The electrocardiographic method for positioning the tip of central venous catheters

Tip position of a central venous access is of paramount importance and should be verified before starting infusion. Intra-procedural methods for verifying the location of the tip are to be preferred, since they avoid the risks, delays and costs of repositioning the tip. Among the intra-procedural methods, the electrocardiography (EKG) method has many advantages since it is as accurate as fluoroscopy, but simpler, more readily available, less expensive, safer and more cost-effective. The only contraindication to utilizing the EKG method is the difficulty in identifying the standard P-wave on a surface EKG (this happens - usually because of severe arrhythmias, such as atrial fibrillation - in only approximately 7% of cases: although such patients are easily identified before the procedure, and are referred to other methods for tip positioning). When dealing with the insertion of peripherally inserted central catheters (PICC), the EKG method (using the column of saline technique) virtually has no risk of false positives. The EKG method removes the need for the post-procedural chest x-ray, as long as there is no expected risk of pleuropulmonary damage to be ruled out (example: ultrasound guided central venipuncture for central venous catheter insertion or any kind of PICC insertion). In conclusion, evidence is mounting that the EKG method may be a valid and cost-effective alternative to the standard radiological control of the location of the tip of any central venous access device (VAD), and that will rapidly become the preferential method for confirming the tip position during PICC insertion.