Chest radiograph after central line placement under fluoroscopy: utility or futility?

doi:10.1016/j.jpedsurg.2007.12.027

Journal of Pediatric Surgery

Volume 43, Issue 5, May 2008, Pages 854-856

https://doi.org/10.1016/j.jpedsurg.2007.12.027 Get rights and content

Abstract

Background

Postoperative portable chest films are routinely performed after fluoroscopic placement of central venous catheters to evaluate positioning and to rule out significant complications (eg, pneumothorax). Emerging evidence in the literature has called this practice into question suggesting that routine postoperative chest x-ray is unnecessary. Therefore, we investigated our recent experience to examine the utility of these films, to examine the development of symptoms relative to therapeutic intervention, and to report a cost-benefit analysis.

Methods

After obtaining institutional review board approval, all charts of patients undergoing central venous catheter placement from January 2004 to December 2005 at our institution were reviewed. Outcome measures included whether or not there was a complication and whether or not that complication required an intervention. Peripherally inserted central catheters were not included.

Results

In the study population, 237 catheters were placed in the operating room. There were two complications, both pneumothoraces (0.085%). One patient required tube thoracostomy, whereas the other was asymptomatic and the pneumothorax resolved spontaneously. Fourteen patients had no postoperative chest film without adverse consequences. Total cost for portable chest films was $56,196.

Conclusions

For catheters placed under fluoroscopic guidance, postoperative chest films in asymptomatic patients add unnecessary cost. For this reason, we feel discontinuation of postoperative chest films in asymptomatic patients undergoing catheter placement with fluoroscopy is justifiable.

Section snippets

Methods

After institutional review board approval (05 12-153X), we conducted a retrospective review of all children who underwent central venous catheterization by the pediatric surgery service at Children's Mercy Hospital from January 2004 to December 2005. Central venous catheters placed by interventional radiology and peripherally inserted central catheters lines were excluded from our study. Demographic data included age and sex. Data collected included use of fluoroscopy, postoperative chest x-ray

Results

A total of 237 central lines were placed by the surgery service during the examined time period. Mean patient age was 4.9 ± 5.5 years (range, 0-18 years). The group was composed of 124 males and 113 females. There were 2 complications; both pneumothoraces (0.085%). One patient became symptomatic with shortness of breath and required tube thoracostomy, whereas the other was asymptomatic and the pneumothorax resolved spontaneously. Fourteen patients had no postoperative chest film and there were

Discussion

Data currently accumulating in the adult literature have suggested a postoperative chest film may not be necessary if a central line is placed under fluoroscopic guidance [1], [3], [4], [5], [6], [7], [8]. A single retrospective review of a pediatric population has been published that, similar to our experience, documented a total complication rate of 1.6%, with a complication rate of 0.6% in the subgroup where fluoroscopy was used for placement of the catheters [2]. The authors concluded that

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Routine chest radiographs after central line insertion: mandatory postprocedural evaluation of unnecessary waste of resources?
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Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access?
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Routine x-ray control of upper central venous lines: is it necessary?
Acta Anaesthesiol Scand
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Confirmatory chest radiographs after central line placement: are they warranted?
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Cited by (20)

