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Effectiveness of intracavitary electrocardiogram-guided peripherally inserted central catheter tip placement in premature infants: a multicentre pre-post intervention study

  • Ai-qing Xiao
  • Jing Sun
  • Li-hui ZhuEmail author
  • Zhen-yu Liao
  • Ping Shen
  • Lin-lin Zhao
  • Jos M. Latour
Original Article

Abstract

This pre-post intervention study was conducted in Neonatal Intensive Care Units in two Chinese hospitals. The objective was to evaluate the effectiveness and safety of intracavitary electrocardiogram (IC-ECG)-guided peripherally inserted central catheter (PICC) placement and tip positioning in premature infants. A total of 161 premature infants who required a PICC were enrolled and divided into two groups: pre-intervention group (n = 83) from October 2017 to July 2018 and post-intervention IC-ECG group (n = 78) from August 2018 to March 2019. Nurses were trained from May 2018 to July 2018. The reposition rate in the IC-ECG group and pre-interventions group was 3.85% and 19.28%, respectively (OR 5.970; 95% CI 1.666–21.395; p = 0.002). More infants achieved optimal tip position at the first attempt in the IC-ECG group than the pre-intervention group (93.59% vs 73.49%; OR 0.190; 95%CI 0.068–0.531; p = 0.001). The overall catheter-related complications in the pre-intervention group were 14.46% compared to 3.84% in the IC-ECG group (OR 2.962; 95%CI 1.013–8.661; p = 0.040). However, no significant differences were observed between the individual complication leakage, phlebitis and catheter-related blood stream infection.

Conclusions: IC-ECG-guided peripherally inserted central catheter placement and tip positioning technology might decrease reposition rates, achieve more accurate tip positioning at the first attempt and might reduce catheter-related complications in premature infants. Further robust RCTs are needed to confirm the effectiveness of IC-ECG-guided PICC placement and tip positioning in neonates.

What is Known:

• Chest radiography is the gold standard for tip position confirmation of peripherally inserted central catheter placement.

• Studies in adult patients have shown that electrocardiogram guidance in the placement of central venous catheters can be beneficial, while evidence in neonates is limited.

What is New:

• Intracavitary electrocardiogram-guided peripherally inserted central catheter placement might be superior to chest radiography in preterm infants.

• Decreasing the repositioning rates and correct tip position of peripherally inserted central catheters might reduce catheter-related complications.

Keywords

Chest radiography Electrocardiogram Peripherally inserted central catheter Preterm infants Tip positioning 

Abbreviations

CRBSI

Catheter-Related Blood Stream Infection

CVC

Central Venous Catheters

IC-ECG

Intracavitary Electrocardiogram

NICU

Neonatal intensive care unit

PICC

Peripherally inserted central catheter

Notes

Acknowledgements

We thank all the parents for consenting and participating in this study. We also thank the nurses and doctors for their participation in our study.

Authors’ contributions

AqX, JS, LhZ, ZyL, PS, LlZ, JML contributed to the design of the study. LhZ secured funding for the study. AqX, ZyL, PS, LlZ contributed to the data collection; JS, JML contributed to the data analysis; JS and JML drafted the first manuscript. AqX, LhZ, ZyL, PS, LlZ provided revisions. All authors contributed to manuscript revision, read and approved the submitted version.

Funding information

This study was partly funded by the Education Department of Hunan Province (number CX2018B510) (JS), Health Commission of Hunan province (number C2019015) (AqX) and the Hunan Provincial Government through the One Hundred Talent Program (JML). The authors do not have a financial relationship with the organization that sponsored the study.

Compliance with ethical standards

All procedures performed in the studies were in accordance with the ethical standards of Ethics Committee of Hunan Children’s Hospital, Xiangtan Central Hospital and the Declaration of Helsinki.

Conflict of interest

All authors declare no competing interest and no financial conflicts.

Ethical approval

The protocol was approved by the Ethics Committee of Hunan Children’s Hospital (HCHLL-2018-06). Parents were informed that their decision to refuse or withdraw from the study would not impact on the care of their infant.

Informed consent

Written informed consent was obtained from all parents included in the study.

