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First: patient safety, second: patient safety
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Journal of Electrocardiology 44 (2011) 389 – 390 www.jecgonline.com
Letter to the Editor First: patient safety, second: patient safety We read with interest the article by Smith et al 1 recommending intravenous electrocardiogram (ECG) to assess the correct placement of peripherally inserted central catheter's (PICC's) tip not only in inpatients but also in outpatients. We agree that the simplicity and accuracy of this technique spares chest x-rays; however, if patient's safety is of the utmost importance, we cannot forget the lesson of ultrasound (US) in venous access placement. The safest approach to venous catheter placement requires both US catheter placement and catheter tip control by ECG, and we are confident that Smith et al, even if they did not state it clearly in the article, adopted a US-guided technique. Doppler US is used today in critical setting not only to place central venous catheters (CVCs) but also to position PICCs, for placing artery catheter for continuous blood pressure monitoring to accelerate chest and abdomen diagnosing.2 In 2009, we always used US-guided placement and ECG method to control catheter tip position for placing 322 US-guided central venous accesses (140 CVCs and 182 PICCs). For every catheter placed in our Unit, a chest x-ray was requested to confirm tip position, and we found a direct correspondence between P wave maximal amplitude and superior vena cava–right atrium junction tip position in 99% of the inserted catheters. To maximize safety in central catheter placement, our intensive care unit adopted a twin “US plus ECG” standard procedure, integrating the safety of US with intraprocedural tip position information acquired by ECG. Because a spared chest x-ray saves about 60€, it is easy to estimate the possible overall saving in United States where about 5 million US are carried out each year.3 We cannot avoid to be surprised that “no commercial ECG guidance system is available for US clinicians” since the “European side of the Moon” provides several models of ECG guidance systems (inserted in catheters kit and homemade, available also for closed ended catheter such as Groshong). Electrocardiogram technique is available not only with metallic guidewire but also with fluid saline column, useful to check tip position during catheter insertion and to control it after the placement, avoiding chest x-ray as a postplacement standard control saving time, cost, and replacement maneuvers. The running of early ECG systems developed for CVCs (ie, Certofix Duo/Trio and Alphacard B-Braun, Melsugen, Germany, Vygocard, Ecouen, France) was based on ECG P wave variation obtained connecting the 0022-0736/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
marked metallic guidewire or liquid column (that works as intracardiac electrode) at the exit site of the guide (usually, the neck skin for CVCs) with a connection cable to an ECG monitor. Peripherally inserted central catheter's tip has the same target of CVCs, with the only difference that the connection to the intracardiac electrode is at the upper arm site instead that at the neck skin; therefore, to extend this approach to PICCs appears reasonable. The article by Smith at al should be commended because it confirms the information on tip position acquired by ECG method with direct fluoroscopy. We are particularly pleased because it is substantially consistent with a quite recent report made by our group.4 We should like to point out that ECG method does not need particular electrocardiograph machines or particular devices; in our experience, standard 3- and 12-lead ECG yields a very similar electric signal. The first one is, of course, the most common device, and it can be used also in outpatient settings such as nursing homes and infusion centers. Even if today no commercial ECG device is licensed for PICC use, the ECG method for determining caval-atrial junction terminal tip location is well documented in Europe, usually, as in our case, with the approval of Ethics Committee.5 In conclusion, we agree that this accurate, safe, and costefficient technique has the potential to become the safest and cheapest method to confirm the tip position after catheter placement, obviously US guided, and should be advocated. Piersandro Sette, MD Anaesthesia and Intensive Care G. Fracastoro Hospital Verona, Italy Romolo M. Dorizzi, MD Corelab, Laboratorio Unico di AvR 47522 Pievesestina di Cesena Cesena (FC), Italy E-mail address: [email protected] Anna Maria Azzini, MD Infectious Diseases Unit Department of Pathology University of Verona Verona, Italy doi:10.1016/j.jelectrocard.2010.08.001
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Letter to the Editor / Journal of Electrocardiology 44 (2011) 389–390
References 1. Smith B, Neuharth RM, Hendrix MA, McDonnall D, Michaels AD. Intravenous electrocardiographic guidance for placement of peripherally inserted central catheters. J Electrocardiol 2010;43:274. 2. Sette P, Dorizzi RM, Azzini AM, Castellano G. Only practice and praxis can limit the unavoidable errors of the practice. J Hosp Med 2010;5:e11.
3. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123. 4. Sette P, Azzini AM, Dorizzi RM, Castellano G. Serendipitous ECG guided PICC insertion using the guidewire as intra-cardiac electrode. J Vasc Access 2010;11:72. 5. Pittiruti M, Scoppettuolo G, La Greca A, et al. The EKG method for positioning the tip of PICCs: results from two preliminary studies. JAVA 2008;14:112.
Articles Appearing in the Next Issue Diagnostic Utility of the Spatial Versus Individual Planar QRS-T angles in Cardiac Disease Detection - Ryanne Brown and Todd T. Schlegel. Heart Fatty Acid Binding Protein in Combination With the 80-Lead Body Surface Potential Map Improves Early Detection of Acute Myocardial Infarction in Patients Who are Cardiac Troponin T-Negative at Presentation - Michael Daly, Conor McCann, Colum Owens, et al. A Simulation Tool for Visualizing and Studying the Effects of Electrode Misplacement on the 12-Lead Electrocardiogram Raymond Bond, Dewar Finlay, Chris Nugent, et al. Evaluation of Depolarization Changes During Acute Myocardial Ischemia by Analysis of QRS Slopes - Michael Ringborn, Daniel Romero, Esther Pueyo, et al.
