Patent Publication Number: US-9833169-B2

Title: Method of locating the tip of a central venous catheter

Description:
PRIORITY 
     This application is a division of U.S. patent application Ser. No. 14/506,552, filed Oct. 3, 2014, now U.S. Pat. No. 9,345,422, which is a division of U.S. patent application Ser. No. 13/969,265, filed Aug. 16, 2013, now U.S. Pat. No. 8,858,455, which is a division of U.S. patent application Ser. No. 12/878,915, filed Sep. 9, 2010, now U.S. Pat. No. 8,512,256, which is a division of U.S. patent application Ser. No. 11/552,094, filed Oct. 23, 2006, now U.S. Pat. No. 7,794,407, each of which is incorporated by reference into this application as if fully set forth herein. 
    
    
     BACKGROUND OF THE INVENTION 
     Field of the Invention 
     The present invention is directed generally to devices for and methods of locating a catheter inside a body and more particularly to devices for and methods of locating the tip of a central venous catheter inside the superior vena cava, right atrium, and/or right ventricle using information obtained from an electrocardiogram. 
     Description of the Related Art 
     Central venous catheters (“CVC”) include any catheter designed to utilize the central veins (e.g., subclavian and superior vena cava) or right sided cardiac chambers for the delivery and/or withdrawal of blood, blood products, therapeutic agents, and/or diagnostic agents. CVCs also include catheters inserted into the central veins or right sided cardiac chambers for the acquisition of hemodynamic data. Standard central venous catheters for intravenous access, dialysis catheters, percutaneously introduced central catheters (“PICC” lines), and right heart (“Swan-Ganz™”) catheters are examples of CVCs. 
     The standard of care for placing a CVC dictates that the tip of the CVC lie just above and not inside the right atrium. In fact, in 1989, the Food and Drug Administration issued a warning citing an increased risk of perforation of the right atrium, clot formation, and arrhythmias among other potential complications resulting from the tip of the CVC being placed inside the right atrium. 
     While CVCs have been used for many years, determining the position of the tip of the CVC has always been problematic. Currently, a chest x-ray is used to determine the position of the tip of the CVC. Because CVC may be a radiopaque and/or include radiopaque materials, the CVC is visible on an x-ray. However, this method has several drawbacks. For example, obtaining a chest x-ray is labor intensive and expensive. In recent years, CVCs, which were traditionally placed in a hospital in-patient setting, are being placed in an outpatient setting more frequently. In an outpatient setting, obtaining a chest x-ray to determine the position of the tip of the CVC can be very cumbersome and may not be obtained in a timely manner. Therefore, using a chest x-ray to determine the position of the tip of the CVC may introduce a considerable delay, prolonging the procedure. Generally, the operator will leave the patient to perform other duties while the x-ray is processed. If the tip is improperly placed, the operator must return to the patient&#39;s bedside to reposition the CVC. To reposition the CVC, the operator must open the sterile dressing, cut the sutures, re-suture, and redress the wound, all of which potentially expose the patient to discomfort and infection. 
     In addition to the need to know where the tip is during initial placement, the CVC may migrate or otherwise move after the initial placement and require re-positioning. Therefore, the operator must monitor or periodically reevaluate the location of the tip. 
     An electrocardiogram (ECG) measures electrical potential changes occurring in the heart. Referring to  FIGS. 1A-1C , the ECG measurements may be visualized or displayed as an ECG trace, which includes ECG waveforms. The P wave portion of the ECG waveforms represents atrial muscle depolarization: the first half is attributable to the right atrium and the second half to the left atrium. Under normal circumstances, atrial muscle depolarization is initiated by a release of an excitatory signal from the sino-atrial node, a specialized strip of tissue located at the juncture of the superior vena cava (“SVC”) and right atrium. 
     Techniques of using ECG waveforms to locate the tip of a CVC have been available since the 1940s. Some of these prior art devices construct an intravascular ECG trace by placing an electrode near the tip of the CVC and using that electrode to measure the voltage near the tip of the CVC relative to a surface electrode(s) and/or a second electrode spaced from the first. 
     These techniques have shown that both the magnitude and shape of the P wave change depending upon the positioning or location of the electrode attached to the tip of the CVC. Referring to  FIGS. 1A and 1B , two exemplary ECG traces are provided for illustrative purposes. 
       FIG. 1A  is an ECG trace made when the electrode attached to tip of the CVC is in the SVC. This tip location corresponds to position “ 1 ” depicted in  FIG. 2A . The portion of the ECG trace corresponding to an exemplary P wave produced when the electrode attached to the tip is located in position “ 1 ” is labeled “P 1 .” 
       FIG. 1B  is an ECG trace made when the electrode attached to the tip of the CVC is approaching the sino-atrial node and stops at a location adjacent to the sino-atrial node. These tip locations correspond to moving the tip from a position “ 2 ” to position “ 3 ” depicted in  FIG. 2A . The portion of the ECG trace corresponding to an exemplary P wave produced when the electrode attached to the tip is approaching the sino-atrial node is labeled “P 2 ” and the portion of the ECG trace corresponding to an exemplary P wave produced when the electrode attached to the tip is located adjacent to the sino-atrial node is labeled “P 3 .” 
     Normally as the electrode attached to the tip of the CVC moves from the SVC (position “ 1 ”) toward the sino-atrial node (position “ 3 ”), the maximum value of the absolute value of the voltage of the P wave increases dramatically. When the electrode attached to tip of the CVC is adjacent to the sino-atrial node (position “ 3 ”), the voltage of the P wave (please see “P 3 ” of  FIG. 1B ) reaches a maximum value that is more than twice the value experienced in the SVC and may be as large as eight times the voltage in the SVC. When this occurs, the tip of the CVC is considered to have entered into the right atrium. Because the magnitude of the P wave more than doubles when the electrode attached to tip of the CVC is adjacent to the sino-atrial node, this information may be used to place the tip of the CVC within 1-2 cm proximal to the sino-atrial node. Additionally, as the electrode attached to tip of the CVC moves from the SVC toward the right atrium, the shape of the P wave changes from a “u” shape ( FIG. 1A ) to a spike-like shape ( FIG. 1B ). 
     Referring to  FIG. 2B , another exemplary illustration of the P wave portion of the ECG trace produced when the electrode attached to the tip of the CVC is located at positions  1 - 5  depicted in  FIG. 2A  is provided. The P wave portions of the ECG traces of  FIG. 2B  are labeled with the letter “P” and occur between the vertical dashed lines. Each of the exemplary traces is numbered to correspond to positions “ 1 ” through “ 5 .” Therefore, the ECG trace “ 1 ” was produced when the electrode attached to the tip was located in the SVC. The trace “ 2 ” was produced when the electrode attached to the tip was in position “ 2 .” And, the trace “ 3 ” was produced when the electrode attached to the tip was adjacent to the sino-atrial node. 
     As the electrode attached to tip of the CVC is advanced further into the right atrium, the polarity of the P wave “P” changes from predominantly negative near the top of the right atrium (position “ 3 ”) to isoelectric (i.e., half has a positive polarity and half has a negative polarity) near the middle of the right atrium (position “ 4 ”) to almost entirely positive at the bottom of the right atrium (position “ 5 ”). These changes in the P wave “P” are illustrated in traces “ 3 ” through “ 5 .” 
