Anyone out there using ECG heard of, seen or have experience with getting the picture perfect ECG reading to be CAJ but on x-ray having the PICC tip in the azygous? We are just going through the training so are still getting x-rays and had two of these incidences.
Thanks,Mary
One of the problems with ECG confirmation is that it is not the last touch to the PICC line after confirmation. You still have to pull the stylet out after it is confirmed. It is not rare that the PICC line tip malpositions with the pulling of the stylet.
Did you confirm azygous location by a lateral chest xray? A PA or AP will not show azygous location easily. The azyyous joins the SVC on the posterior side at the level of the 2nd intercostal space. This is also about the same level as the pericardium. Any tip location within the pericardium will produce changes in the P wave. This is why ECG tip location can not rule out arterial placement. Any question about the P wave changes requires a chest xray. I am curious as to what you saw with the P wave changes or were you using VasoNova where you only see the change in lights? Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
The VPS or VasoNova system works with two vectors, and an algotherim of physiologic measures to determine tip placement. The VPS system does not use ECG alone, but a combination of the ECG system, and doppler which reads blood flow. If the tip was in the azygous vein, you would receive doppler changes to retrograde flow, and also obtain an "do not enter" signal on the machine. As an insertor, you would not leave the tip in this location, even if you had the ideal measurement. With the VPS technology, it is very possible to know the precise and accurate tip location.
With the VPS system, the doppler is also able to detect arterial or venous blood flow, thus eliminating the possibility of threading in an artery.
Thanks!!
Rita M.Larson RN,BSN,CRNI,MBA,VA-BC
Clinical Specialist
VPS Arrow/Teleflex
Yes, we have experienced this as well.
Darilyn Cole
May I ask which system you were using?
I am with Lynn regarding the PA and Lateral readings on the x-ray, that is the main way to confirm azygous placement. The best way is really to identify adequate flow during the insertion. I have seen a few experienced people check briskness of blood return and just know it was azygous and needed to be moved before completion. I understand the VPS system with Vasonova also checks ECG and flow which to me seems ideal especially for the azygous. With ECG alone it checks for location and azygous is near the point of electrical impulse, SA node and makes it look like a good position, flow indicators and doppler would help this situation. Just my opinion.
Nancy Moureau
PICC Excellence.com
Nancy L. Moureau, PhD, RN, CRNI, CPUI, VA-BC
PICC Excellence, Inc.
[email protected]
www.piccexcellence.com
Nancy can you eloborate on the briskness of blood return, I would love to know more.
The system being trialed along with x-rays is Sapiens. They were azygous placements that were clear without a lateral required. The point is the change in P waves that can occur by beinging near the SA node material and the potential for using this technology without x-rays with subsequent improper catheter placement.
I appreciate the reponses and hearing from others with similar experiences and thoughts about moving forward with technology.
Mary
When learning either of these systems it is important to remember all of the information available to you. In the case of Sapiens you still have the depth monitor on the Sherlock which will show an early depth drop as the PICC travels posterior into the Azygous. I very often will pick up Azygous just with Sherlock, with Vasanova the Doppler will change with retrograde flow. It is easy to focus on the "new" when learning a new system, especially the signal for a successful endpoint. If the goal is to eliminate chest X-ray then we have a responsibility to slow it down just a bit and process all the feedback the two systems give us.
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
When learning either of these systems it is important to remember all of the information available to you. In the case of Sapiens you still have the depth monitor on the Sherlock which will show an early depth drop as the PICC travels posterior into the Azygous. I very often will pick up Azygous just with Sherlock, with Vasanova the Doppler will change with retrograde flow. It is easy to focus on the "new" when learning a new system, especially the signal for a successful endpoint. If the goal is to eliminate chest X-ray then we have a responsibility to slow it down just a bit and process all the feedback the two systems give us.
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
with the early drop in depth change with the sherlock.
