Objective: Assess the location effect of the atrial electrogram in the PICC catheter tip. Method: Make online research in the CNKI, CBM, Wanfang, VIP, Database, Cochrane Library, JBI Library, PubMed, Ovid, Springer, Web of science, MEDLINE database to collect the randomized controlled trial data of using the atrial electrogram to locate the PICC catheter tip. When making the online research, only the data to November 20, 2016 can be searched out. Two researchers independently select the literature and information, make quality assessment, and then use the RevMan 5.2 software to make Meta analysis. Result: 16 random tests are done. The Meta analysis results show that compared with the traditional X ray chest radiograph location method, the atrial electrogram can increase the accuracy rate of the location of the catheter tip [RR = 1.13, 95%CI (1.07, 1.19), P < 0.00001]; it can decrease the incidence rate of related complications [RR = 0.37, 95%CI (0.21, 0.66), P < 0.0008]; and it can save the catheter placing time [RR = −12.56, 95%CI ( −18.56, −6.57), P < 0.0001]. Conclusion: The atrial electrogram can increase the accuracy rate of the location of the catheter tip, decrease the incidence rate of related complications and save the catheter placing time. Therefore, it is worthy of clinical application.
Peripherally inserted central catheter (PICC) has been widely applied in our country due to its advantages, namely, long-term use, reduced puncture pain, safety, efficiency, resistance to hypertonic and intense irritant drugs as well as fewer complications [
1) PICC catheterized patients aged over 18 and voluntary to participate in this research. 2) Patients with body surface electrocardiograms being normal before catheterizing. 3) Patients whose catheter head ends were localized through intra-atrial electrocardiogram technology. 4) Patients who didn’t have heart diseases or previous operation history of heart diseases. Exclusion criterion: 1) Patients whose electrocardiographic examination results were normal before catheterizing such as patients with atrial fibrillation and ventricular tachycardia and those carrying cardiac pacemakers.
In the control group: The PICC catheter was implanted with the predicted length according to the length of the in vitro measurement. X-ray examination was performed to determine that the tip of the catheter was located in the lower 1/3 of the superior vena cava.
Pick up the surface ECG, observe the ECG P wave changes during the catheterization process in real time, and then determine the catheter tip should be in the lower 1/3 of the superior vena cava based on the specificities of P wave, further X-ray examination should be performed to verify the location of the tip of PICC cathether [
The main outcome indicator is estimation accuracy of intra-atrial electrocardiogram technology for PICC catheter head end to reach ideal position. Secondary indicators mainly include occurrence rate catheter-related complications and the time taken by catheterizing.
Randomized Controlled Trial (RCT) of atrial electro-gram applied to PICC catheter head-head location. Exclusion criteria: non-randomized controlled trials, clinical controlled trials, systematic review.
Using “Peripherally inserted central catheter”, “PICC”, “Catheter tip location”, “Atrial electro-gram positioning”, “Electrocardiography”, “ECG”, “EKG” as key words ,the authors searched the CNKI, CBM, WanFang ,VIP databases, Cochrane Library, JBI Library, PubMed, Ovid, Springer, Web of science, and MED- LINE databases. The time limit of these databases is from the establishment to April, 2016, and the retrieval is conducted in the form of free words with a keyword. In this study, CNKI and PubMed are taken as an example to introduce specific retrieval strategy [
Two researchers independently screened the literature according to the inclusion and exclusion criteria set out in this study. By reading the literature title and abstract, the literature that clearly did not conform to the study was excluded. The controversial literature shall be discussed to decide whether or not to be included. If the result of the discussion is not consistent, a third party shall be asked to decide. For the literatures that meet the inclusion criteria, the information needed for this study, including the author’s name, the time of publication, the source of the literature, the baseline data comparability, the sample size, as well as the intervening measures and outcome indicators of intervention group and the control group, were included in the study.