       FIG. 1C  is an ECG trace made when the electrode attached to tip of the CVC is in the right ventricle. The portion of the ECG trace corresponding to an exemplary P wave produced when the electrode attached to the tip is labeled “P 6 .” When the electrode attached to tip of the CVC is advanced into the right ventricle, the maximum magnitude of the absolute value of the P wave “P 6 ” approximates the maximum magnitude of the absolute value of the P wave “P 1 ” when the electrode attached to tip of the CVC was inside the SVC above the sino-atrial node (i.e., located at position “ 1 ”). However, the polarity of the first half of P wave “P 6 ,” which corresponds to the right atrium, is opposite. 
     The first technique developed for viewing the ECG waveform during the insertion of a CVC used a column of saline disposed within a hollow tube or lumen longitudinally traversing the CVC. The column of saline provides a conductive medium. Saline was inserted into the lumen by a saline filled syringe with a metal needle. The needle of the syringe remained within the entrance to the lumen or port in contact with the column of saline after the lumen was filled. One end of a double-sided alligator clip was attached to the needle and the other end was attached to an ECG lead, which in turn was attached to an ECG monitor. By using the saline solution filled CVC as a unipolar electrode and a second virtual electrode generated by ECG software from three surface electrodes, an intravascular ECG was obtained. The operator would adjust the position of the tip of the CVC based on the magnitude and shape of the P wave displayed by the ECG monitor. 
     Subsequently, this technique was modified by substituting an Arrow-Johans adapter for the metal needle. The Arrow-Johans adapter is a standard tubing connector with an embedded conductive ECG eyelet. The Arrow-Johans adapter may be placed in line with any conventional CVC. In a closed system, the tubing and CVC may be filled with saline, i.e., a conductive medium, and the CVC used as a unipolar electrode in conjunction with surface electrodes and a standard ECG monitor. The ECG eyelet is placed in contact with the saline in the lumen of the CVC. One end of the ECG lead is attached to the ECG eyelet and the other end to the ECG monitor for displaying the intravascular ECG waveforms. Because the system must be closed to prevent the saline from leaking out, this system works best after the guide wire used to thread the CVC forward has been withdrawn, i.e., after placement has been completed. Therefore, although the catheter may be withdrawn after initial placement, it may not be advanced into proper position. 
     B. Braun introduced its Certofix catheter to be used in conjunction with its CERTODYNE adapter. In this system, a patch lead with two ends has an alligator clip connected to one end. The alligator clip is clipped to the CVC guide wire. The other end of the patch lead includes a connector that is plugged into the CERTODYNE adapter. The ECG may be obtained during placement and the catheter may be advanced or withdrawn as desired. However, the CERTODYNE adapter has many moving parts and is not sterile, making the procedure cumbersome to perform and the operative field more congested. Additionally, the sterile field may become contaminated by the non-sterile equipment. 
     With respect to all of these prior art methods of using an ECG trace to place the tip of the CVC, some degree of expertise is required to interpret the P waves measured because the user must advance the guide wire slowly and watch for changes in the P wave. If the catheter is inserted too far too quickly and the changes to the P wave go unnoticed (i.e., the operator fails to notice the increase or spike in the voltage experienced when the electrode attached to the tip is in the right atrium), the operator may mistakenly believe the tip is in the SVC when, in fact, the tip is in the right ventricle. If this occurs, advancing the tip may injure the patient. 
     U.S. Pat. Nos. 5,078,678 and 5,121,750 both issued to Katims teach a method of using the P wave portion of an ECG trace to guide placement of the tip of the CVC. The CVC includes two empty lumens into which a transmission line is fed or an electrolyte is added. Each of the lumens has a distal exit aperture located near the tip of the CVC. The two exit apertures are spaced from one another. In this manner, two spaced apart electrodes or a single anode/cathode pair are constructed near the tip of the CVC. The voltage or potential of one of the electrodes relative to the other varies depending upon the placement of the electrodes. The voltage of the electrodes is conducted to a catheter monitoring system. The catheter monitoring system detects increases and decreases in the voltage of the P wave. The voltage increases as the electrodes approach the sino-atrial node and decrease as the electrodes move away from the sino-atrial node. Based on whether the voltage is increasing or decreasing, the operator is instructed by messages on a screen to advance or withdraw the CVC. 
     While Katims teaches a method of locating the tip of a CVC relative to the sino-atrial node, Katims relies on advancing or withdrawing the CVC and observing the changes of the P wave. Katims does not disclose a method of determining the location of the tip of the CVC based on a single stationary position. Unless the entire insertion procedure is monitored carefully, the method cannot determine the position of the tip of the CVC. Further, the Katims method may be unsuitable for determining the location of a previously positioned stationary tip. 
     Other devices such as Bard&#39;s Zucker, Myler, Gorlin, and CVP/Pacing Lumen Electrode Catheters are designed primarily to pace. These devices include a pair of electrodes at their tip that are permanently installed and designed to contact the endocardial lining. These devices include a lumen, which may be used to deliver and/or withdraw medications or fluids as well as for pressure monitoring. These leads are not designed for tip location and do not include multi-lumen capability. 
     A method of obtaining an intravascular ECG for the purposes of placing a temporary pacing wire was described in U.S. Pat. No. 5,666,958 issued to Rothenberg et. al. Rothenberg et. al. discloses a bipolar pacing wire having a distal electrode. The distal electrode serves as a unipolar electrode when the pacing wire is inserted into the chambers of the heart. The pacing wire is connected to a bedside monitor through a specialized connector for the purposes of displaying the ECG waveforms detected by the distal electrode. 
     Given the volume of CVCs placed yearly and the increasing demand particularly for PICC lines (devices that permit the delivery of intravenous therapeutic agents in the outpatient setting, avoiding the need for hospitalization) a great need exists for methods and devices related to locating the tip of a CVC. Particularly, devices and methods are needed that are capable of determining the location of the tip before the operator leaves the bedside of the patient. Further, a method of determining the location (SVC, right atrium, or right ventricle) of the tip from a single data point rather than from a series of data points collected as the catheter is moved may be advantageous. Such a system may be helpful during initial placement and/or repositioning. A need also exists for a device for or a method of interpreting the ECG waveforms that does not require specialized expertise. Methods and devices that avoid the need for hospital and x-ray facilities are also desirable. A need also exists for devices and methods related to determining the position of the tip of the CVC that are less expensive, expose patients to fewer risks, and/or are less cumbersome than the x-ray method currently in use. 
    