We are also using ekg system. I experienced this problem on several occasions but I noted during the insertion the p wave began to rise as the cath was advanced then stayed the same for several cm never having a deflection of the p wave. (biphasic p)
When the cath was slightly retracted there was a delay in the decline of the p wave. We placed several of these lines with both having this same "effect" during insertion. The next time we experienced the problem, we retracted the ekg wire a little and flushed, then reinsearted the wire and proceeded with the insertion. xray demonstrated proper placement in the lower 3rd of the CAJ.
Under normal circumstances we have noted the p wave rises and falls in proportion to the insertion or retraction of the cath with the deflection at the farthest insertion point. When we see this and add in the magnetic tip direction detection we have always be in the correct place. We are Xray free now.
David
Cardiology proceedural nurse.
You should consider some way to measure and analyze the types of patients where this appears and then publish your data. We definitely need to broaden and strengthen the merger of VAD insertion with ECG technology for tip location. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn, I heard about that data base that INS is starting for tracking??? I think it was INS. I am not at work right now to check the email. I really need some help with tracking type issues and hope our hospital will buy off on it.
Sorry I don't know about that INS project. I know there are registry services available for collecting PICC insertion data now available. That would also be an alternative way to collect outcome data. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Disagree with both the brisk return and sherlock depth to indicate azygous placement. Have had good blood return with azygous placement and many times and even regardless of chest size have had the Sherlock indicator shrink and the depth drop when the placement is clearly CAJ on x-ray.
I also can't agree with the comments about the changes in P waves being an indicator as what is described does not sound like an exact science. I am not about to have a PICC tip placement in the azygous infusing a vesicant or irritant and causing a patient damage, or worse, until this technology improves.
Have not tried Vasonova yet.
Mary
Disagree with both the brisk return and sherlock depth to indicate azygous placement. Have had good blood return with azygous placement and many times and even regardless of chest size have had the Sherlock indicator shrink and the depth drop when the placement is clearly CAJ on x-ray.
I also can't agree with the comments about the changes in P waves being an indicator as what is described does not sound like an exact science. I am not about to have a PICC tip placement in the azygous infusing a vesicant or irritant and causing a patient damage, or worse, until this technology improves.
Have not tried Vasonova yet.
Mary
I should add, when we see this p wave NOT rising and falling with insertion and retraction in a direct relational effect it is obvious there is a problem. upon xrays we found azygous placements. Whe we do as I previously stated in fixing the problem, We always follow with a CXR to confirm placement in these cases.
When we were in testing mode of this new technology we did CXR on all cases as a verification of the new tech. When the p wave rose and fell directly with the insertion and retraction,( that is an uncomplicated insertion) we found 100% success rate. If there was any question in the mind we cxr.
sorry, I am not good sometimes writing out my words, I have the gift of gab, lol ;)
David
I can't agree with you more Mary. Until the tip verification technique without imaging is mature, I don't feel comfortable leaving a line for patient who is getting vesicant or irritant with a tiny possibility of being in the azygouz.
ECG for tip location on most all CVADs is the standard of care in Europe. So we are actually behind on this technology. It is not a new practice, although we must learn how to use it correctly. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thanks David for the clarification. I understand how you are making it work.
I am aware of the claims to the use of this technology in Europe and find it reassuring. At the same time, those claims have come via the companies that sell this technology or those who work for those companies. I have also heard that the majority of those lines are placed by physicians, with maybe a slightly different level of liability. As we know there is also not the same FDA entity in force (yes, it has its good and bad points). So, who can give me un-biased literature about the use of this technology in Europe? I hope there is some out there. Also, any data base collection tool for sentinel events over in Europe?
Thanks,Mary
Thanks David for the clarification. I understand how you are making it work.