The literature quality for randomized controlled trials and semi-randomized controlled trials is evaluated according to the quality criteria of Cochrane Review's Handbook [
Meta-analysis was performed using Rev Man 5.2 software. The outcome index was classified as binary information, and used the RR (relative risk) value or OR (odds risk) as effective size. The continuous variable was expressed by using the weighted mean difference MD as the effect size, and the first thing was to determine whether there is heterogeneity in the study. If there is no heterogeneity in different studies (P > 0.1, I2 < 50%) the fixed effect model is selected; if heterogeneity exists in different studies. (P < 0.1, I2 > 50%), then it is necessary to analyze the reason for the heterogeneity. If there is statistical heterogeneity but no clinical heterogeneity among the various studies, random effects model will be adopted [
576 articles were retrieved in the relevant databases, after reading the title and abstract, 531 articles of repeated publication or obviously do not meet the inclusion criteria were excluded, so 45 articles were included initially. In the following, 29 articles with unclear interventions, no outcome evaluation indicators or low quality were also excluded after reading the full text, and 16 articles were finally included [
A total of 16 randomized controlled trials were included. The total sample size was 2996. In the experimental group, atrial electro-gram real time location was used as an intervention measure during the catheterization, and then X-ray examination was used to confirm the accuracy of atrial electro-gram positioning; In the control group, X-ray examination was used as an intervention measure to have the catheter tip location after the end of the catheterization. The observed indicators were catheter tip arrival rate, complication rate, catheterization time- consuming. The general situation of the study literature is shown in
The 16 studies included were evaluated according to the Cochrane Review's Handbook quality assessment criteria, among the 16 studies that included in Meta-analysis, 10 studies [
Included research | Sample size | Intervention measure | Outcome indicator | ||
---|---|---|---|---|---|
Experimental group | Control group | Experimental group | Control group | ||
Liu et al. [ | 85 | 85 | I | II | a |
Elli et al. [ | 77 | 44 | I | II | a |
Baldinelli et al. [ | 42 | 48 | I | II | a |
Lei Wenlan et al. [ | 130 | 130 | I | II | a |
Pan Longfang et al. [ | 90 | 90 | I | II | a, b, c |
Zhu Ya et al. [ | 65 | 64 | I | II | a |
Lin Cuifang et al. [ | 60 | 60 | I | II | a, b |
Zhang Ronghua et al. [ | 45 | 45 | I | II | a |
Zhou Lianqing et al. [ | 51 | 49 | I | II | a, c |
Zhuo Yajuan et al. [ | 60 | 60 | I | II | a, b |
Xu Mingming et al. [ | 70 | 70 | I | II | a, b |
Jiang Guichun et al. [ | 500 | 500 | I | II | a |
Wang Chaohong et al. [ | 43 | 40 | I | II | a, b |
Li Xiangjun et al. [ | 98 | 106 | I | II | a |
Zheng Chunhua et al. [ | 60 | 60 | I | II | a |
Ren Xiaomin et al. [ | 35 | 35 | I | II | a, c |
Note: 1) indicates the verified catheter tip position after the atrial electro-gram and X-ray chest positioning; indicates the verified catheter tip position after traditional catheterization and X-ray chest positioning. 2) a indicates the Arrival rate of catheter tip, b indicates the complication rate, c indicates the catheterization time-consuming.
Included research | Random method | Blind method | Allocation concealment | Withdrawal and loss to follow-up | ITI analysis | Baseline comparability | Quality grade |
---|---|---|---|---|---|---|---|
Liu et al. [ | unclear | single-blind | unclear | No | No | Yes | B |
Elli et al. [ | random number | unclear | unclear | Yes | No | Yes | B |
Baldinelli et al. [ | random number | single-blind | unclear | Yes | No | Yes | B |
Lei Wenlan et al. [ | unclear | unclear | unclear | Yes | No | Yes | B |
Pan Longfang et al. [ | random number | single-blind | Yes | Yes | Yes | Yes | A |
Zhu Ya et al. [ | sequential order of catheterization | unclear | unclear | No | No | Yes | B |
Lin Cuifang et al. [ | random number table | unclear | unclear | No | No | Yes | B |
Zhang Ronghua et al. [ | unclear | unclear | unclear | No | No | Yes | B |
Zhou Lianqing et al. [ | Hospitalization number | unclear | unclear | No | No | Yes | B |
Zhuo Yajuan et al. [ | random number table | unclear | unclear | No | No | Yes | B |
Xu Mingming et al. [ | unclear | unclear | unclear | No | No | Yes | B |
Jiang Guichun et al. [ | envelope method | unclear | unclear | No | No | Yes | B |
Wang Chaohong et al. [ | random number table | unclear | unclear | No | No | Yes | B |
Li Xiangjun et al. [ | unclear | unclear | unclear | No | No | Yes | B |
Zheng Chunhua et al. [ | unclear | unclear | unclear | Yes | No | Yes | B |
Ren Xiaomin et al. [ | random number table | unclear | unclear | No | No | Yes | B |