Journal of Electrocardiology 44 (2011) 389 – 390 www.jecgonline.com
Letter to the Editor First: patient safety, second: patient safety We read with interest the article by Smith et al 1 recommending intravenous electrocardiogram (ECG) to assess the correct placement of peripherally inserted central catheter's (PICC's) tip not only in inpatients but also in outpatients. We agree that the simplicity and accuracy of this technique spares chest x-rays; however, if patient's safety is of the utmost importance, we cannot forget the lesson of ultrasound (US) in venous access placement. The safest approach to venous catheter placement requires both US catheter placement and catheter tip control by ECG, and we are confident that Smith et al, even if they did not state it clearly in the article, adopted a US-guided technique. Doppler US is used today in critical setting not only to place central venous catheters (CVCs) but also to position PICCs, for placing artery catheter for continuous blood pressure monitoring to accelerate chest and abdomen diagnosing.2 In 2009, we always used US-guided placement and ECG method to control catheter tip position for placing 322 US-guided central venous accesses (140 CVCs and 182 PICCs). For every catheter placed in our Unit, a chest x-ray was requested to confirm tip position, and we found a direct correspondence between P wave maximal amplitude and superior vena cava–right atrium junction tip position in 99% of the inserted catheters. To maximize safety in central catheter placement, our intensive care unit adopted a twin “US plus ECG” standard procedure, integrating the safety of US with intraprocedural tip position information acquired by ECG. Because a spared chest x-ray saves about 60€, it is easy to estimate the possible overall saving in United States where about 5 million US are carried out each year.3 We cannot avoid to be surprised that “no commercial ECG guidance system is available for US clinicians” since the “European side of the Moon” provides several models of ECG guidance systems (inserted in catheters kit and homemade, available also for closed ended catheter such as Groshong). Electrocardiogram technique is available not only with metallic guidewire but also with fluid saline column, useful to check tip position during catheter insertion and to control it after the placement, avoiding chest x-ray as a postplacement standard control saving time, cost, and replacement maneuvers. The running of early ECG systems developed for CVCs (ie, Certofix Duo/Trio and Alphacard B-Braun, Melsugen, Germany, Vygocard, Ecouen, France) was based on ECG P wave variation obtained connecting the 0022-0736/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
marked metallic guidewire or liquid column (that works as intracardiac electrode) at the exit site of the guide (usually, the neck skin for CVCs) with a connection cable to an ECG monitor. Peripherally inserted central catheter's tip has the same target of CVCs, with the only difference that the connection to the intracardiac electrode is at the upper arm site instead that at the neck skin; therefore, to extend this approach to PICCs appears reasonable. The article by Smith at al should be commended because it confirms the information on tip position acquired by ECG method with direct fluoroscopy. We are particularly pleased because it is substantially consistent with a quite recent report made by our group.4 We should like to point out that ECG method does not need particular electrocardiograph machines or particular devices; in our experience, standard 3- and 12-lead ECG yields a very similar electric signal. The first one is, of course, the most common device, and it can be used also in outpatient settings such as nursing homes and infusion centers. Even if today no commercial ECG device is licensed for PICC use, the ECG method for determining caval-atrial junction terminal tip location is well documented in Europe, usually, as in our case, with the approval of Ethics Committee.5 In conclusion, we agree that this accurate, safe, and costefficient technique has the potential to become the safest and cheapest method to confirm the tip position after catheter placement, obviously US guided, and should be advocated. Piersandro Sette, MD Anaesthesia and Intensive Care G. Fracastoro Hospital Verona, Italy Romolo M. Dorizzi, MD Corelab, Laboratorio Unico di AvR 47522 Pievesestina di Cesena Cesena (FC), Italy E-mail address: [email protected] Anna Maria Azzini, MD Infectious Diseases Unit Department of Pathology University of Verona Verona, Italy doi:10.1016/j.jelectrocard.2010.08.001
390
Letter to the Editor / Journal of Electrocardiology 44 (2011) 389–390
References 1. Smith B, Neuharth RM, Hendrix MA, McDonnall D, Michaels AD. Intravenous electrocardiographic guidance for placement of peripherally inserted central catheters. J Electrocardiol 2010;43:274. 2. Sette P, Dorizzi RM, Azzini AM, Castellano G. Only practice and praxis can limit the unavoidable errors of the practice. J Hosp Med 2010;5:e11.
3. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123. 4. Sette P, Azzini AM, Dorizzi RM, Castellano G. Serendipitous ECG guided PICC insertion using the guidewire as intra-cardiac electrode. J Vasc Access 2010;11:72. 5. Pittiruti M, Scoppettuolo G, La Greca A, et al. The EKG method for positioning the tip of PICCs: results from two preliminary studies. JAVA 2008;14:112.
Articles Appearing in the Next Issue Diagnostic Utility of the Spatial Versus Individual Planar QRS-T angles in Cardiac Disease Detection - Ryanne Brown and Todd T. Schlegel. Heart Fatty Acid Binding Protein in Combination With the 80-Lead Body Surface Potential Map Improves Early Detection of Acute Myocardial Infarction in Patients Who are Cardiac Troponin T-Negative at Presentation - Michael Daly, Conor McCann, Colum Owens, et al. A Simulation Tool for Visualizing and Studying the Effects of Electrode Misplacement on the 12-Lead Electrocardiogram Raymond Bond, Dewar Finlay, Chris Nugent, et al. Evaluation of Depolarization Changes During Acute Myocardial Ischemia by Analysis of QRS Slopes - Michael Ringborn, Daniel Romero, Esther Pueyo, et al.