Central venous catheter placement: An alternative of Certodyn(®) (Universal Adapter).

Sir,

A use of central venous catheters (CVCs) is increasing day by day. Guidelines for CVCs positioning by FDA and other experts suggest that CVCs tip should not be placed in right atrium in order to avoid complications.[12] ECG guided CVCs insertion is done with the help of ECG adapter (Certodyn®, B.Braun Medical). But this adapter is expensive and not easily available in developing countries.

Present innovation is an alternative to Certodyn® which is very simple to make and very cost effective to correctly identify CVC tip position during its insertion. Changes in ‘P’ wave amplitude is used as a guide to position CVCs.

Two ECG Electrodes [Figure 1a]

Figure 1

(a) Two ECG electrode. (b) One non plastic coated steel ‘U’ paper clip. (c) Adhered two ECG electrode (vertical view). (d) Adhered two ECG electrode with paper clip (horizontal view)

One ‘U’ shaped steel paper clip [Figure 1c]

Certofix® (B.Braun.Medical, Bethlehem, PA)

ECG monitor [Figures 2a and b]

Figure 2a

Showing normal ECG recording on standard monitor

Figure 2b

Showing peaked ‘P’ wave on ECG while putting CVC

Two ECG electrodes were stick together by central sticky portion [Figures 1c and 3]. Right Arm lead of ECG monitor was attached to one side of ECG electrode assembly and other leads of ECG monitor were attached to surface electrodes in usual manner. A paper clip was attached to other side on metallic tip of ECG electrode assembly [Figures 1d and 3].

Figure 3

Whole assembly on patient

CVC was inserted by usual Seldinger technique. A CVC (20 cm) was inserted over guide wire (50 cm) until 20 cm guide mark of CVC was at skin level. The guide wire was then withdrawn through the catheter until a mark on guide wire indicated the tip to be exactly positioned at the tip of catheter. Then alligator was clip attached to guide wire at indicated position. The other end of cable was attached to ‘U’ shaped paper clip [Figure 3]. The catheter with guide wire was slowly adjusted according to ECG guidance. ‘P’ wave on lead II was observed on ECG monitor [Figure 2a]. Peaked ‘P’ wave [Figure 2b] indicates CVCs position in RA (right atrium), then CVC with guide wire was withdrawn until ‘P’ wave return to normal configuration. After further withdrawal of CVC for another 2 cm, CVC was secured with skin sutures and dressing was done.

It is very important to confirm the correct position of CVCs tip. It should never be placed in right atrium.[12] Improper placement of CVCs tip can result into many complications like pleural effusion, hydrothorax, hemothorax, hydromediastinum, pneumothorax, and pneumomediastinum.[3] Radiological method (X-Ray, Image intensifier, computed tomography) are practical and reliable tools for confirmation of depth of CVCs tips. However confirmation by this method is usually done several hours after the insertion of CVCs with extra financial burden on patients or hospital and radiation hazard to patient. Ultrasound have very limited role for aiding confirmation of tip placement. However it is very much useful to find-out correct puncture site.

We have developed a very simple and cost effective technique for correct placement of CVCs tip. Principle of our technique is same as that of Certodyn®. Materials used in our technique are easily available and simple to assemble on spot. Its performance is equivalent to Certodyn®. It has no side effects. Safety of patient is ensured and avoids unnecessary exposure to radiation. Hence we conclude that this simple, safe and easy to assemble alternative can be used for accurate positioning of CVCs, thus avoiding complications which are not only difficult to manage but also a financial burden on patient and hospital.