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Is Routine Chest X-Ray After Ultrasound-Guided Central Venous Catheter Insertion Choosing Wisely?

A Population-Based Retrospective Study of 6,875 Patients
Published:February 28, 2018DOI:https://doi.org/10.1016/j.chest.2018.02.017

      Background

      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.

      Methods

      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.

      Results

      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.

      Conclusions

      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.

      Key Words

      Abbreviations:

      CVC (central venous catheter), CXR (chest radiograph), LIJ (left internal jugular vein), LSCV (left subclavian vein), NNT (number needed to test), RIJ (right internal jugular vein), RSCV (right subclavian vein)
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      References

        • McGee D.C.
        • Gould M.K.
        Preventing complications of central venous catheterization.
        N Engl J Med. 2003; 348: 1123-1133
        • Abraham E.
        • Shapiro M.
        • Podolsky S.
        Central venous catheterization in the emergency setting.
        Crit Care Med. 1983; 11: 515-517
        • Eisen L.A.
        • Narasimhan M.
        • Berger J.S.
        • Mayo P.H.
        • Rosen M.J.
        • Schneider R.F.
        Mechanical complications of central venous catheters.
        J Intensive Care Med. 2016; 21: 40-46
        • Yilmazlar A.
        • Bilgin H.
        • Korfali G.
        • Eren A.
        • Özkan U.
        Complications of 1303 central venous cannulations.
        J R Soc Med. 1997; 90: 319-321
        • Frykholm P.
        • Pikwer A.
        • Hammarskjöld F.
        • et al.
        Clinical guidelines on central venous catheterisation. Swedish Society of Anaesthesiology and Intensive Care Medicine.
        Acta Anaesthesiologica Scandinavica. 2014; 58: 508-524
        • Rupp S.M.
        • Apfelbaum J.L.
        • et al.
        • American Society of Anesthesiologists Task Force on Central Venous Access
        Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access.
        Anesthesiology. 2012; 116: 539-573
        • Troianos C.A.
        • Hartman G.S.
        • Glas K.E.
        • et al.
        Guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.
        Anesth Analg. 2012; 114: 46-72
        • Harris N.
        • Hodzovic I.
        • Latto P.
        A national survey of the use of ultrasound locating devices for placing central venous catheters.
        Anaesthesia. 2007; 62: 306-307
        • Brass P.
        • Hellmich M.
        • Kolodziej L.
        • Schick G.
        • Smith A.F.
        Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization.
        Cochrane Database Syst Rev. 2015; 1: CD006962
        • Lalu M.M.
        • Fayad A.
        • Ahmed O.
        • et al.
        Ultrasound-guided subclavian vein catheterization.
        Crit Care Med. 2015; 43: 1498-1507
        • Denys B.G.
        • Uretsky B.F.
        • Reddy P.S.
        Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique.
        Circulation. 1993; 87: 1557-1562
        • Troianos C.A.
        • Jobes D.R.
        • Ellison N.
        Ultrasound-guided cannulation of the internal jugular vein. A prospective, randomized study.
        Anesth Analg. 1991; 72: 823
        • Mallory D.L.
        • McGee W.T.
        • Shawker T.H.
        • et al.
        Ultrasound guidance improves the success rate of internal jugular vein cannulation.
        Chest. 1990; 98: 157-160
        • Wigmore T.J.
        • Smythe J.F.
        • Hacking M.B.
        • Raobaikady R.
        • MacCallum N.S.
        Effect of the implementation of NICE guidelines for ultrasound guidance on the complication rates associated with central venous catheter placement in patients presenting for routine surgery in a tertiary referral centre.
        Br J Anaesth. 2007; 99: 662-665
