Page 1of13 between this versionandtheVersionrecord. Pleasecitethis articleasdoi:10.1002/mus.25497. through thecopyediting, typesetting, paginationandproofreadingprocess, whichmayleadtodifferences This istheauthormanuscript acceptedforpublicationandhasundergone full peerreviewbuthasnotbeen

ECG leads I and II fromleads study ECG and a cent subjectI withII a base of the neck. The neck. the arrows4of base artifindicate shock delivered at the standard stimulation deliveredstandard the site r the at of Accepted Article This article isprotected by copyright. All rights reserved.

32x8mm (300 x 300 DPI) (300 30032x8mm DPI) x rhythm are detected.are rhythm Muscle & ight spinal accessory motornerve. accessory in ca ightchanges Nospinal act from 0. act and Hz2 (100 repetitivemA stimulation ralline exit in internal the with an jugular vein

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Ann Arbor, MIAnn 48109Arbor, MedicalCenterE. 1500 Dr. Taubman 1324 Center N. Zachary MDLondon, Correspondingauthor: Manuscript word count: 1564 Abstract word count: 150 electrocardiogram The technologists studyfor this fundedstudy in This was through part donationfr a Acknowledgements: DepartmentInternal # of ,Division ofCard DepartmentNeurology, ‡ of SpectrumHealth, Grand R , *Department of University ofA Michigan, N. Zachary MD*,London Andrew Mundwiler Hakan MD‡, O conductionNerve studies patients in safeare with Accepted Article This article isprotected by copyright. All rights reserved. John Wiley& Sons,Inc. Muscle &Nerve wereKevin McHughandJustin Grohoski. om the Jerryom Isler Neuromuscular Fund. iology,University of Michigan,Ann Arbor, MI centralvenous catheters nn Arbor, MI nnArbor, apids,MI ral Gary MD#, Gallagher W. MD* NCS andCentral Lines Page 2of13 Page 3of13

None of the None authorsany hasof conflictinterest of to report this consistentthat is with guidelinethose We confirm thatWe wehaveread Journal’s the position presentedmaterial This was theAnnual AANEM at Mee NCSand Running title: central lines [email protected]

Accepted Article

This article isprotected by copyright. All rights reserved. John Wiley& Sons,Inc. Muscle &Nerve s. dsls. disclose. issues involvedon inethical andpublicationaffi tinginNew Orleans, SeptemberLA on 15, 2016 NCS andCentral Lines rm

It is unknown is central ifIt catheters venous bypass th Introduction: Abstract: catheters underwent catheters a seriesof upper extremity ner continuousUnder 12-lead electrocardiogram monitori Methods: catheters. venous stimulation, do notstimulation, appear confer increasedto risk To determine if To conductionnerve studies affect car Objective: conductionstudy-inducednerve arrhythmia. cardiac Nerve conductionstudiesNerve upper of the extremities, Discussion protocol.No study malignantarrhythmiasconduct or control subjectsTen and subjects10 with central v Results: electrocardiogramtracings evidence for cardiac of central with catheters venous whoare notcriticall

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Accepted Article This article isprotected by copyright. All rights reserved. John Wiley& Sons,Inc. Muscle &Nerve y ill y have a history or prior arrhythmia. of enouscatheters underwent the conductionnerve of conduction cardiac abnormalityinthose patient eskin’s resistanceelectrical and risk a engender conductionabnormality arrhythmia. or diacconductionand rhythm in centralpatients with includingstimulations proximal andrepetitive both ve conductionstudies.ve A cardiologist reviewed the ionabnormalities notedineitherwere group. ng, subjects andng,subjects with centralwithout venous NCS andCentral Lines of of s s

Page 4of13 Page 5of13 Safety conductionCardiac Arrhythmia Central catheters venous conductionstudiesNerve words: Key

Accepted Article This article isprotected by copyright. All rights reserved. John Wiley& Sons,Inc. Muscle &Nerve NCS andCentral Lines