References

  1. 1.
    Chen XX, Lo YC, Su LH, Chang CL (2015) Investigation of the case numbers of catheter-related bloodstream infection overestimated by the central line-associated bloodstream infection surveillance definition. J Microbiol Immunol Infect 48(6):625–631.  https://doi.org/10.1016/j.jmii.2014.03.006 CrossRefPubMedGoogle Scholar
  2. 2.
    Chen H, Zhang X, Wang H, Hu X (2019) Complications of upper extremity versus lower extremity placed peripherally inserted central catheters in neonatal intensive care units: a meta-analysis. Intensive Crit Care Nurs 21:102753.  https://doi.org/10.1016/j.iccn.2019.08.003 CrossRefGoogle Scholar
  3. 3.
    Chopra V, Flanders SA, Saint S, Woller SC, O’Grady NP, Safdar N, Trerotola SO, Saran R, Moureau N, Wiseman S, Pittiruti M et al (2015) The Michigan appropriateness guide for intravenous catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med 163:S1–S40.  https://doi.org/10.7326/M15-0744 CrossRefPubMedGoogle Scholar
  4. 4.
    Cong X, Wu J, Vittner D, Xu W, Hussain N, Galvin S, Fitzsimons M, McGrath JM, Henderson WA (2017) The impact of cumulative pain/stress on neurobehavioral development of preterm infants in the NICU. Early Hum Dev 108:9–16.  https://doi.org/10.1016/j.earlhumdev.2017.03.003 CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    da Silva PSL, Waisberg J (2010) Induction of life-threatening supraventricular tachycardia during central venous catheter placement: an unusual complication. J Pediatr Surg 45(8):e13–e16.  https://doi.org/10.1016/j.jpedsurg.2010.05.013 CrossRefPubMedGoogle Scholar
  6. 6.
    Dabrowska M, Przybylo Z, Zukowska M, Kobylecka M, Maskey-Warzechowska M, Krenke R (2018) Should we be concerned about the doses of ionizing radiation related to diagnostic and follow-up imaging in patients with solitary pulmonary nodules. Radiat Prot Dosim 178:201–207.  https://doi.org/10.1093/rpd/ncx099 CrossRefGoogle Scholar
  7. 7.
    Desai MY, Windecker S, Lancellotti P, Bax JJ, Griffin BP, Cahlon O, Johnston DR (2019) Prevention, diagnosis, and management of radiation-associated cardiac disease: JACC scientific expert panel. J Am Coll Cardiol 74(7):905–927.  https://doi.org/10.1016/j.jacc.2019.07.006 CrossRefPubMedGoogle Scholar
  8. 8.
    Division of Healthcare Quality Promotion. Centers for Disease Control and Prevention. (2008) The National Healthcare Safety Network (NHSN) manual: patient safety component protocol. Available at: www.dhcs.ca.gov/provgovpart/initiatives/nqi/Documents/NHSNManPSPCurr.pdf [Accessed 25 Oct 2019]
  9. 9.
    Fallouh N, McGuirk HM, Flanders SA, Chopra V (2015) Peripherally inserted central catheter-associated deep vein thrombosis: a narrative review. Am J Med 128(7):722–738.  https://doi.org/10.1016/j.amjmed.2015.01.027 CrossRefPubMedGoogle Scholar
  10. 10.
    Galen B, Baron S, Young S, Hall A, Berger-Spivack L, Southern W (2019) Reducing peripherally inserted central catheters and midline catheters by training nurses in ultrasound-guided peripheral intravenous catheter placement. BMJ Qual Saf.  https://doi.org/10.1136/bmjqs-2019-009923
  11. 11.
    Goldwasser B, Baia C, Kim M, Taragin BH, Angert RM (2017) Non-central peripherally inserted central catheters in neonatal intensive care: complication rates and longevity of catheters relative to tip position. Pediatr Radiol 47(12):1676–1681.  https://doi.org/10.1007/s00247-017-3939-1 CrossRefPubMedGoogle Scholar
  12. 12.
    Gorski LA, Hadaway L, Hagle M, McGoldrick M, Orr M, Doellman D (2016) Infusion therapy standards of practice. J Infus Nurs 39(1 Suppl):S1–S159Google Scholar
  13. 13.
    Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, Altman DG, Barbour V, Macdonald H, Johnston M, Lamb SE, Dixon-Woods M, McCulloch P, Wyatt JC, Chan AW, Michie S (2014) Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ 348:g1687.  https://doi.org/10.1136/bmj.g1687 CrossRefPubMedGoogle Scholar
  14. 14.
    Jain A, Deshpande P, Shah P (2013) Peripherally inserted central catheter tip position and risk of associated complications in neonates. J Perinatol 33(4):307–312.  https://doi.org/10.1038/jp.2012.112 CrossRefPubMedGoogle Scholar
  15. 15.
    Janes M, Kalyn A, Pinelli J, Paes B (2000) A randomized trial comparing peripherally inserted central venous catheters and peripheral intravenous catheters in infants with very low birth weight. J Pediatr Surg 35(7):1040–1044.  https://doi.org/10.1053/jpsu.2000.7767 CrossRefPubMedGoogle Scholar
  16. 16.
    Jeon Y, Ryu HG, Yoon SZ, Kim JH, Bahk JH (2006) Transesophageal echocardiographic evaluation of ECG-guided central venous catheter placement. Can J Anesth 53(10):978–983.  https://doi.org/10.1007/BF03022525 CrossRefPubMedGoogle Scholar
  17. 17.
    Jumani K, Advani S, Reich NG, Gosey L, Milstone AM (2013) Risk factors for peripherally inserted central venous catheter complications in children. JAMA Pediatr 167(5):429–435.  https://doi.org/10.1001/jamapediatrics.2013.775 CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Katheria AC, Fleming SE, Kim JH (2013) A randomized controlled trial of ultrasound-guided peripherally inserted central catheters compared with standard radiograph in neonates. J Perinatol 33(10):791–794.  https://doi.org/10.1038/jp.2013.58 CrossRefGoogle Scholar
  19. 19.
    Keller EJ, Aragona E, Molina H, Lee J, Salem R, Resnick SA, Chrisman H, Collins JD (2019) Cost-effectiveness of a guided peripherally inserted central catheter placement system: a single-center cohort study. J Vasc Interv Radiol.  https://doi.org/10.1016/j.jvir.2018.07.032 CrossRefGoogle Scholar
  20. 20.
    Legemaat MM, Jongerden IP, van Rens RM, Zielman M, van den Hoogen A (2015) Effect of a vascular access team on central line-associated bloodstream infections in infants admitted to a neonatal intensive care unit: a systematic review. Int J Nurs Stud 52(5):1003–1010.  https://doi.org/10.1016/j.ijnurstu.2014.11.010 CrossRefPubMedGoogle Scholar
  21. 21.
    Legemaat M, Carr PJ, van Rens RM, van Dijk M, Poslawsky IE, van den Hoogen A (2016) Peripheral intravenous cannulation: complication rates in the neonatal population: a multicenter observational study. J Vasc Access 17(4):360–365.  https://doi.org/10.5301/jva.5000558 CrossRefPubMedGoogle Scholar
  22. 22.
    Liu YJ, Dong L, Lou XP, Miao JH, Li XX, Li XJ, Li J, Liu QQ, Chang ZW (2015) Evaluating ECG-aided tip localization of peripherally inserted central catheter in patients with cancer. Int J Exp Med 8(8):14127–14129Google Scholar
  23. 23.
    Liu G, Hou W, Zhou C, Yin Y, Lu S, Duan C, Li M, Toft ES, Zhang H (2019) Meta-analysis of intracavitary electrocardiogram guidance for peripherally inserted central catheter placement. J Vasc Access.  https://doi.org/10.1177/1129729819826028 CrossRefGoogle Scholar
  24. 24.
    Morano SG, Latagliata R, Girmenia C, Massaro F, Berneschi P, Guerriero A, Giampaoletti M, Sammarco A, Annechini G, Fama A, di Rocco A, Chistolini A, Micozzi A, Molica M, Barberi W, Minotti C, Brunetti GA, Breccia M, Cartoni C, Capria S, Rosa G, Alimena G, Foà R (2015) Catheter-associated bloodstream infections and thrombotic risk in hematologic patients with peripherally inserted central catheters (PICC). Support Care Cancer 23(11):3289–3295.  https://doi.org/10.1007/s00520-015-2740-7 CrossRefPubMedGoogle Scholar
  25. 25.