    
     
       BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWING(S) 
         FIG. 1A  is an exemplary ECG trace obtained from an electrode placed inside the SVC. 
         FIG. 1B  is an exemplary ECG trace obtained from an electrode approaching the sino-atrial node and stopping adjacent thereto. 
         FIG. 1C  is an exemplary ECG trace obtained from an electrode placed inside the right ventricle. 
         FIG. 2A  is an illustration of a partial cross-section of the heart providing three exemplary tip locations  1 ,  2 ,  3 ,  4 , and  5 . 
         FIG. 2B  is a series of exemplary P wave traces  1 ,  2 ,  3 ,  4 , and  5  obtained from an electrode placed in each of the exemplary tip locations  1 ,  2 ,  3 ,  4 , and  5  depicted in  FIG. 2A , respectively. 
         FIG. 3  is a CVC constructed in accordance with aspects of the present invention. 
         FIG. 4  is an embodiment of a signal analysis system for use with the CVC of  FIG. 3 . 
         FIG. 5  is a block diagram illustrating the components of the signal analysis system of  FIG. 4 . 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     Aspects of the present invention are directed toward a device for locating the tip of a CVC and a method of determining the location of the tip of a CVC. In the embodiment depicted in  FIG. 3 , the invention includes a CVC  100  constructed using any manner known in the art from a flexible nonconductive material, such as polyurethane or other suitable polymer material. It may also be desirable to use a radiopaque material. As is appreciated by those of ordinary skill in the art, the material used to construct the CVC  100  may include materials and/or coatings that provide improved anti-thrombotic or anti-bacterial properties. The CVC  100  has a body  130  configured to be received within a central vein. The body  130  may include a distal end  110  having a tapered tip  112  and a proximal end  120  spaced longitudinally along the body  130  from the distal end  110 . 
     The body  130  may include one or more lumens  132  that traverse the length of the body and may have one or more openings  134  at or spaced from the tip  112 . The openings  134  permit passage of material(s) between the lumen  132  and the environment outside the CVC  100 . The lumens  132  may be used as conduits for the passage of materials such as medications and/or other fluids to and from the environment outside the CVC  100 . For example, the lumen  132  may be used to aspirate blood into the CVC  100  and/or provide a conduit through which pressure data may be collected and used to construct pressure waveforms. The environment outside the CVC  100  may include the inside of the SVC, right atrium, and/or right ventricle. The CVC  100  is provided for illustrative purposes and those of ordinary skill in the art appreciate that alternate embodiments of CVC  100  including embodiments with additional lumens, a flow directed balloon tip, thermistors, thermodilution ports, pacing wire ports, embedded pacing electrodes, and the like are within the scope of the present invention. 
     In one embodiment, the invention includes four longitudinally spaced apart electrodes  150 ,  152 ,  154 , and  156 . Each electrode  150 ,  152 ,  154 , and  156  is in electrical communication with a wire  160 ,  162 ,  164 , and  166 , respectively. In one embodiment, the electrodes  150 ,  152 ,  154 , and  156  are constructed from the distal end of each of the wires  160 ,  162 ,  164 , and  166 . In another embodiment, the electrodes  150 ,  152 ,  154 , and  156  are attached to the ends of the wires  160 ,  162 ,  164 , and  166  by any method known in the art for attaching an electrode to a wire, including soldering. The wires  160 ,  162 ,  164 , and  166  are electrically isolated from one another. The wires  160 ,  162 ,  164 , and  166  may be insulated from the environment outside the body  130  by the body  130 . 
     The electrodes  150 ,  152 ,  154 , and  156  and the wires  160 ,  162 ,  164 , and  166  may be constructed from any suitable materials known in the art such as stainless steel or platinum. The electrodes  150 ,  152 ,  154 , and  156  may be about 6 mm to about 12 mm long, about 6 mm to about 12 mm wide, and about 1 mm to about 4 mm thick. The wires  160 ,  162 ,  164 , and  166  may be constructed using any electrical lead wire suitable for obtaining an ECG trace. 
     Optionally, the invention may include two longitudinally spaced apart electrodes  157  and  158 . Each of the electrodes  157  and  158  may be electrical communication with a wire  167  and  168 , respectively. The electrodes  157  and  158  and wires  167  and  168  may be constructed in a manner substantially similar to that used to construct the electrodes  150 ,  152 ,  154 , and  156  and the wires  160 ,  162 ,  164 , and  166 , respectively. In one embodiment, the electrode  157  and  158  are positioned proximal to the electrodes  150 ,  152 ,  154 , and  156 . 
     Electrodes  150 ,  152 ,  154 , and  156  may form two anode/cathode pairs. For example, electrodes  150  and  152  may form a first or proximal anode/cathode pair  180  and electrodes  154  and  156  may form a second or distal anode/cathode pair  182 . Optional electrodes  157  and  158  may form an optional third or reference anode/cathode pair  184 . A pair of electrodes forming an anode/cathode pair may be attached to a pair of insulated wires housed within a single cable. In one embodiment, a pair of bipolar lead wires are used. In this manner, the four electrodes of the proximal and distal anode/cathode pairs  180  and  182  may be attached to two lead wires. A third bipolar lead wire may be included for use with the reference anode/cathode pair  184 . Alternatively, the proximal and distal anode/cathode pairs  180  and  182  may be attached to four insulated wires housed within a single cable such a dual bipolar lead wire. 
     The wires  160 ,  162 ,  164 , and  166  and electrodes  150 ,  152 ,  154 , and  156  may be permanently embedded into the body  130  of the CVC  100  or removably inserted into one or more channels or lumens  132  formed in the CVC  100  for potential future removal and/or replacement. The wires  167  and  168  and electrodes  157  and  158  may be incorporated into the CVC  100  in any manner described with respect to wires  160 ,  162 ,  164 , and  166  and electrodes  150 ,  152 ,  154 , and  156 , respectively. 