The intrinsic pacingintrinsic The subject of is the disto Introduction: induce a life-threateninginduce a arrhythmia.[1] Thea skin suggest studies that little as as current 200 µA of electrical conduitelectrical theto heart.[6] Any app current pacemakerTranscutaneous electrodes, occasionallyu that breachskinLines the resistancreduce may the anddefibrillators.[3-5] conductionstudies cannot by detected intracardi be peripheral stimulation of . Inpatients with conductionstudies,Nerve componentstandard a of e crosses circuit the heart ininduce order to a mali intactpatients skin,with asas much 100-500 (m mA pacemakersordefibrillators andperipheral intrave appear studies safe be into peripherpatients with pacemaker the electrodes, confer would enormousan electricalsubstantial resistance anddiluting any clamped clamped wasor saline running it.through devices the anddid notaffect their pacing.[7] Thi upperextremity and (up100to mA 0.5msinduratio

Accepted Article This article isprotected by copyright. All rights reserved. John Wiley& Sons,Inc. Muscle &Nerve ruptionexogenous electricalby current. Experiment currents that arecurrents appliedthat the tothe surface bod of , when , applied todirectly myocardial tissue, may gnantarrhythmia.[2] s was the case was the s whetherthe intravenous line was dry, skin,impulsesdry, intact the from standardnerve liedsuch patient’s a to body, inproximespecially ndpericardial soft prevent tissues by this providi alintravenous Inlines. series patientsa of with nousroutinenerve lines, conductionstudies inthe e protectse thethat heartstray from currents. illiamperes)be applied must bodyso that the to th acsensingdevices implantable as such pacemakers n)notdetectedwere by the sensingamplifiersin sed incriticallypatients,ill sed direct a create lectrodiagnostictesting, involve electrical risk of cardiac risk arrhythmia.of conductionNerve NCS andCentral Lines y. In y. ng ityto al

e Page 6of13 Page 7of13

resuscitation, resuscitation, medicationadministration, plasmaphe Central catheters venous in internal the jugular or tissues of the torso.tissues Some of havesuggested authors theIn towards heart. theory, this bypass may the l catheters are catheters larger peripheralthan lines, breach Subjects with Subjects central venous and catheters control Materialsand Methods: rhythmconductionor cardiac inpatients centr with purpose studyofThe this determine to if was nerve [8] stimulations. or making modificationssuch stimulating as contral Patients who Patients located critically(i.e. illwere ina Control participate. subjects recruitedwere in the lines were identifiedwere lines by reviewingthe schedules of the studyunderwent beforeprotocol subjects with c arrhythmia cardiac excludedwere participating from Accepted Article

This article isprotected by copyright. All rights reserved. John Wiley& Sons,Inc. Muscle &Nerve nintensive unit), care encephalopathic, orh had a the proximityin close skin theto heart, andexten subclavian veins aresubclavian commonly veins forusedfluid lab.electromyographyAll 10 control ofsubjecthe argeelectrical providedby sink intactand skin th the dialysisinpatient andapheresis laboratories. subjects intravenouswithout recruitedwere lines t avoidingconductionnerve studies populatioin this ateraltheto centraland line proximal avoiding alcatheters. venous conduction affect studies cardiac measures of entral lines recruited.were with Patients central . resis,dialysis, andintracardiac monitoring. Thes NCS andCentral Lines istory of e soft e d

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tracings were tracings atmarked the time stimulatio of each in the ulnar nerve inthe withand 100 a mA 0.1 msduratio with a mA secondduration. 0.02 High voltage stimul stimulations stimulations seconds) over both 2 lowat andhigh v At stimulations. each site, performe stimulation we atnerves accessory the neck. groundA electrodewa standardstimulation sitesfor the left andright u protocol The consisted of stimulations16 sets or o conductionstudiesnerve in room, patient a the dia nerve underwent conduction studies inthe electromy Neurology(Natus Incorporated 3150 ViewPleasant Ro performed nerve We conductionstudies subjecall on committee human on experimentation Universit of the provided Allsubjects informed consent.The study w seconds of secondsof continuous recording and before after ea study,Throughout the hadeach subject elec12-lead centralsubjects lines.with controlpotentialinall subjects. Therefore,to mi found sufficientms was be to supramaxielicitto a Accepted Article This article isprotected by copyright. All rights reserved. John Wiley& Sons,Inc. Muscle &Nerve nimizediscomfort, duration this in used was the lnarnerves at the leftwrist andandright the spi mal mal spinalcompoundaccessory actionmuscle f stimulations,f for a 40 total the of impulses, at lysisorlab,the infusioninpatient center. d both single dboth andrepetitive2-Hzstimulations (4 oltages. Low oltages.Low voltagestimulation was asdefined 100 n. certified board A cardiologistreviewed all ECG n ationwas defined as 100 a mAwith 0.5ms duration asapprovedbyinstitutional the ethical standards chset stimulation or Theof stimulations. paper EC trocardiogram(ECG) atmonitoring, leastwith 10 supper placed the on extremity ipsilateral theto