Contemporary postoperative imaging practices among pediatric surgeons for image-guided central venous line placement: A survey of the American Pediatric Surgical Association
2020, Journal of Pediatric Surgery
Rare life-threatening complications after central venous line (CVL) placement in children may encourage the routine use of postoperative imaging, despite multiple studies demonstrating the limited utility of this practice. The aim of this study was to investigate the nature of this discordance.
A 10-question survey was sent to 1,239 members of the American Pediatric Surgical Association (APSA) addressing contemporary practices regarding CVL placement and postoperative imaging.
Five hundred eighteen (42%) surveys were completed. The majority of respondents routinely obtain a chest radiograph (CXR) after image-guided CVL placement (52%). Years in practice, operative volume, and practice type were not statistically associated with postoperative CXR usage (all p > 0.05). ‘Routine’ users were more likely to cite “standard of care” (p < 0.001), position verification (p < 0.001), and complication identification (p < 0.001) as indications for use than those who use CXR selectively.
Routine use of postoperative CXR after image-guided CVL placement remains common among pediatric surgeons. Significant variation exists in the indication for this study, with considerable disagreement between ‘selective’ and ‘routine’ users. Consideration should be given for an APSA standardized guideline utilizing a clinically-driven approach to CVL placement and postoperative imaging to align with evidence-based practice.
N/A — descriptive analysis of survey results.
Routine Chest Radiographs in Children After Image-Guided Central Lines Offer Little Diagnostic Value
2020, Journal of Surgical Research
Citation Excerpt :
The introduction of intraoperative ultrasonography and fluoroscopy is likely the principal reason for this improvement, increasing the accuracy of anatomic and catheter-position verification.6 In this context, our finding of 1% pneumothorax rate is comparable to the 0.6%-0.8% rate reported in most pediatric studies where routine postoperative CXRs were obtained.9,10 However, the incidence of additional technical complications after CVL placement in the pediatric literature is generally under-reported, as most retrospective studies report only complications that become symptomatic.15
The aim of this study was to investigate the utility of postoperative chest radiograph (CXR) after image-guided central venous line (CVL) placement in children.
A retrospective review was conducted of all tunneled CVLs placed at two pediatric institutions from 2010 to 2017. A subgroup analysis comparing a clinically driven approach to postoperative imaging against routine imaging was performed.
During the study period, 1080 lines were placed in 915 patients. There were 892 postoperative CXRs (82.6%). An abnormality was seen on 40 radiographs (4.5%, n = 891), with 16 false-positive (1.3%) and 5 false-negative (0.6%) CXRs. The sensitivity and specificity of CXR to identify complications requiring intervention were 50.0% (95% confidence interval [95% CI], 10.0-90.0) and 95.8% (95% CI, 94.5-97.1), respectively. Positive predictive value of CXR was 7.5% (95% CI, 0-15.7) with a negative predictive value of 99.6% (95% CI, 99.2-100). A clinically driven approach to postoperative imaging was associated with 41% decrease in CXR (P < 0.001) without increased incidence of missed complications. Only three complications requiring intervention (0.3%) were suspected on postoperative CXR alone, and all of those were symptomatic before intervention.
Routine postoperative CXR offers minimal value in identifying technical complications requiring intervention after image-guided CVL placement in asymptomatic children. We recommend abandoning this practice in favor of a clinical symptom-driven approach to postoperative imaging.
Simple preoperative radiation safety interventions significantly lower radiation doses during central venous line placement in children
2019, Journal of Pediatric Surgery
Citation Excerpt :
The radiation time-out draws upon the principles of structured surgical checklists, which have been shown to be low-cost, highly effective tools for improving patient outcomes and reducing complications [34–36]. The consistent use of the last-image-hold allowed for the elimination of routine postoperative chest radiographs in asymptomatic patients without increased postoperative complications, confirming the findings of prior studies [4,37–40]. Avoiding this unnecessary test produced an additional modest reduction in patient dose; while we did not measure this exact dose reduction, prior studies estimate that DAP from a single postoperative chest radiograph ranges from 9.4 to 17 rad·cm2 [41–43].
The purpose of this study was to reduce radiation exposure during pediatric central venous line (CVL) placement by implementing a radiation safety process including a radiation safety briefing and a job-instruction model with a preradiation time-out.
We reviewed records of all patients under 21 who underwent CVL placement in the operating room covering 22 months before the intervention through 10 months after 2013–2016. The intervention consisted of a radiation safety briefing by the surgeon to the intraoperative staff before each case and a radiation safety time-out. We measured and analyzed the dose area product (DAP), total radiation time pre- and postintervention, and the use of postprocedural chest radiograph.
100 patients with valid DAP measurements were identified for analysis (59 preintervention, 41 postintervention). Following implementation of the radiation safety process, there was a 79% decrease in median DAP (61.4 vs 13.1 rad*cm², P < 0.001) and a 73% decrease in the median radiation time (28 vs 7.6 s, P < 0.001). Additionally, there was a significant reduction in use of confirmatory CXR (95% vs 15%, P < 0.01).
A preoperative radiation safety briefing and a radiation safety time-out supported by a job-instruction model were effective in significantly lowering the absorbed doses of radiation in children undergoing CVL insertion.
Case–control study.
Level III.
Routine chest X-ray is unnecessary after ultrasound-guided central venous line placement in the operating room
2018, Journal of Critical Care
Citation Excerpt :