     The electrodes  150 ,  152 ,  154 , and  156  are in electrical communication with the environment outside the CVC  100 . In one embodiment, a portion of each of the electrodes  150 ,  152 ,  154 , and  156  are exposed to the environment outside the CVC  100  by apertures  170 ,  172 ,  174 , and  176  formed in the body  130  adjacent to the electrodes  150 ,  152 ,  154 , and  156 , respectively. In embodiments including optional electrodes  157  and  158 , a portion of each of the electrodes  157  and  158  may be exposed to the environment outside the CVC  100  by apertures  177  and  178  formed in the body  130  adjacent to the electrodes  157  and  158 , respectively. The apertures  177  and  178  may be constructed in any manner suitable for constructing apertures  170 ,  172 ,  174 , and  176 . The apertures  170 ,  172 ,  174 , and  176  may be formed in the body  130  by any method known in the art and the invention is not limited by the method used to construct the apertures  170 ,  172 ,  174 , and  176 . While the electrodes  150 ,  152 ,  154 , and  156  depicted in the drawings extend outwardly from the body  130  through the apertures  170 ,  172 ,  174 , and  176 , it is understood by those of ordinary skill in the art, that electrodes  150 ,  152 ,  154 , and  156  may reside at the bottom of the apertures  170 ,  172 ,  174 , and  176  which may provide a passageway for fluids in the outside environment to the electrodes  150 ,  152 ,  154 , and  156 . Alternatively, the portion of the electrodes  150 ,  152 ,  154 , and  156  in electrical communication with the environment outside the CVC  100  may be flush with the outside surface of the CVC  100 . 
     The electrode  156  may be located at or spaced from the tip  112 . In one embodiment, the electrode  156  is less than about 5 mm from the tip  112 . The spacing between an anode and cathode of the anode/cathode pairs  180  and  182  may be about 1 mm to about 4 mm. In one embodiment, the spacing between an anode and cathode of the anode/cathode pairs  180  and  182  is about 3 mm. 
     In one embodiment, the distance between the electrodes  154  and  152  is less than the height of the right atrium. In an adult, the height of the right atrium may be approximately equal to or greater than about 4 cm. In one exemplary embodiment, the distance between the electrode  154  and  152  may be about 3 cm. In embodiments including optional electrodes  157  and  158 , the distance between the electrodes  150  and  158  may be about 10 cm to about 18 cm. 
     Those of ordinary skill in the art appreciate that the size and spacing of the electrodes provided herein may require modification for use with patients that are larger or smaller than a typical adult and such embodiments are within the scope of the present invention. For example, smaller electrodes with a closer spacing may be required for use with a pediatric patient. 
     Referring to  FIG. 4 , the CVC  100  may gain venous access to the SVC by any method known in the art including inserting the CVC  100  in a standard sterile fashion through the subclavian, one of the jugular veins, or a peripheral vein and directing the tip  112  of the CVC  100  through that vein to the SVC. 
     Each of the anode/cathode pairs  180  and  182  may be used to generate an ECG trace. In this manner, the ECG waveforms detected by the proximal pair  180  may be compared to the ECG waveform detected by the distal pair  182 . In one embodiment, the P wave portion of each trace is compared to determine the position of the tip  112  of the CVC  100  within the SVC, right atrium, and right ventricle. 
     In embodiments including the reference anode/cathode pair  184 , the reference anode/cathode pair  184  may be used to generate an ECG trace. Referring to  FIG. 4 , because the reference anode/cathode pairs  184  may be located substantially proximally from the proximal and distal anode/cathode pairs  180  and  182 , the reference anode/cathode pair  184  may remain in the SVC after the proximal and distal anode/cathode pairs  180  and  182  have entered the heart. In one embodiment, the spacing between the anode/cathode pair  184  and the proximal pair  180  is large enough to insure the reference anode/cathode pair  184  remains inside the SVC when the distal anode/cathode pair  182  is inside the right ventricle. In this manner, the reference anode/cathode pair  184 , may be used to detect the ECG waveform within the SVC while the catheter is being placed. 
     The ECG waveforms detected by the proximal anode/cathode pair  180  and/or distal anode/cathode pair  182  may be compared to the ECG waveform detected by the reference anode/cathode pair  184 . In one embodiment, the P wave portion of the ECG trace detected by the proximal anode/cathode pair  180  and/or distal anode/cathode pair  182  is compared to P wave portion of the ECG trace detected by the reference anode/cathode pair  184  to determine whether the tip  112  of the CVC  100  is located within the SVC, right atrium, or right ventricle. 
     The deflection of the trace, i.e., its vertical height relative to the baseline may be used to compare the P waves of the proximal and distal anode/cathode pairs  180  and  182 . The deflection of the trace may also be used to compare the P waves of the proximal anode/cathode pair  180  and/or distal anode/cathode pair  182  to the reference anode/cathode pair  184 . Because a P wave constitutes a voltage change over time, the deflection of the P wave is not constant. In one embodiment, the P wave is represented by an array or series of discrete numerical values. 
     The deflection value may be calculated in several ways. For example, the maximum or peak deflection may be used. Alternatively, the deflection value may be calculated as the difference between the maximum deflection and the minimum deflection. The deflection value may also be calculated as the sum of the absolute value of the maximum and minimum deflections. If the P wave has two peaks, which may occur when one of the anode/cathode pairs  180  and  182  are located within the right atrium (see position  4  of  FIGS. 2A and 2B ), the deflection value may be calculated by totaling the absolute value of the two peaks. When this method is used, the deflection value of the P wave measured at positions  3 - 5  may all be approximately be equal. Further, if discrete data is being used, the discrete deflection quantities may be totaled. If continuous data is being used, the integral under the P wave may be used. Further, the average P wave deflection may be used. Because the polarity of portions of the P wave change depending upon the location of the anode/cathode pairs  180  and  182 , it may be beneficial to use the absolute value of the deflection of the P wave to calculate the deflection value. 