        • Alrajab S.
        • Youssef A.M.
        • Akkus N.I.
        • Caldito G.
        Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis.
        Crit Care. 2013; 17: R208
        • Dulce M.
        • Steffen I.G.
        • Preuss A.
        • Renz D.M.
        • Hamm B.
        • Elgeti T.
        Topographic analysis and evaluation of anatomical landmarks for placement of central venous catheters based on conventional chest X-ray and computed tomography.
        Br J Anaesth. 2014; 112: 265-271
        • Galante O.
        • Slutsky T.
        • Fuchs L.
        • et al.
        Single-operator ultrasound-guided central venous catheter insertion verifies proper tip placement.
        Crit Care Med. 2017; 45: e994-e1000
        • McComb B.L.
        • Chung J.H.
        • Crabtree T.D.
        • et al.
        ACR Appropriateness Criteria® Routine Chest Radiography.
        J Thorac Imaging. 2016; 31: W13-W15
        • Hourmozdi J.J.
        • Markin A.
        • Johnson B.
        • Fleming P.R.
        • Miller J.B.
        Routine chest radiography is not necessary after ultrasound-guided right internal jugular vein catheterization.
        Crit Care Med. 2016; 44: e804-e808
        • Ammirati C.
        • Maizel J.
        • Slama M.
        Is chest X-ray still necessary after central venous catheter insertion?.
        Crit Care Med. 2010; 38: 715-716
        • Pikwer A.
        • Bååth L.
        • Perstoft I.
        • Davidson B.
        • ÅKESON J.
        Routine chest X-ray is not required after a low-risk central venous cannulation.
        Acta Anaesthesiologica Scandinavica. 2009; 53: 1145-1152
        • Bailey S.H.
        • Shapiro S.B.
        • Mone M.C.
        • Saffle J.R.
        • Morris S.E.
        • Barton R.G.
        Is immediate chest radiograph necessary after central venous catheter placement in a surgical intensive care unit?.
        Am J Surg. 2000; 180: 517-522
        • Lucey B.
        • Varghese J.C.
        • Haslam P.
        • Lee M.J.
        Routine chest radiographs after central line insertion: mandatory postprocedural evaluation or unnecessary waste of resources?.
        Cardiovasc Intervent Radiol. 1999; 22: 381-384
        • Palesty J.A.
        • Amshel C.E.
        • Dudrick S.J.
        Routine chest radiographs following central venous recatheterization over a wire are not justified.
        Am J Surg. 1998; 176: 618-621
        • Chang T.C.
        • Funaki B.
        • Szymski G.X.
        Are routine chest radiographs necessary after image-guided placement of internal jugular central venous access devices?.
        Am J Roentgenol. 1998; 170: 335-337
        • Oner B.
        • Karam A.R.
        • Surapaneni P.
        • Phillips D.A.
        Pneumothorax following ultrasound-guided jugular vein puncture for central venous access in interventional radiology: 4 years of experience.
        J Intensive Care Med. 2012; 27: 370-372
        • Hosmer D.W.
        • Lemeshow S.
        Interpretation of the fitted logistic regression model.
        in: Applied Logistic Regression. Wiley, 2005
        • Keckler S.J.
        • Spilde T.L.
        • Ho B.
        • et al.
        Chest radiograph after central line placement under fluoroscopy: utility or futility?.
        J Pediatr Surg. 2008; 43: 854-856
        • Ruesch S.
        • Walder B.
        • Tramèr M.R.
        Complications of central venous catheters: internal jugular versus subclavian access—a systematic review.
        Crit Care Med. 2002; 30: 454-460
        • Lessnau K.D.
        Is chest radiography necessary after uncomplicated insertion of a triple-lumen catheter in the right internal jugular vein, using the anterior approach?.
        Chest. 2005; 127: 220-223
        • Pikwer A.
        • Bååth L.
        • Davidson B.
        • Perstoft I.
        • Åkeson J.
        The incidence and risk of central venous catheter malpositioning: a prospective cohort study in 1619 patients.
        Anaesth Intensive Care. 2008; 36: 30-37
