Effectiveness of intracavitary electrocardiogram-guided peripherally inserted central catheter tip placement in premature infants: a multicentre pre-post intervention study
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.
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.
KeywordsChest radiography Electrocardiogram Peripherally inserted central catheter Preterm infants Tip positioning
Catheter-Related Blood Stream Infection
Central Venous Catheters
Neonatal intensive care unit
Peripherally inserted central catheter
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.
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.
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.
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.
Written informed consent was obtained from all parents included in the study.
- 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
- 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.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
- 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.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.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]
- 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.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.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.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
- 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
- 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
- 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
- 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
- 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
- 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