     For the purposes of this application, the term “deflection value” will be used hereafter to describe the metric used to compare the P waves detected by the proximal and distal anode/cathode pairs  180  and  182 . The deflection value may also be used to compare the P wave detected by the reference anode/cathode pair  184  to the P wave detected by one or both of the proximal and distal anode/cathode pairs  180  and  182 . It is appreciated by those of ordinary skill in the art that the deflection value may be determined in numerous ways including those listed above and others not listed and the invention is not limited by the method and manner of determining the deflection value of the P wave. 
     In one exemplary embodiment, the deflection value is calculated as the sum of the absolute value of the maximum and minimum deflections when the maximum and minimum deflections have opposite polarities. The deflection value is calculated as the larger of the absolute value of the maximum and minimum deflections when the maximum and minimum deflections have the same polarity. In other words, the vertical height of the P wave is used. A first ratio of the deflection value of the distal anode/cathode pair  182  to the deflection value of the proximal anode/cathode pair  180  may be calculated. 
     When both of the anode/cathode pairs  180  and  182  are within the SVC, the deflection value of the P wave detected by each of them is substantially identical and the first ratio of their P wave deflection values equals approximately one. The deflection value of one or both of the P waves may be stored or otherwise recorded. 
     The user or operator may wish to continue advancing the CVC until the sino-atrial node is detected. When an anode/cathode pair  180  or  182  is approximately 1 cm to approximately 2 cm proximal to the sino-atrial node and therefore, by inference, approximately 1 cm to approximately 2 cm proximal to the entrance of the right atrium, the deflection value of the P wave detected by that anode/cathode pair may increase. 
     When the distal anode/cathode pair  182  enters the right atrium and the proximal anode/cathode pair  180  is still in the SVC, the deflection value of the P wave detected by the distal anode/cathode pair  182  may be at least double the deflection value of the P wave detected by the proximal anode/cathode pair  180 . Therefore, the first ratio of the P wave deflection values of the distal anode/cathode pair  182  to the proximal anode/cathode pair  180  is greater than or equal to two. When this happens, the user or operator should withdraw the CVC  100 . 
     A predetermined maximum threshold value may be used to determine whether the user or operator should withdraw the CVC  100 . If the first ratio exceeds the maximum threshold value, the CVC  100  should be withdrawn. In one embodiment, the maximum threshold value may be approximately two. 
     When the distal anode/cathode pair  182  enters the right ventricle, the proximal anode/cathode pair  180  may be in the right atrium. Because the deflection value of the P wave experienced in the right ventricle is approximately equal to the deflection value of the P wave experienced in the SVC, the first ratio of the P wave deflection values of the distal anode/cathode pair  182  to the proximal anode/cathode pair  180  is less than or equal to about one half. Therefore, when the ratio is less than about one half, the user or operator should withdraw the CVC  100 . 
     A predetermined minimum threshold value may be used to determine whether the user or operator should withdraw the CVC  100 . If the first ratio is less than the minimum threshold value, the CVC  100  should be withdrawn. In one embodiment, the minimum threshold value may be approximately one half. 
     The distal anode/cathode pair  182  and the proximal anode/cathode pair  180  may be in the right atrium at the same time. When this occurs, the deflection value of the P waves detected by each would be very similar if not identical making their first ratio approximately equal to one. Therefore, a second ratio may be calculated to determine the location of the tip  112  of the CVC  100 . The second ratio may include the ratio of the deflection value of the P wave detected by the proximal anode/cathode pair  180  to the deflection value of the P wave detected in the SVC. In one embodiment, the second ratio may include the ratio of the deflection value of the P wave detected by the proximal anode/cathode pair  180  to the deflection value of the P wave detected by the reference anode/cathode pair  184 . In embodiments that include a reference anode/cathode pair  184 , the reference anode/cathode pair  184  may detect the P wave in the SVC. Because the proximal anode/cathode pair  180  is inside the right atrium the deflection value of its P wave is greater than or equal to twice the deflection value of the P wave observed in the SVC. When the second ratio is equal to or greater than two, the user or operator should withdraw the CVC  100 . The predetermined maximum threshold value may be used to determine whether the user or operator should withdraw the CVC  100 . If the second ratio exceeds the maximum threshold value, the CVC  100  should be withdrawn. 
     Alternatively, a third ratio may be calculated to determine the location of the tip  112  of the CVC  100 . The third ratio may include the ratio of the deflection value of the P wave detected by the distal anode/cathode pair  182  to the deflection value of the P wave detected in the SVC. In one embodiment, the third ratio may include the ratio of the deflection value of the P wave detected by the distal anode/cathode pair  182  to the deflection value of the P wave detected by the reference anode/cathode pair  184 . In embodiments that include a reference pair  184 , the reference pair  184  may detect the P wave in the SVC. Because the distal anode/cathode pair  182  is inside the right atrium, the deflection value of its P wave is greater than or equal to twice the deflection value of the P wave observed in the SVC. When third ratio is equal to or greater than two, the user or operator should withdraw the CVC  100 . Under these circumstances, the predetermined maximum threshold value may be used to determine whether the user or operator should withdraw the CVC  100 , i.e., if the third ratio exceeds the maximum threshold value, the CVC  100  should be withdrawn. 
     Determining when to withdraw the CVC  100  is unaffected by wide anatomic variability between individual people because instead of using predetermined threshold deflection values, the first, second, and/or third ratio of the deflection values obtained from each individual is used. 
     The following table summarizes the relationship between the location of the tip  112  of the CVC  100  and the deflection values of the P waves detected by the proximal and distal anode/cathode pairs  180  and  182 : 
     
