Comparison of the bedside central venous catheter placement techniques: landmark vs electrocardiogram guidance

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1 British Journal of Anaesthesia 102 (5): (09) doi: /bja/aep046 Advance Access publication March 26, 09 Comparison of the bedside central venous catheter placement techniques: landmark vs electrocardiogram guidance J.-H. Lee 1, J.-H. Bahk 2 *, H.-G. Ryu 2, C.-W. Jung 2 and Y. Jeon 2 1 Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. 2 Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 28 Yongon-Dong, Jongno-Gu, Seoul , Republic of Korea *Corresponding author. bahkjh@plaza.snu.ac.kr Background. Electrocardiogram (ECG)-guided central venous catheter (CVC) placement has been reported to be accurate and successful. It has been shown that the CVC tip can be reliably placed at the level of the carina using a simple formula based on the puncture site, the brachiocephalic notch on the clavicle, and the carina as landmarks. This study was performed to compare the accuracy of CVC tip localization between ECG- and landmarkguided catheterization. Methods. Patients were randomized either to the ECG (n¼121) or to the landmark (n¼128) group. All catheterizations were performed via the right internal jugular vein (IJV). In the ECG group, CVCs were placed where P-wave returned to a normal configuration on right atrial ECG. In the landmark group, CVCs were placed at a depth derived by adding the distance between insertion point and the notch on the clavicle and the vertical length between the notch and the carina on a routine chest radiograph. On the postoperative portable chest radiograph, incidences of correct CVC tip position, defined as in the superior vena cava, were checked. Results. CVCs were correctly placed in 96.1% of the landmark group (123/128) and in 95.9% of the (116/121). The mean CVC tip position relative to the carina was 0.0 [95% confidence interval (CI).28 to 0.19] cm in the landmark group and 0.0 (95% CI.19 to 0.28) cm in the. Conclusions. During central venous catheterization via the right IJV, landmark guidance was comparable with ECG guidance with regard to CVC tip positioning in the superior vena cava. Br J Anaesth 09; 102: Keywords: equipment, cannulae intravascular; monitoring, electrocardiography; veins, jugular cannulation Accepted for publication: February 15, 09 Central venous catheterization is frequently performed in the operating theatres and intensive care units for cardiac preload monitoring, fluid management, and a route for medication. To minimize the risk of cardiac tamponade, it has been suggested that the central venous catheter (CVC) tip should be located above the cephalic limit of the pericardial reflection, not merely above the superior vena cava (SVC)/right atrial (RA) junction. 1 3 The position of the CVC tip is usually confirmed at the end of the case, and this check is sometimes omitted. 4 Thus, confirmation of correct CVC positioning before starting the case by a simple bedside technique and accurate prediction of the optimal CVC depth would be helpful for patient safety. Electrocardiogram (ECG)-guided central venous catheterization has been reported to be accurate and successful. 5 8 With regard to correct localization of CVC tips in the SVC, the ECG-guided technique was superior to the practitioners estimation, 9 which is currently a standard Presented in part at the annual meeting of European Association of Cardiothoracic Anaesthesiologists (EACTA 08), Antalya, Turkey, June 11 14, 08. # The Author [09]. Published by Oxford University Press on behalf of The Board of Directors of the British Journal of Anaesthesia. All rights reserved. For Permissions, please journals.permissions@oxfordjournal.org

2 Landmark- vs ECG-guided central venous catheterization technique in many units. On the basis of the previous reports that the carina is a level with the pericardial reflection on the SVC, we recently showed that the CVC tip can be reliably placed near the carina level when CVCs are inserted to a depth derived by a simple formula using the skin puncture site, the brachiocephalic notch of the clavicle, and the carina as landmarks. 