Continuous real-time ECG monitor-
ing is an essential part of basic intra-
operative monitoring guidelines [1,
2]. However, the three-lead ECG
electrodes routinely placed in the
Mason–Likar (M-L) conﬁguration
(i.e. both infraclavicular fossae, and
the anterior axillary line midway
between the iliac crest and the costal
margin) can encroach on the surgical
ﬁeld during anterior chest wall, upper
abdominal and shoulder surgery.
Further electrode relocation reduces
their access by the anaesthetist, and
risks misinterpretation .
Takuma et al. suggest relocation
to the anterior acromial region and
anterior superior iliac spines bilater-
ally, but this is associated with
abnormalities in R-wave amplitude
(speciﬁcally an increase in lead 2) .
Instead, we have found that plac-
ing electrodes on the left and right
sides of the forehead and a third
anywhere below neck on the left
side improves accessibility without
detriment to ECG output morphol-
ogy (Fig. 3). With minor re-adjust-
ment, this conﬁguration can be used
successfully alongside processed elec-
All India Institute of Medical
No external funding or competing
interests declared. The authors
would like to thank Dr Surender
Deora for his help with this letter.
The volunteer shown in Fig. 3 gave
written consent for use of their
1. American Society of Anesthesiologists.
Standards for basic anaesthetic monitoring
anesthetic-monitoring.pdf. (accessed 02/
2. Association of Anaesthetists of Great
Britain and Ireland. Recommendations
for standards of monitoring during
anaesthesia and recovery 2015. Anaes-
thesia 2016; 71:85–93.
3. Jowett NI, Turner AM, Cole A, Jones PA.
Modiﬁed electrode placement must be
recorded when performing 12-lead elec-
trocardiograms. Postgraduate Medical
Journal 2005; 81: 122–5.
4. Takuma K, Hori S, Sasaki J, et al. An
alternative limb lead system for electro-
cardiographs in emergency patients.
American Journal of Emergency Medi-
cine 1995; 13: 514–17.
Figure 3 Suggested position of ECG electrodes.
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Correspondence Anaesthesia 2018, 73, 515–525