       
         
           
               
               
            
               
                   
               
               
                   
                 Location of the distal 
               
               
                   
                 anode/cathode pair 182 
               
            
           
           
               
               
               
               
               
            
               
                   
                   
                 Right 
                 Right 
                 Right 
               
               
                   
                 SVC 
                 Atrium 
                 Atrium 
                 Ventricle 
               
            
           
           
               
               
            
               
                   
                 Location of the proximal 
               
               
                   
                 anode/cathode pair 180 
               
            
           
           
               
               
               
               
               
            
               
                   
                   
                   
                 Right 
                 Right 
               
               
                   
                 SVC 
                 SVC 
                 Atrium 
                 Atrium 
               
               
                   
               
            
           
           
               
               
               
               
               
            
               
                 First Ratio: Ratio of the 
                 ≈1 
                 ≧2 
                 ≈1 
                 ≦0.5 
               
               
                 deflection value of the distal 
                   
                   
                   
                   
               
               
                 anode/cathode pair 182 to the 
                   
                   
                   
                   
               
               
                 deflection value of the 
                   
                   
                   
                   
               
               
                 proximal anode/cathode pair 180 
                   
                   
                   
                   
               
               
                 Second Ratio: Ratio of the 
                 ≈1 
                 ≈1 
                 ≧2 
                 ≧2 
               
               
                 deflection value of the P wave 
                   
                   
                   
                   
               
               
                 detected by the proximal anode/ 
                   
                   
                   
                   
               
               
                 cathode pair 180 and the deflection 
                   
                   
                   
                   
               
               
                 value of the P wave detected in 
                   
                   
                   
                   
               
               
                 the SVC 
                   
                   
                   
                   
               
               
                 Third Ratio: Ratio of the 
                 ≈1 
                 ≧2 
                 ≧2 
                 ≈1 
               
               
                 deflection value of the Pwave 
                   
                   
                   
                   
               
               
                 detected by the distal anode/ 
                   
                   
                   
                   
               
               
                 cathode pair 182 and the 
                   
                   
                   
                   
               
               
                 deflection value of the P wave 
                   
                   
                   
                   
               
               
                 detected in the SVC 
               
               
                   
               
            
           
         
       
     