12 It remains to be determined which of the above techniques is a better technique or if both are equivalent. Therefore, we hypothesized that landmark-guided catheterization would be comparable with ECG-guided catheterization with regard to the localization of CVC tips in the SVC. This prospective, randomized study was performed to compare the accuracy of CVC tip localization between ECG- and landmark-guided catheterization. Methods After obtaining institutional review board approval and patients informed consent, 249 patients undergoing elective thoracic surgery requiring central venous catheterization were enrolled in this study. Patients with P-wave abnormalities, such as atrial fibrillation, or undergoing pneumonectomy were excluded. Patients were randomized using an Internet-based computer program ( randomizer.org) either to the (central venous catheterization using an ECG-guided technique) or to the landmark group (central venous catheterization using a landmark-guided technique). After induction of general anaesthesia, the patients were placed in a slight Trendelenburg position with the head turned to the left. A 1 litre saline bag was placed under the right shoulder to prevent extreme leftward rotation of the head. The anterior approach was used for right internal jugular vein (IJV) catheterization using the sternocleidomastoid muscle as a landmark. After antiseptic preparation and draping, a cm long, triple-lumen CVC (Certofix w, B. Braun, Melsungen, Germany) was inserted over a guidewire using a modified Seldinger technique. Afterwards, patients were returned to the supine position and their head and neck were placed in the neutral position. In the, the guidewire was then withdrawn through the CVC until a mark on the guidewire indicated the tip to be exactly positioned at the tip of the CVC. A connection between the guidewire and an ECG adapter was then established in the following fashion. The ECG adapter was connected in-line between the ECG monitor and the right-arm electrode. An alligator clip attached to a cable leading to the ECG adapter was then placed on the metal guidewire just above the CVC hub. Using a switch function in the adapter, ECG conduction was then transferred from a regular three-lead surface ECG to an RA or i.v. ECG. While lead II was observed on the ECG monitor, the catheter was slowly advanced until the RA ECG indicated a CVC position in the SVC/RA junction ( peaked, elevated P-wave) or in the RA (biphasic P-wave). 5 Thereafter, the CVC was withdrawn at 0.5 cm intervals until the P-wave returned to a normal configuration. At that point, the CVC was secured at the skin with suture and dressed with a transparent dressing. If RA ECG could not be obtained, the CVC and guidewire combination was withdrawn together to an insertion depth of 8 cm. The CVC and guidewire combination was then re-advanced and another attempt was made to obtain the RA ECG. During the re-trials, an assistant elevated the right shoulder to the cephalad direction on the assumption that the CVC might have been directed to the right SCV. 5 Our protocol indicated that if an RA ECG could not be obtained after the third attempt, the CVC, the landmark-guided technique, should be used. In the landmark group, the CVC depth was determined as described in our previous study. 12 Before CVC placement, the vertical distance between the brachiocephalic notch of the right clavicle and the carina was measured on the routine preoperative posterior anterior chest X-ray (CXR), using an internal measuring tool available on the hospital s picture archiving communication system. The shortest straight length between the insertion point of the puncture needle and the brachiocephalic notch of the right clavicle was measured using a sterile disposable paper ruler. The CVC was inserted and secured to a depth determined by adding the two measurements (length between skin insertion point and brachiocephalic notch of the clavicle plus vertical distance between the notch and the carina). All the measurements in the landmark group were also determined at 0.5 cm intervals. A portable antero-posterior CXR was taken in all supine patients immediately after surgery in either the postanaesthesia or the intensive care unit. Before CXR was taken, it was ensured that the patient was positioned completely flat in the bed with the patient s head and neck in the neutral position. CXRs were read by one attending radiologist, who was aware of the study protocol but blinded to the group assignment. The whole length of SVC was defined on CXR as from the lower border of the first right costal cartilage close to the sternum 13 to the conventional radiographic SVC/RA junction 14 (the apex of the concave shadow formed by the superimposition of the distal SVC on the RA). A standardized method was used to describe the position of the CVC tip, so that the whole length of SVC on CXR was divided into three equal parts as in the upper, middle, and lower SVC. The CVC position was judged correct, if the tip was positioned in the SVC. All other positions were judged to be a failure. Additionally, the vertical distance between the CVC tip and the carina was measured on the postoperative CXR. 12 The CVC tip positioned above the carina level was presented as a positive value and below the carina as a negative value. In both groups, final insertion depth, number of venous puncture attempts, incidence of premature ventricular contractions during CVC placement, and complications such as arterial puncture or pneumothorax were recorded. 663

