Comparison of ECG Saline-Conduction Technique and ECG Wire-Based Technique for Peripherally Inserted Central Catheter Insertion: A Randomized Controlled Trial

Figures

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  Figure 1. Wire-based technique (WT) displaying external ECG (upper trace) and intravascular ECG (lower trace). The intravascular ECG shows an increased P-wave relative to the external ECG.

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  Figure 2. Saline conduction technique (ST) displaying external ECG (upper trace) and intravascular ECG (lower trace). The intravascular ECG shows an increased P-wave relative to the external ECG.

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  Figure 3. (A) Chest X-ray showing the CAJ localization. The tip of the catheter in T1 (within 1 cm of the CAJ) is considered optimal (green zone). The tip in T2 (within 1–3 cm of the CAJ) is considered suboptimal (yellow zone). The tip in T3 (more than 3 cm below the CAJ or not in the SVC) is considered inadequate and needs to be repositioned (red zone). (B) Intracavitary electrocardiogram. A catheter tip in T3, distant from the SVC, will feature a trace similar to the superficial ECG trace, with a P-wave lower than the Twave immediately preceding it. (C) Intracavitary electrocardiogram. A catheter tip in T2, nearing the CAJ, will feature a trace with increasing P-wave, equaling the Twave immediately preceding it. (D) Intracavitary electrocardiogram. A catheter tip in T1, positioned at the CAJ level, will feature a P-wave with maximal amplitude without initial negative deflection. (E) Intracavitary electrocardiogram. A catheter tip in T2-T3, beyond the CAJ, will present a decreasing P-wave and negative deflection. CAJ, cavoatrial junction (open arrow); SVC, superior vena cava; P-wave (closed arrow).

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  Figure 4. PICC hub side at insertion point. Outside catheter length classified as: E1 from 0 to 2 cm apart from the hub (optimal); E2 from 2 to 5 cm apart from the hub (suboptimal); and E3 > 5 cm apart from the hub (inadequate, requiring recut). Upper catheter: Wire-based technique (WT); lower catheter: Saline conduction technique (ST).

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  Figure 5. Wave ratio calculation. The maximal P-wave (dashed arrow) is divided by the maximal QRS height (open arrow), both arising from the isoelectric line (closed arrow; considered as the prolongation of the TP interval immediately preceding the P-wave as displayed on the Pilot Tip-Location-System).

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  Figure 6. Study flowchart shows participant selection and allocation. PICC: peripherally inserted central catheter.

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  Figure 7. External and intravascular ECG trace of the Wire-based technique (WT) and Saline conduction technique (ST). (A) WT trace featuring maximal P-wave at the level of CAJ (open arrow). (B) ST trace featuring maximal P-wave at the level of CAJ (open arrow). (C) WT trace featuring initial negative deflection just beyond the level of CAJ (closed arrow). (D) ST trace featuring initial negative deflection just beyond the level of CAJ (closed arrow). (E) ST trace displaying important drifts (dashed arrow). CAJ, cavoatrial junction.

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  Figure 8. PICC−to−cavoatrial junction distance for PICC placements with saline or wire guidance. PICC: peripherally inserted central catheter; DCAJ: distance between the catheter tip and the cavoatrial junction.