     Because the voltage across each of the anode/cathode pairs  180  and  182  may vary depending over time, the voltage across wires  164  and  166  and wires  160  and  162  may each constitute a time-varying signal that can be analyzed using standard signal processing methods well known in the art. In a typical patient, the maximum of voltage across the anode/cathode pairs  180  and  182  may range from about 0.2 mV to about 3 mV. The signal from each anode/cathode pairs  180  and  182  may be amplified and/or filtered to improve the signal quality. A distal signal may be detected by the distal anode/cathode pair  182  and a proximal signal may be detected by the proximal anode/cathode pair  180 . Similarly, an optional reference signal may be detected by the reference anode/cathode pair  184 . 
     A separate ECG trace may be constructed for distal and proximal signals. In some embodiments, an ECG trace may also be constructed for the reference signal. The P wave portion of one or more of these ECG traces may be identified and analyzed. For example, the ECG trace of the distal signal may be visualized by connecting wires  164  and  166  of the distal anode/cathode pair  182  to a device such as a PACERVIEW® signal conditioner designed specifically to construct and display an ECG trace from a time varying low voltage signal. Similarly, the ECG trace of the proximal signal may be viewed by connecting the wires  160  and  162  of the proximal anode/cathode pair  180  to a PACERVIEW® signal conditioner. The ECG trace of the reference signal may be viewed by connecting the wires  167  and  168  of the proximal anode/cathode pair  184  to a PACERVIEW® signal conditioner. 
     In one embodiment, each of the four wires  160 ,  162 ,  164 , and  166  may be coupled to a signal analysis system for analysis of the voltage information detected by the electrodes  150 ,  152 ,  154 , and  156 , respectively. In embodiments including electrodes  157  and  158 , the wires  167  and  168  may be coupled to the signal analysis system for analysis of the voltage information detected by the electrodes  157  and  158 , respectively. An exemplary signal analysis system  200  for analyzing the signals carried by wires  160 ,  162 ,  164 , and  166  and alerting the user or operator when to withdraw the tip  112  of the CVC  100  may be viewed in  FIG. 4 . In an alternate embodiment, the system  200  may also analyze the signals carried by wires  167  and  168 . 
       FIG. 5  is a block diagram of the components of the exemplary system  200 . The system  200  may include a programmable central processing unit (CPU)  210  which may be implemented by any known technology, such as a microprocessor, microcontroller, application-specific integrated circuit (ASIC), digital signal processor (DSP), or the like. The CPU  200  may be integrated into an electrical circuit, such as a conventional circuit board, that supplies power to the CPU  210 . The CPU  210  may include internal memory or memory  220  may be coupled thereto. The memory  220  may be coupled to the CPU  210  by an internal bus  264 . 
     The memory  220  may comprise random access memory (RAM) and read-only memory (ROM). The memory  220  contains instructions and data that control the operation of the CPU  210 . The memory  220  may also include a basic input/output system (BIOS), which contains the basic routines that help transfer information between elements within the system  200 . The present invention is not limited by the specific hardware component(s) used to implement the CPU  210  or memory  220  components of the system  200 . 
     Optionally, the memory  220  may include external or removable memory devices such as floppy disk drives and optical storage devices (e.g., CD-ROM, R/W CD-ROM, DVD, and the like). The system  200  may also include one or more I/O interfaces (not shown) such as a serial interface (e.g., RS-232, RS-432, and the like), an IEEE-488 interface, a universal serial bus (USB) interface, a parallel interface, and the like, for the communication with removable memory devices such as flash memory drives, external floppy disk drives, and the like. 
     The system  200  may also include a user interface  240  such as a standard computer monitor, LCD, colored lights  242  (see  FIG. 4 ), PACERVIEW® signal conditioner, ECG trace display device  244  (see  FIG. 4 ), or other visual display including a bedside display. In one embodiment, a monitor or handheld LCD display may provide an image of a heart and a visual representation of the estimated location of the tip  112  of the CVC  100 . The user interface  240  may also include an audio system capable of playing an audible signal. In one embodiment, the user interface  240  includes a red light indicating the CVC  100  should be withdrawn and a green light indicating the CVC  100  may be advanced. In another embodiment, the user interface  240  includes an ECG trace display device  244  capable of displaying the ECG trace of the distal and proximal signals. In the embodiment depicted in  FIG. 4 , the user interface  240  includes a pair of lights  242 , one red and the other green, connected in series with an ECG trace display device  244 . In some embodiments, a display driver may provide an interface between the CPU  210  and the user interface  240 . 
     The user interface  240  may permit the user to enter control commands into the system  200 . For example, the user may command the system  200  to store information such as the deflection value of the P wave inside the SVC. The user may also use the user interface  240  to identify which portion of the ECG trace corresponds to the P wave. The user interface  240  may also allow the user or operator to enter patient information and/or annotate the data displayed by user interface  240  and/or stored in memory  220  by the CPU  210 . The user interface  240  may include a standard keyboard, mouse, track ball, buttons, touch sensitive screen, wireless user input device and the like. The user interface  240  may be coupled to the CPU  210  by an internal bus  268 . 
     Optionally, the system  200  may also include an antenna or other signal receiving device (not shown) such as an optical sensor for receiving a command signal such as a radio frequency (RF) or optical signal from a wireless user interface device such as a remote control. The system  200  may also include software components for interpreting the command signal and executing control commands included in the command signal. These software components may be stored in memory  220 . 
     The system  200  includes an input signal interface  250  for receiving the distal and proximal signals. The input signal interface  250  may also be configured to receive the reference signal. The input signal interface  250  may include any standard electrical interface known in the art for connecting a double dipole lead wire to a conventional circuit board as well as any components capable of communicating a low voltage time varying signal from a pair of wires through an internal bus  262  to the CPU  210 . The input signal interface  250  may include hardware components such as memory as well as standard signal processing components such as an analog to digital converter, amplifiers, filters, and the like. 
     The various components of the system  200  may be coupled together by the internal buses  262 ,  264 , and  268 . Each of the internal buses  262 ,  264 , and  268  may be constructed using a data bus, control bus, power bus, I/O bus, and the like. 