I am aware of the claims to the use of this technology in Europe and find it reassuring. At the same time, those claims have come via the companies that sell this technology or those who work for those companies. I have also heard that the majority of those lines are placed by physicians, with maybe a slightly different level of liability. As we know there is also not the same FDA entity in force (yes, it has its good and bad points). So, who can give me un-biased literature about the use of this technology in Europe? I hope there is some out there. Also, any data base collection tool for sentinel events over in Europe?
Thanks,Mary
There are numerous studies published in peer-reviewed respected journals where the content is not directed or influenced by any manufacturer. A literature seaerch can be done by going to http://www.ncbi.nlm.nih.gov/pubmed/ and entering your search terms. Some journals offer free download of the full article while most do require you to pay for the article. Or you can locate the article and then take your list to a medical library and find and photocopy the article. Sorry I only have time to do these searches for clients. It is not difficult to do these searches yourself. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I found something quite by accident one day at work. If you search from work and your company has a supscription to a "clearing house" of journals. I don't quite know what to call them. :) The site can see your work domain and there is no charge even for the pay sites.
I don't quite know how they do it but it did same me some $$$ :)
enjoy,
David
Hi Mary,
That is very interesting.....I personally have not entertaineded the notion of using these "new" tip location devices because there is no substitute for actually visualizing the location. But that's me...I know alot of hospitals are going in the direction to so called "save money"...but if it's showing OK location in the azygos...that's a problem.
Hi Mary,
That is very interesting.....I personally have not entertaineded the notion of using these "new" tip location devices because there is no substitute for actually visualizing the location. But that's me...I know alot of hospitals are going in the direction to so called "save money"...but if it's showing OK location in the azygos...that's a problem.
Mary, I think it is more than just money savings, it is radiation exposure. I just went to a talk on it and it seems we are radiating people 6x more than 30 years ago.
Since the environmental aspect has not changed signifigantly they attributed it to the massive amount of dianostic exams we give today.
The I don't remember his name, but he said "less is better" should be our motto. When we use this proven technology, we save exposure of the patient and the xray tech.
As far as xrays go, When I went to the RN radiology class to certify to read xrays for picc placement, The radiologist who spoke was cutting edge. He and His group found a way to use ct and xray images to prove that a large portion of the radiologist read the lower 3rd of the CAV as 2 cm too high. Their findings have changed the way radiologists read the CAV or should. It was a facinating class. I will see if I can find the paperwork to get his name for you soon if possible.
He had great evidenced based practices, I think we all left changed.
Hope that helps you grasp, :)
David
I agree with Lynn, we have to learn how to use it correctly, and I also agree with David, having used this technology for about 6 weeks. (our team was a beta site for trialling it). The key is, that you must see a definite change in the P wave. It is important to know that a difference occurs after inserting it to your measurement. It helps to freeze a reading to look back at so you know what it looked like at 1cm out, or 2, etc. It is also important, as David said, to insert, either to your measurement or to the hub, note the P wave, and retract 1cm at a time, so that you are confident you have max P. With the Sapiens, it is also helpful to look at the Sherlock as well. I sometimes re-calibrate and check to see if the Sherlock matches what the ECG tells me. The Sherlock is not perfect, but good to use as a confirmation back-up. I have not used the Vasanova, but it seems that it is a good device as far as having dual confirmation ability, with the Doppler feature. And of course, when in doubt, just get a CXR!
Sheila Hale, MSN, RN, CRNI, VA-BC, Austin, TX
Thank you all for your comments. I do believe it is important to continue to have discussions about this and any other new use of technology.
I work at a university hospital and we were also part of the beta site testing. I also have access to wonderful librarians who have helped to do an extensive search. Limitations include articles written in foreign languages and I am currently reviewing a bibliography. I have worked with Dr. Peter Verhey who wrote the article “The Right Mediastinal Border and Central Venous Anatomy on Frontal Chest Radiograph—Direct CT Correlation” and Jamie Santolucito who pioneered the x-ray read classes. We have not abandoned our current trial of the technology, however, we are keeping a close eye on tip placement when using it (still getting x-rays). It appears to be a wise protocol that for any left sided placements that do not become bi-phasic, then you always get a chest x-ray. Unfortunate, but at this time realistic, for those patients who are never bi-phasic to have to use both technologies to be safe there is no azygous tip placement.
