy = - £106 per pt• ECG v blind insertion + CXR = cost

neutral

NICE (2015)

What’s best? ECG or CXR?

CXR:

• Historically deemed ‘gold standard’

• ‘discrepancies’ between ECG & CXR:

can be related to image quality, view

or breathing!

• CXR interpretation can be very

subjective

ECG:

• Relies upon the competency of

the practitioner

• Organisational ‘buy-in’ may be

required to be CXR free

• Supported by recent literature &

guidance

Combined Technology:USS, navigation & ECG • USS that can identify & measure

vessel capacity• Promotes vessel health

• Navigation that tracks the line during insertion

• ↓ incidence of catheter mal-position & related complications

• ECG that promotes optimal PICC tip placement

• Printer to evidence insertion/documentation

Thank you for listening!