     The system  200  may include instructions  300  executable by the CPU  210  for processing and/or analyzing the distal and/or proximal signals. These instructions may include computer readable software components or modules stored in the memory  220 . The instructions  300  may include an ECG Trace Generator Module  310  that generates a traditional ECG trace from the distal and/or proximal signals. In some embodiments, the ECG Trace Generator Module  310  may generate a traditional ECG trace from the reference signal. As is appreciated by those of ordinary skill in the art, generating an ECG trace from an analog signal, such as the distal and proximal signals, may require digital or analog hardware components, such as an analog to digital converter, amplifiers, filters, and the like and such embodiments are within the scope of the present invention. In one embodiment, some or all of these components may be included in the input signal interface  250 . In an alternate embodiment, some or all of these components may be implemented by software instructions included in the ECG Trace Generator Module  310 . The ECG Trace Generator  310  may include any method known in the art for generating an ECG trace from a time varying voltage signal. 
     The instructions  300  may include a P Wave Detection Module  320  for detecting or identifying the P wave portion of the ECG trace. The P wave portion of the ECG trace may be detected using any method known in the art. In one embodiment, the P Wave Detection Module  320  receives input from the user or operator via the user interface  240 . The input received may identify the P wave portion of the ECG trace. 
     The instructions  300  may include an Interpretive Module  330  for comparing the P wave generated for the distal, proximal, and/or reference signals. In one embodiment, the Interpretive Module  330  determines the deflection value of the P wave generated for the distal and/or proximal signals. In some embodiments, the Interpretive Module  330  determines the deflection value of the P wave generated for the reference signal. The Interpretive Module  330  may direct the CPU  210  to store the deflection value of the distal, proximal, and/or reference signals in memory  220 . In particular, it may be desirable to store the deflection value of the P wave encountered in the SVC. The Interpretive Module  330  may receive input from the user or operator via the user interface  240  instructing the Interpretive Module  330  to store the deflection value. 
     The Interpretive Module  330  may also determine the first ratio by calculating the ratio of the deflection value of the distal signal to the deflection value of the proximal signal. If the first ratio is approximately equal to or greater than the maximum threshold value, the tip  112  of the CVC  100  may be in the right atrium. The Interpretive Module  330  may alert the user or operator that the tip  112  is in the right atrium and the CVC  100  should be withdrawn from the right atrium. On the other hand, if the first ratio is approximately equal to or less than the minimum threshold value, the tip  112  of the CVC  100  may be in the right ventricle. The Interpretive Module  330  may alert the user or operator that the tip  112  is in the right ventricle and the CVC  100  should be withdrawn from therefrom. 
     If the first ratio is less than the maximum threshold value and greater than the minimum threshold value, the tip  112  may be in either the right atrium or the SVC. When this happens, the Interpretive Module  330  may calculate either the second ratio or third ratio. If the second or third ratio is approximately equal to or greater than the maximum threshold value, the tip may be in the right atrium and should be withdrawn therefrom. The Interpretive Module  330  may alert the user or operator that the tip  112  is in the right atrium. If the second or third ratio is approximately less than the maximum threshold value, the tip  112  is in the SVC and may be advanced if the operator so chooses. The Interpretive Module  330  may communicate to the user or operator that the tip  112  may be advanced. 
     In an alternate embodiment, the second ratio may be calculated first. Whenever the second ratio is approximately equal to or greater than the maximum threshold value, the user or operator may be alerted to withdraw the CVC  100 . If the second ratio is approximately less than the maximum threshold value, the first or third ratio may be calculated and used to determine the position of the tip  112  of the CVC  100 . 
     In one embodiment, the instructions in the Interpretive Module  330  direct the CPU  210  to use the user interface  240  to communicate whether the tip  112  should be withdrawn to the user. The CPU  210  may use the user interface  240  to communicate the tip  112  may be advanced. 
     While exemplary minimum and maximum threshold values have been provided as a general guideline, those of ordinary skill in the art appreciate that these values may benefit from adjustment as additional anatomic or electrophysiologic data is acquired and such modified values are within the scope of the present invention. Because the Interpretive Module  330  may interpret the P wave to obtain the deflection values of the distal and proximal signals, compare the deflection values and provide the operator with immediate real-time feedback, the operator need not interpret the actual ECG waveforms. 
     The foregoing described embodiments depict different components contained within, or connected with, different other components. It is to be understood that such depicted architectures are merely exemplary, and that in fact many other architectures can be implemented which achieve the same functionality. In a conceptual sense, any arrangement of components to achieve the same functionality is effectively “associated” such that the desired functionality is achieved. Hence, any two components herein combined to achieve a particular functionality can be seen as “associated with” each other such that the desired functionality is achieved, irrespective of architectures or intermedial components. Likewise, any two components so associated can also be viewed as being “operably connected”, or “operably coupled”, to each other to achieve the desired functionality. 
     While particular embodiments of the present invention have been shown and described, it will be obvious to those skilled in the art that, based upon the teachings herein, changes and modifications may be made without departing from this invention and its broader aspects and, therefore, the appended claims are to encompass within their scope all such changes and modifications as are within the true spirit and scope of this invention. Furthermore, it is to be understood that the invention is solely defined by the appended claims. It will be understood by those within the art that, in general, terms used herein, and especially in the appended claims (e.g., bodies of the appended claims) are generally intended as “open” terms (e.g., the term “including” should be interpreted as “including but not limited to,” the term “having” should be interpreted as “having at least,” the term “includes” should be interpreted as “includes but is not limited to,” etc.). It will be further understood by those within the art that if a specific number of an introduced claim recitation is intended, such an intent will be explicitly recited in the claim, and in the absence of such recitation no such intent is present. For example, as an aid to understanding, the following appended claims may contain usage of the introductory phrases “at least one” and “one or more” to introduce claim recitations. However, the use of such phrases should not be construed to imply that the introduction of a claim recitation by the indefinite articles “a” or “an” limits any particular claim containing such introduced claim recitation to inventions containing only one such recitation, even when the same claim includes the introductory phrases “one or more” or “at least one” and indefinite articles such as “a” or “an” (e.g., “a” and/or “an” should typically be interpreted to mean “at least one” or “one or more”); the same holds true for the use of definite articles used to introduce claim recitations. In addition, even if a specific number of an introduced claim recitation is explicitly recited, those skilled in the art will recognize that such recitation should typically be interpreted to mean at least the recited number (e.g., the bare recitation of “two recitations,” without other modifiers, typically means at least two recitations, or two or more recitations). 
     Accordingly, the invention is not limited except as by the appended claims.