What we are currently more discouraged by the numerous PICC tip placements that are either proximal SVC or mid SVC despite “perfect” Sapiens readings. I hear all your arguments already about position at the time of placement and x-ray, etc. We have not found it to be the case that all these “other” explanations can account for tips that end up several cm’s above the apical appendage.
So, here’s the bigger question for you all; Do you throw out Dr. Verhey’s work and only look at potential SA node conductivity occurring in places in the SVC other then distal SVC or at the CAJ to be your indicator of placement? I will grant that maybe, despite 3 solid weeks training with lots of PICCs placed, and a team of very skilled PICC nurses our team could use additional training. I also know that my current anatomical knowledge of the SVC and CAJ makes me want my PICCs “down” in the region of the CAJ and not proximal SVC. The decrease in radiation is a great idea but already significantly less then it has been.
For us the verdict if still out.
Thanks, Mary
Hi Mary,
I have an explanation for you. First, my disclosure...I work for Telflex who has the Arrow VPS (Vasonova) system which incorporates both ECG and Doppler into tip verification, because of the specific issues you have raised.
Once one understands the anatomy of the SVC and pericardial reflection, it makes sense as to why one can get a p-wave spike but yet be short of the CAJ or distal third with systems that only rely on ECG technology alone. The Schummer article (I have included the abstract) very nicely describes why and how this occurs. I don't really want to get into much more than this on the list serve because of my affiliation with manufacturing. I am happy to offer additional info if you would like. [email protected] Thank you.
Central venous catheters—the inability of ‘intra-atrial ECG’ to prove adequate positioning
W. Schummer1,*, C. Schummer1, C. Schelenz1, H. Brandes2, U. Stock3, T. Mu¨ ller3, U. Leder4 and E. Hu¨ttemann1
British Journal of Anaesthesia 93 (2): 193–8 (2004)
Background. The classic increase in P wave size, known as ‘P-atriale’, is a widely accepted criterion for determination of proper positioning of central venous catheter tips. Recent transoesophageal echocardiography (TOE) studies did not confirm intra-atrial position despite advancing the central venous catheter further than indicated by ECG guidance. We postulate that the pericardial reflection rather than the entry into the right atrium corresponds to the ECG changes. In order to test our hypothesis we sought to determine the anatomical substrate for the electrical changes in an animal study. Subsequently, a modified version of the study was undertaken in man and is also reported.
Methods. In six juvenile pigs the left external jugular vein and right carotid artery were cannulated. A triple-lumen central venous catheter was positioned by ECG guidance using a Seldinger wire as an exploring electrode. The venous and arterial catheters were suture fixed 2 cm beyond the onset of an increase in P wave size. The corresponding anatomical catheter tip position was determined by open exploration of the vessels and the heart. Subsequently the catheter tip position (during advancement) of a pulmonary artery catheter and the corresponding electrical ECG changes were examined in 10 patients during open chest cardiac surgery.
Results. All catheters—arterial and venous, in animals and humans—revealed an increase in size of the P wave as well as the QRS complex. All venous catheters were positioned in the superior vena cava, beyond the pericardial reflection but outside the right atrium. All arterial catheters were positioned in the ascending aorta thus also beyond the pericardial reflection.
Conclusions. The start of an increase in P wave size does not correspond with the entrance of the right atrium. The anatomic equivalent for the electrophysiological changes of the ECGis the pericardial reflection. ECG guidance is unable to distinguish between venous and arterial catheter position.
Cheryl Kelley RN BSN, VA-BC
Hi Mary,
I would like to discuss this with you in more detail. Please email me at [email protected]
Thank,
Darilyn