How to correctly position the tip of central vein access device in a newborn?

What is it about?

The use of the method of intracavitary electrocardiography (IC-ECG) for real-time verification of the tip position appears to be particularly appropriate in children. A recent multicenter study conducted by GAVeCeLT (the Italian Group for Venous Access Devices) in six Italian hospital centers on more than 300 patients has already demonstrated the safety and feasibility of IC-ECG in the positioning of central venous accesses in pediatric patients and has confirmed its accuracy compared with the postoperative chest X-ray. The aim of our study and its particularity is to compare the use of echocardiography (ECHO) to the use of the method of IC-ECG for CVAD tip location in a neonatal intensive care unit (NICU). In the IC-ECG method for positioning of the tip, the catheter itself is used as an intracavitary electrode and this can be obtaine filling the catheter itself by saline solution. This methodology required a device specifically designed for the IC-ECG. We used Vygocard (Vygon) for easy shifting from surface ECG tracing to intracavitary ECG tracing. We used the defibrillator Defigard 5000 (DG5000, Schiller Medical, Wissembourg) as an ECG monitor. Three electrodes were used: yellow—left shoulder, red—right shoulder, and green—left flank. The IC-ECG focused on lead II (red to green), which is ideal for the visualization of the P wave. After having registrated basal ECG, the red electrode is detached from the shoulder and connected with special Vygocard clip. After that, we begin to position the catheter. We used surface landmark for estimating the length of insertion of catheter from puncture site. The catheter is threaded further on into the venous system; when the tip is 2 cm before the optimal measured position, the catheter is filled with saline solution and attached to the connector of the transducer. The surface ECG is switched to the intracavitary ECG, and by watching the variation of the shape of P wave on the intracavitary lead II, it is possible to infer the position of the catheter tip. As the catheter proceeds slowly into the SVC, the P wave gets higher, reaches its peak at CAJ, and proceeding further gradually decreases to become diphasic. To ensure that the tip is well-positioned, it is appropriate to insert the catheter until the P wave becomes diphasic and then pull it back until the P wave is at its peak (positioning that will correspond to the CAJ).

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Why is it important?

The intracavitary electrocardiography method for tip location of central venous access device is safe and accurate in infants, as demonstrated by post-procedural comparative echocardiographic controls. As an alternative to echocardiography, not always achievable, the diffusion of intracavitary electrocardiography method could reduce X-ray exposition and complications of a malpositioned tip. It reduces the costs because the IC-ECG use–related products are easily available and very cheap.

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