        • Benarroch-Gampel J.
        • Sheffield K.M.
        • Duncan C.B.
        • et al.
        Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery.
        Ann Surg. 2012; 256: 518-528
        • Ablordeppey E.A.
        • Drewry A.M.
        • Beyer A.B.
        • et al.
        Diagnostic accuracy of central venous catheter confirmation by bedside ultrasound versus chest radiography in critically ill patients.
        Crit Care Med. 2017; 45: 715-724
        • Amir R.
        • Knio Z.O.
        • Mahmood F.
        • et al.
        Ultrasound as a screening tool for central venous catheter positioning and exclusion of pneumothorax.
        Crit Care Med. 2017; 45: 1192-1198
        • Maury E.
        • Guglielminotti J.
        • Alzieu M.
        • Guidet B.
        • Offenstadt G.
        Ultrasonic examination: an alternative to chest radiography after central venous catheter insertion?.
        Am J Respir Crit Care Med. 2001; 164: 403-405
        • Bedel J.
        • Vallée F.
        • Mari A.
        • et al.
        Guidewire localization by transthoracic echocardiography during central venous catheter insertion: a periprocedural method to evaluate catheter placement.
        Intensive Care Med. 2013; 39: 1932-1937
        • Vezzani A.
        • Brusasco C.
        • Palermo S.
        • Launo C.
        • Mergoni M.
        • Corradi F.
        Ultrasound localization of central vein catheter and detection of postprocedural pneumothorax: an alternative to chest radiography.
        Crit Care Med. 2010; 38: 533-538
        • Bortman J.
        • Knio Z.
        • Amir R.
        • Hamid K.
        • Mahmood F.
        • Matyal R.
        Perioperative surface ultrasound for placement and confirmation of central venous access.
        A A Case Rep. 2017; 8: 197-199
        • Saul T.
        • Doctor M.
        • Kaban N.L.
        • Avitabile N.C.
        • Siadecki S.D.
        • Lewiss R.E.
        The ultrasound-only central venous catheter placement and confirmation procedure.
        J Ultrasound Med. 2015; 34: 1301-1306
        • Gekle R.
        • Dubensky L.
        • Haddad S.
        • et al.
        Saline flush test: can bedside sonography replace conventional radiography for confirmation of above-the-diaphragm central venous catheter placement?.
        J Ultrasound Med. 2015; 34: 1295-1299
        • Duran-Gehring P.E.
        • Guirgis F.W.
        • McKee K.C.
        • et al.
        The bubble study: ultrasound confirmation of central venous catheter placement.
        Am J Emerg Med. 2015; 33: 315-319
        • Bou Chebl R.
        • Kiblawi S.
        • Khuri El C.
        • et al.
        Use of contrast-enhanced ultrasound for confirmation of central venous catheter placement: systematic review and meta-analysis.
        J Ultrasound Med. 2017; 28: 3445
        • Lefrant J.Y.
        • Muller L.
        • La Coussaye De J.E.
        • et al.
        Risk factors of failure and immediate complication of subclavian vein catheterization in critically ill patients.
        Intensive Care Med. 2002; 28: 1036-1041
        • Brody H.
        Medicine's ethical responsibility for health care reform—the top five list.
        N Engl J Med. 2010; 362: 283-285
        • Wolfson D.
        • Santa J.
        • Slass L.
        Engaging physicians and consumers in conversations about treatment overuse and waste.
        Acad Med. 2014; 89: 990-995
        • Rosenberg A.
        • Agiro A.
        • Gottlieb M.
        • et al.
        Early trends among seven recommendations from the Choosing Wisely campaign.
        JAMA Intern Med. 2015; 175: 1913-1920
        • Parks A.L.
        • O'Malley P.G.
        From Choosing Wisely to practicing value—more to the story.
        JAMA Intern Med. 2016; 176: 1571-1572
        • Parks A.L.
        • O'Malley P.G.
        Applying academic detailing and process change to promote Choosing Wisely—reply.
        JAMA Intern Med. 2017; 177: 283