ts usingViking EDX a ts Electrodiagnostic System ography lab.Subjects ography lineswith central underwent in the spinal accessoryin the nerve. The duration of 0.1 ad Middleton,ad WI 53562).subjects Control y y System.of Health Michigan NCS andCentral Lines nal G G

Page 8of13 Page 9of13 had The 38.7). meanbody controlindex mass subjects of subjects yrs.was The39.3 body mean index mass of protocol. study The meanage of subjects with centr Ten control subjectTen and10 subjects with Results consecutive more ectopic beats a triplet. or withtracings attention cardiacto conductionabnor exit siteat the exit base Six of the subjectsneck. ha noted incidentally inboth noted studyandcontrol subjec notedinanywere ofthe study or control subjects. nerve Duringthe conduction noprotocol, cardiac co stimulations40 becausethe ofdiscomfort. completedthe entirestudy protocol.One subject re the internal into jugularansitein vein with exit Discussion conductionstimulations.nerve Bard Power-Trialysis™ Bard

Accepted Article dialysis short term catheters insertedin into the This article isprotected by copyright. All rights reserved. John Wiley& Sons,Inc. central Muscle &Nerve anterior the Nineteenchest wall. subjects20 of d venousunderwent catheters theconductionnerve Arrow Cannon II™Catheter (Figure 1) Benign ectopic beatsruns and atrial w ts. ts. these correlated None of timingwith the the of malities malities arrhythmias,or malignant defined as 3 or allines was The44.6 yrs. ofcontrol meanage quested the procedurethat be abortedafter of 31 nductionabnormalities or malignantarrhythmias was 25.7 (rangewas 25.7 17.8 – 33.6).study Four subjects subjects central lineswith (rangewas 25.6 18.0 – ternal with jugularan vein dialysiscatheters inserted NCS andCentral Lines ere

notable limitation notable studyof that this is thesepati individuals Many with centralcatheters venous are istaught. often It merely a point reference forth populations. studies neededFurther determineare to nerve if co excluded. were Wefelt that prudentit was firsto to exogenousto electricityas contraindication.[9] a Appropriately, catheters. the package inserts for conductionabnormality or inarrhythmiathe general andlow stimulations, frequency repetitive stimulat conductionstudiesNerve upper of the extremities, safety. The ground The safety. electrode doesnotactually serv catheter. The catheter.results this should study of be only Although the ground Althoughthe electrode always was placed on areinsertion sitescoveredthat withsemi-permea a site could resultsite inelectrolytean solution which the theoretical risksof central is lines of that l used in this study,in this usedare madeoutof polyurethane, a Accepted Article This article isprotected by copyright. All rights reserved. John Wiley& Sons,Inc. Muscle &Nerve eakageintravenous of fluid around catheter the ins ents and pre-existingents with those arrhythmia cardiac would conduct wouldconduct electricityaround the outside of the eandreference active electrodes.[11] generalized patientsto central with lines dr with [10] Standard central catheters, venous assuch tho the catheters the inused2 notstudylist this do expo t demonstrate t in safety general the population. ninert polymer conducts that electricitypoorly. ions do notionsappear do conferto acardiac risk of e to directto stray e away charges the from body,as is includingstimulations, ipsilateral proximal criticallyill intensiveand require care.medical bledressing. nductionstudies are equally safe inat-risk population patients of with central venous the ipsilateral has arm,it noinrolepatie actual NCS andCentral Lines ertion y A sure