3 Lee et al. Sample size calculation was based on our pilot data (n¼35), which showed that the mean (SD) vertical distance of CVC tips from the carina was 0.0 (1.6) cm using the ECG technique. Assuming a two-sided type-i error of 0.05 and a power of 0.99, at least 121 patients were needed in each group. For testing for equivalence with confidence intervals (CI), any difference in the CVC tip position,1 cm above/below the carina was defined to be clinically acceptable, in that both techniques in this study were intended for mid-svc positioning of CVC tips around the level of the carina. The 95% CI of the vertical distances of CVC tips from the level of the carina was, respectively, calculated to determine if two techniques were comparable with respect to the reliable placement of CVC tips near the carina level. Under a null hypothesis of non-equivalence, the 95% CI of the mean difference in the CVC tip level between the two groups was also calculated to determine if the two techniques are equivalent for obtaining this clinically acceptable position. Relative CVC tip positions were analysed using the x 2 test with regard to the SVC or out-of-the SVC positions. The SPSS for Windows version 12.0 (SPSS, Chicago, IL, USA) was used for statistical analysis. Data are presented as median (range), mean (SD), or number of patients. A P-value of,0.05 was considered statistically significant. Results Patient characteristics were similar between the two groups (Table 1). There were no catheterization failures during the study period. There was no case in which an RA ECG could not be obtained after the third attempt. The number of attempts and complication rate were not different between the two groups (P¼0.162 for both comparisons) (Table 2). The mean (SD) CVC tip position relative to the carina was 0.0 (1.3) cm in the landmark group and 0.0 (1.3) cm in the (Table 2) and the mean (SD) difference in the vertical CVC tip positions between the two groups was.09 (0.17) cm. The 95% CI of the CVC tip position relative to the carina was found to be within the predetermined acceptable distance from the carina in both Table 1 Patient characteristics. Data are presented as median (range), mean (SD), or number of patients., central venous catheterization was performed using a landmark-guided technique;, central venous catheterization was performed using an ECG-guided technique (n5128) (n5121) Age (yr) 60 (18 83) 56 (15 80) Height (cm) (8.8) (7.9) Body mass index (kg m 22 ) 22.9 (3.2) (3.7) Weight (kg) 60.6 (10.3) 63.0 (11.7) Male/female 77/51 75/46 groups (.28 to 0.19 cm in the landmark group and.19 to 0.28 cm in the ), and the 95% CI of the mean difference in the vertical CVC tip positions between the two groups lay within 0.5 cm from each other (.37 to 0.19 cm). Therefore, we can conclude with 95% CI that two techniques are equivalent. CVCs were placed in the SVC in 96.1% of the landmark group (123/128) and 95.9% of the (116/121). Neither the incidence of the relative CVC tip positions with regard to the SVC or out-of-the SVC positions (P¼0.928) nor the incidence regarding the brachiocephalic vein, RA, the upper, middle, or lower SVC (P¼0.971) was different between the two groups (Fig. 1). CVC tip positions in the failures were RA (n¼3) and brachiocephalic vein (n¼2) in each group. Table 2 Central venous catheter position and number of attempts and complications during catheterization. Data are expressed as mean (SD) or number of patients. There were no statistically significant differences in the number of attempts and complications (P¼0.162, for both comparisons) (n5128) (n5121) Insertion depth (cm) 13.0 (1.6) 13.3 (1.5) Vertical distance from the carina (cm) 0.0 (1.3) 0.0 (1.3) Number of catheterization attempts (1/2/3) 126/2/0 115/6/0 Complications Ventricular premature contraction 2 4 Arterial puncture 1 2 Number of patients Brachiocephalic vein Upper SVC Middle SVC Lower SVC Right atrium Fig 1 Overall incidence of correct catheter tip positions in the ECG and landmark groups. The catheter position was regarded as correct if the tip was positioned in the SVC. All the other positions were judged to be a failure. The numbers of patients in each catheter tip position are displayed on top of the bars. Neither the incidence of the relative CVC tip positions with regard to the SVC or out-of-the SVC positions (P¼0.928) nor the incidence regarding the brachiocephalic vein, the right atrium, the upper, middle, or lower SVC (P¼0.971) was different between the two groups. 664

