腔内心电图技术在三向瓣膜式经外周静脉置入中心静脉导管置管术中的应用

Application of intracavitary electrocardiography in the insertion of the groshong peripherally inserted central catheters

目的评估腔内心电图技术在三向瓣膜式经外周静脉置入中心静脉导管（PICC）穿刺置管术中的应用。方法入选2013年1月至2014年12月期间武汉大学中南医院因各种临床情况而需置入三向瓣膜式PICC的妇科肿瘤患者168例（年龄20～76岁）。置管过程中以腔内心电图P波特征指导置管操作及导管头端定位，判断导管头端位置和方向。导管固定后行X线检查确定导管尖端位置，据此评估腔内心电图技术在三向瓣膜式PICC穿刺置管术中的准确率及敏感度。结果所有研究对象腔内心电图的P波均有特征性改变，15例患者在置管中第1次送管无论深浅均未出现特征性P波的变化，向后撤退导管，调整体位重新送管，直至引导出特异性P波。以胸部X线片结果为金标准，诊断导管尖端位于上腔静脉的准确率为98．8％，敏感度为98．8％。位于上腔静脉最佳留置部位的准确率可达到97．0％。结论置入三向瓣膜式PICC导管时，采用腔内心电图监测技术能引导出高尖P波，波形无大的差异；腔内心电图技术可以明显提高三向瓣膜式PICC导管头端位于中心静脉部位的到位率；置管过程中，可监测腔内心电图P波的变化来判定最佳的导管体内留置长度。

Objective To assess the application of intracavitary electrocardiography （IC-ECG） during the insertion of the Groshong peripherally inserted central catheters （PICC）. Methods A total of 168 patients （aged 20 -76 years） with gynecologic tumors who required the insertion of Groshong PICC because of various clinical conditions between January 2013 and December 2014 were selected into this study in Zhongnan Hospital of Wuhan University. During PICC insertion, the P-wave of IC-ECG helped general judgments about the posi- tion and direction of the tip of catheters, hence guiding the intubation. Precise position was determined by X- ray following the fastening of catheters, based on which the accuracy and sensitivity of IC-ECG in the insertion of Groshong PICC were evaluated. Results All the cases presented typical changes of P-wave. However, 15 cases exhibited no such alternations in the first placement however deep or shallow the catheters were, in whom the typical P-wave was induced after withdrawal and replacement of the catheters with adjustment of patient po- sition. According to the X-ray （ gold standard）, the accuracy and sensitivity of IC-ECG in diagnosing position of tip in the superior vena cava （SVC） were 98. 8% and 98.8% , respectively. The accuracy of diagnosing the position at the optimum location in the SVC reached 97. 0%. Conclusions A high peaked P-wave of similar shape could be observed in IC-ECG in the insertion of Groshong PICC. IC-ECG could remarkably increase the positioning accuracy of PICC tip into the SVC ; meanwhile, the optimal inserted length of the catheters could be determined by monitoring the changes of the P-wave with IC-ECG during insertion.