The accuracy of applying atrial electro-gram technique to PICC catheter tip location was analyzed in 16 randomized controlled studies, and the total sample size was 2996 (there was 1507 cases in atrial electro-gram positioning group, and 1489 cases in X-ray chest positioning group), statistical heterogeneity exists among various studies (RR = 1.13, I2 = 79%, P < 0.00001), so the random effect model was used for meta-analysis (P < 0.05). The Meta-analysis showed that the accuracy of the PICC catheter at the lower 1/3 of the superior vena cava in the atrial electro-gram positioning group was higher than that in the X-ray chest positioning group. [RR = 1.13, 95% CI (1.07, 1.19), P < 0.00001]. See
The results of two studies showed the effect of two different positioning methods on the incidence of complications in PICC catheter. The total number of samples was 643 (323 cases in atrial electro-gram group, 320 cases in X-ray chest group), and there was no heterogeneity among various studies (RR = 0.41, I2 = 32%, P < 0.21). The restorative model was used for meta-analysis. Meta-analysis showed that PICC catheter-related complications in the atrial electro-gram positioning group were lower (RR = 0.37, 95% CI (0.21, 0.66), P < 0.0008] compared with the X-ray chest positioning group. See
Two studies compared the time consumed in two different positioning methods. The total number of samples was 350 (174 cases in atrial electro-gram group, and 176 cases in X-ray chest positioning group), statistical heterogeneity exists between two studies (RR = −12.56, I2 = 99%, P < 0.00001), and the random effects model was used. Meta-analysis showed that PICC catheterization in atrial electro-gram positioning group took less time than in X-ray chest positioning group [RR = −12.56, 95% CI (−18.56, −6.57), P < 0.0001]. See
This study evaluated the accuracy of atrial electro-gram techniques for PICC catheter tip positioning. The results showed that atrial electro-gram has enhanced the positioning accuracy. The principle of atrial electro-gram (ECG) in PICC catheter tip location was mainly based on the saline and the conductivity of blood, which were regarded as probe electrodes. Changes of P wave in atrial electro-gram (ECG) was picked up, the location of the catheter tip can be determined from the wave mode and amplitude of P wave. When the catheter tip was just entering the superior vena cava, the shape and amplitude of the P wave did
not change; when the catheter was located at the lower 1/3 of the superior vena cava, and about 1 - 2 cm from the cavoatrial Junction (CAJ), the upright P wave with the amplitude equivalent to 50% - 80% of the QRS wave was introduced; when the catheter tip was located at the CAJ, the upright P wave with the amplitude equivalent to QRS waveform was introduced; when the catheter When the head end is located in the right atrium, leads to the biphasic P wave; when the catheter tip was located in the right atrium, diphasic P wave was introduced; when the catheter tip was located in the ventriculus dexter, negative P wave that showed double peaks was introduced [
Included literature research results showed that the use of atrial electro-gram positioning greatly reduced the incidence of related complications than the traditional X-ray positioning method. Studies have shown that during the PICC catheterization process, it is possible the catheter tip can’t be accurately placed in the ideal position as some patients had vascular anatomical changes and other diseases. As a result, the catheter tip needs repeated debugging after ectopia, and the incidence of mechanical vein inflammation, catheter-related bloodstream infection, thrombosis, lymphatic leakage and other complications can be increased [
The results of this study (
Since the literature included in this study included only published Chinese and English literature, publication bias may exist for incomplete search; the meta-analysis included 16 randomized controlled trials, and the sample sizes range from 70 to 500 cases, so methodological and sample heterogeneity exists; the quality of the 16 literature included are graded to be lower-intermediate, which is not high. Only one literature [
In summary, the existing studies show that atrial electro-gram applied to PICC catheter tip positioning can improve the arrival accuracy of catheter tip, reduce the incidence of related complications and save the catheterization time, which can also provide scientific basis for further promotion of the atrial electro-gram positioning method. However, in view of the quality limitations of the literature included in this study, multi-center and large sample of randomized controlled studies are still required in the future to further explore and confirm the superiority of applying atrial electro-gram to PICC catheter tip positioning.
Song, J., Wang, C.L. and Hu, J.-E. (2017) Meta-Analysis of Atrial Electro-Gram Applied to PICC Catheter Tip Positioning. Yangtze Medicine, 1, 65-76. https://doi.org/10.4236/ym.2017.12007