4 Landmark- vs ECG-guided central venous catheterization Discussion This study showed that, with regard to positioning of CVCs inserted via the right IJV in the SVC, the landmarkguided central venous catheterization technique was equivalent to the ECG-guided technique without any increase in complications. When the ECG-guided central venous catheterization technique was used, CVCs were correctly placed in 96% of patients in a recent study, 9 which is consistent with the result of this study. This study also corresponds to our previous study, which showed that the catheter tips could be successfully placed near the carina level using the landmark-guided technique. 12 During the ECG-guided central venous catheterization, the peak P-wave is observed when the CVC tip was located at the SVC/RA junction, 5 and the P-wave returns to a normal shape and size at about 4.0 cm above the SVC/RA junction. 5 Of the landmarks easily identifiable on a routine CXR, the level of the carina has been studied as an attractive target for the CVC tip position The carina level is always within 1 cm above the pericardial reflection In an in vivo study where the SVC length was measured, about 60 mm, almost half of the SVC is located to be within the pericardium and the other half is out of the pericardium. 16 Taken together, it seems that the carina level corresponds to the mid-svc level where the P-wave becomes a normal configuration during the ECG-guided technique. Therefore, the carina level and the normal configuration of P-wave were used as the main landmarks in this study. The carina is located in the centre of the thorax. Therefore, image distortion and measurement error by parallax effect are less important, if we use the carina on CXR as a landmark. Moreover, previous formulae to predict optimal CVC tip position did not consider any variables or landmarks available from the CXR, despite the use of post-procedural CXR to confirm the location of CVC tips. The landmark-guided technique used in this study seems to be superior to previous formulae using patient height or skin-to-vein distance because of simultaneous consideration of variable insertion points and anatomical or radiological landmarks. The landmarkguided technique has some advantages over the ECG-guided technique, in that it is a very simple technique without any potential complications. Although CXRs are not routinely warranted for asymptomatic patients who are,75 yr of age and free of risk factors, it is highly probable that preoperative CXR is available in patients undergoing a major surgery requiring CVCs. The first limitation of this study is that all CVCs were inserted through the right IJV. Because there is a previous report that intra-atrial ECG was not a reliable method for positioning CVCs inserted through the left IJV, 21 we did not include left IJV catheterization in this study. Intuitively, there may be a demand that the landmarkguided technique should be compared with the standard practice based on clinicians estimation. For the purpose of developing clinicians estimation into a formula, one of the authors (J.-H.B.) developed the landmark technique used in this paper, 12 which takes the insertion point variation and patient s body build into account. Because colleagues of our department already use the landmark technique, we suggest that the landmark technique should be compared with the standard practice based on clinicians estimation in the other departments. The second limitation is the greater and variable parallax effect of the portable antero-posterior CXR in the supine position, which was used to check the position of CVC tips. This effect is exaggerated on the periphery of CXRs. However, because the carina and the SVC are situated at the same depth and the centre of the thorax, this effect may be negligible. The last limitation is that only radiographic definition of the SVC was used to evaluate CVC tip positions. Because echocardiographic estimation of the SVC/RA junction position places it a little deeper than the radiographic SVC/RA junction, 14 the CVC tip position in the upper RA may have actually been in the distal SVC or SVC/RA junction. However, the use of portable CXRs is a current practice to check the CVC tip position after central venous catheterization so that the conventional radiographic definitions were used in this study. In conclusion, landmark guidance was comparable with ECG guidance with regard to CVC tip positioning when CVCs were placed through the right IJV. Therefore, we recommend the landmark-guided central venous catheterization, because it is simple and does not run any inherent risks. However, neither technique assures an extrapericardial CVC tip position. Further studies may be needed to determine the predictive values of the landmark-guided technique when CVC is to be placed through the left IJV or subclavian veins. Acknowledgement The authors would like to thank the radiologist, Hyun Ju Lee, MD, for her essential help in preparation of this article. Funding This study was supported solely from departmental sources. References 1 Collier PE, Blocker SH, Graff DM, Doyle P. 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