Due to advancement of devices and insertion techniques, complication rates have steadily declined. It is now recommended that CVCs be placed using ultrasound guidance, reducing the risk of early complications to below 5% in some series [12-19]. In a study by O. Molgaard and colleagues, none of 42 patients who received a CVC without a follow-up CXR was found to have related complications during their hospitalization.
Central venous catheters (CVC) can be useful for perioperative monitoring and insertion has low complication rates. However, routine post insertion chest X-rays have become standard of care and contribute to health care costs with limited impact on patient management.
200 patient charts who underwent pancreaticoduodenectomy with central line placement and early line removal were reviewed for clinical complications related to central line placement as well as radiographic evidence of malpositioning. A cost analysis was performed to estimate savings if CXR had not been performed across routine surgical procedures requiring central access.
In 200 central line placements for Whipple procedures, 198 lines were placed in the right internal jugular and 2 were placed in the subclavian. No cases of pneumothorax or hemothorax were identified and 30 (15.3%) of CVCs were improperly positioned. Only 1 (0.5%) of these was deemed clinically significant and repositioned after the CXR was performed.
Routine CXR consumes valuable time and resources (≅$155,000 annually) and rarely affects management. Selection should be guided by clinical factors.
Is Routine Chest X-Ray After Ultrasound-Guided Central Venous Catheter Insertion Choosing Wisely?: A Population-Based Retrospective Study of 6,875 Patients
2018, Chest
A routine chest radiograph (CXR) is recommended as a screening test after central venous catheter (CVC) insertion. The goal of this study was to assess the value of a routine postprocedural CXR in the era of ultrasound-guided CVC insertion.
This population-based retrospective cohort study was performed to review the records of all adult patients who had a CVC inserted in the operating room in a tertiary institution between July 1, 2008, and December 31, 2015. We determined the incidence of pneumothorax and catheter misplacement after ultrasound-guided CVC insertion. A logistic regression analysis was performed to examine the potential risk factors associated with these complications, and a cost analysis was conducted to evaluate the economic impact.
Of 18,274 patients who had a CVC inserted, 6,875 patients were included. The overall incidence of pneumothorax and catheter misplacement was 0.33% (95% CI, 0.22-0.5) (23 patients) and 1.91% (95% CI, 1.61-2.26) (131 patients), respectively. The site of catheterization was the major determinant of pneumothorax and catheter misplacement; left subclavian vein catheterization was the site at a higher risk for pneumothorax (OR, 6.69 [95% CI, 2.45-18.28]; P < .001), and catheterization sites other than the right internal jugular vein were at a higher risk for catheter misplacement. Expenditures on routine postprocedural CXR were US $105,000 to $183,000 per year at our institution.
This study found that pneumothorax and catheter misplacement after ultrasound-guided CVC insertion were rare, and the costs of a postprocedural CXR were exceedingly high. We concluded that a routine postprocedural CXR is unnecessary and not a wise choice in our setting.
Chest radiograph after fluoroscopic guided line placement: No longer necessary
2016, Journal of Pediatric Surgery
Citation Excerpt :
The pneumothorax rate was not significantly different for the 2 services, occurring in 2 of 205 (1%) patients on the surgery service and 2 of 417 (0.5%) patients of lines placed by interventional radiology, p = 0.6. Previous studies have questioned the necessity of chest radiograph in both children and adults [1–4]. A previous study from our center showed a very low complication rate (0.8%) and need for one chest tube out of 237 patients.
Historically, a chest radiograph was obtained after central line placement in the operating room. Recent retrospective studies have questioned the need for this radiograph. The prevailing current practice at our center is to order chest radiograph only for symptomatic patients. This study examines the outcomes of selective chest radiography after fluoroscopic guided central line placement.
After obtaining institutional review board approval, a single institution retrospective chart review of patients undergoing central venous catheter placement by the pediatric surgery or interventional radiology service between January 2010 and July 2014 was performed. Outcome measures included CXR within 24 h of catheter placement, reason for chest radiograph, complication, and complication requiring intervention.
In the study population 622 catheters were placed under fluoroscopy. A chest radiograph was performed in 118 (19%) patients within 24 h of the line placement with 25 (4%) of these patients being symptomatic in the recovery room. One patient required chest tube for shortness of breath and pleural effusion. Four symptomatic patients (0.6%) were found to have a pneumothorax, none of which required chest tube placement. There were no re-operations because of mal-position of the catheter. In the 504 patients with no postoperative chest x-ray, there were no adverse outcomes. At our institution the current average charge of a chest radiograph is $283, thus we produced savings of $142,632 for the study period without adverse events.
After placement of central venous catheter under fluoroscopic guidance, a chest radiograph is unlikely to be helpful in an asymptomatic patient.

View all citing articles on Scopus

: Presented at the 39th Annual Meeting of the Canadian Association of Pediatric Surgeons, August 23-26, 2007, St John's Newfoundland, Canada.

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CAPS original papersChest radiograph after central line placement under fluoroscopy: utility or futility?

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Routine chest radiographs after central line insertion: mandatory postprocedural evaluation of unnecessary waste of resources?

Cardiovasc Interv Radiol

Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access?

J Pediatr Surg

Routine x-ray control of upper central venous lines: is it necessary?

Acta Anaesthesiol Scand

Confirmatory chest radiographs after central line placement: are they warranted?

South Med J

CAPS original papers
Chest radiograph after central line placement under fluoroscopy: utility or futility?