One se se nt

Page 10of13 Page 11of13

inducedsupportsarrhythmia, the safety proc of the beenneverhas reported a patient a case aof with acceptable. A acceptable. casesinglereport patient a of with recognize,however, a evensmall risk that very of lead diddeleterioustonot on effects cardiac cond this study. of right atrium. It notright atrium. is if results clear the thi of With the class With of centralincluded lines inthis st proximalthese other stimulation sites. durations stimulation thanstudied we wouldnece be comparedsuperficial theto bundlesnerve at the ax The number ofThe subjects inthis small,butstudy was catheters, extendthroughwhich right the atrium,r accessory is also is accessory commonly the most proximastudied the stimulationsbecause givenwere inclose proxim potential response inpotentialresponse control population.our c We useto findneed longer a stimulation durations to It is alsounknown is proximalIt if stimulationsdu with Accepted Article This article isprotected by copyright. All rights reserved. John Wiley& Sons,Inc. Muscle &Nerve sstudy can generalized be patientsto with Swan-Ga udy,the catheter in is tip lower the superior vena an iatrogenican couldarrhythmia finding outweighthe alife-threatening complication notbe would achievesupramaximal a compound action muscular uction.in This, conjunction factwith thatthe the rationsgreater of 0.1thanare safe, butwedid ms centraldevelopingline nerve a conductionstudy- 391 total stimulationspatientsto with central li ightventricle, andinto the artery.pulmonary hosethe spinalnerve accessory in study protocthe illaErb andItthe point. possible is higher that eduregeneral inthe population. important is It to ity the to insertion catheter sites. The spinal ssaryachieveto a response supramaximal from l laboratory. inour nerve itHowever, relativel is NCS andCentral Lines cava or nz re nes nes not s s

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1: ECG ECG 1: Accepted Article leadsandIII study a subject from had who centr a This article isprotected by copyright. All rights reserved. John Wiley& Sons,Inc. Muscle &Nerve indicatethe artifactshock Hzfrom repetitive 2 andardsite stimulation the of rightspinal accesso ted. ted. alintheline internal jugular vein with NCS andCentral Lines ry ry Page 12of13 Page 13of 9. 9. 7. Mellion, M.L.,et Mellion, al., 7. 8. Al-Shekhlee, A., Al-Shekhlee, andShapiro, B.E. Preston, D.C. 8. 6. Merkel, R. Merkel, andM.D.Sovie, 6. 5. Cronin, E.M., Cronin, etal., 5. 4. LaBan, al., LaBan, M.M., et 4. 10. Robinson,Christie,L.R., M. andS.Nandedkar, 11. 2. Lee, W.R. andJ.R. W.R. Scott, Lee, 2. 1. Starmer, C.F.,H.D. Starmer, McIntosh,andWhalen,R.E. 1. 3. Schoeck, A.P., Schoeck, etal., 3. August 8]; Available from:August 8]; Power-Trialysis(TM){package Bardinsert}. Access S lines. conductionand needle studies electromyography. Nurs,1968. electronic devices. electronic Arch Phys MedPhysArchRehabil, 1988. Cannon (TM) II CannonPlus[package (TM) insert]Arrow Internat Nerve, 2016.Nerve, Trialysis_IFU_web.pdf devices. an experimental study.an experimental Engl J Med, EnglJMed, 1971.

MuscleNerve, 2010. Accepted ArticleMuscleNerve, 2007. 68 (12):p.2560-3. 284 Muscle 2013.Nerve, This article isprotected by copyright. All rights reserved. Safety nerve Safety repetitive of stimulation inpatients Peripheralnerveconduction stimulation: its effect Safety Safety nerveconductionof studies inpatients with Safety nerveconductionof studies inpatients with (4): p. (4): 181-6. . Cardiovasc Res,1973. Thresholdsof fibrillatingleakage along currents i http://www.bardaccess.com/assets/literature/0736073 42 Electrocution hazards Electrocution with transvenouspacemakerel (2):p.189-91. 35 69 John Wiley& Sons,Inc. (4): p. (4): 521-4. (5):p.358-62. Muscle &Nerve 47 (6):p.840-4. 7 A Ground the fromMessage Electrode.

(4): p. (4): 495-500. Electricalhazardsand cardiovascular function. Iatrogeniccomplications and risks nerveof MuscleNerve, 2003. ystems, Salt UT. LakeCity, ional, Inc., Reading 2014.PA; with cardiac with implantable oncardiac pacemakers. peripheral intravenous implanted cardiac 27 ntracardiac catheters: (5):p.517-26. NCS andCentral Lines [cited 2016 ectrodes. _Power- Muscle Am J N