    Motz P, Von Saint Andre Von Arnim A, Iyer RS, Chabra S, Likes M, Dighe M (2019) Point-of-care ultrasound for peripherally inserted central catheter monitoring: a pilot study. J Perinat Med.  https://doi.org/10.1515/jpm-2019-0198 CrossRefGoogle Scholar
  26. 26.
    Oliver G, Jones M (2016) ECG-based PICC tip verification system: an evaluation 5 years on. Br J Nurs 25:S4–4S10.  https://doi.org/10.12968/bjon.2016.25.19.S4 CrossRefPubMedGoogle Scholar
  27. 27.
    Ozkiraz S, Gokmen Z, Anuk Ince D, Akcan AB, Kilicdag H, Ozel D, Ecevit A (2013) Peripherally inserted central venous catheters in critically ill premature neonates. J Vasc Access 14:320–324.  https://doi.org/10.5301/jva.5000157 CrossRefPubMedGoogle Scholar
  28. 28.
    Ray-Barruel G, Polit DF, Murfield JE, Rickard CM (2014) Infusion phlebitis assessment measures: a systematic review. J Eval Clin Pract 20(2):191–202.  https://doi.org/10.1111/jep.12107 CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Rossetti F, Pittiruti M, Lamperti M, Graziano U, Celentano D, Capozzoli G (2012) The intracavitary ECG method for positioning the tip of central venous catheters: results of an Italian multicenter study. J Vasc Access 13(3):357–365.  https://doi.org/10.5301/jva.5000281 CrossRefGoogle Scholar
  30. 30.
    Telang N, Sharma D, Pratap OT, Kandraju H, Murki S (2017) Use of real-time ultrasound for locating tip position in neonates undergoing peripherally inserted central catheter insertion: a pilot study. Indian J Med Res 145(3):373–376.  https://doi.org/10.4103/ijmr.IJMR_1542_14 CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Vinall J, Grunau RE (2014) Impact of repeated procedural pain-related stress in infants born very preterm. Pediatr Res 75(5):584–587.  https://doi.org/10.1038/pr.2014.16 CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Wang G, Guo L, Jiang B, Huang M, Zhang J, Qin Y (2015) Factors influencing intracavitary electrocardiographic p-wave changes during central venous catheter placement. PLoS One 10(4):e0124846.  https://doi.org/10.1371/journal.pone.0124846 CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Yu T, Wu L, Yuan L, Dawson R, Li R, Qiu Z, Wu X, Chen P, Qi J, Yang Y (2019) The diagnostic value of intracavitary electrocardiogram for verifying tip position of peripherally inserted central catheters in cancer patients: a retrospective multicenter study. J Vasc Access.  https://doi.org/10.1177/1129729819838136 CrossRefGoogle Scholar
  34. 34.
    Zaghloul N, Watkins L, Choi-Rosen J, Perveen S, Kurepa D (2019) The superiority of point of care ultrasound in localizing central venous line tip position over time. Eur J Pediatr 178(2):173–179.  https://doi.org/10.1007/s00431-018-3269-9 CrossRefPubMedGoogle Scholar
  35. 35.
    Zhao R, Chen C, Jin J, Sharma K, Jiang N, Shentu Y, Wang X (2016) Clinical evaluation of the use of an intracardiac electrocardiogram to guide the tip positioning of peripherally inserted central catheters. Int J Nurs Pract 22(3):217–223.  https://doi.org/10.1111/ijn.12409 CrossRefPubMedGoogle Scholar
  36. 36.
    Zhou L, Xu H, Liang J, Xu M, Yu J (2017) Effectiveness of intracavitary electrocardiogram guidance in peripherally inserted central catheter tip placement in Neonates. J Perinat Neonatal Nurs 31:326–331.  https://doi.org/10.1097/JPN.0000000000000264 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Neonatal MedicineHunan Children’s HospitalChangshaChina
  2. 2.Nursing schoolHunan University of Chinese MedicineChangshaChina
  3. 3.Nursing DepartmentHunan Children’s HospitalChangshaChina
  4. 4.Division of Neonatal MedicineXiangtan Central HospitalXiangtanChina
  5. 5.School of Nursing and Midwifery, Faculty of Health and Human SciencesUniversity of PlymouthPlymouthUK

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