- Email: [email protected]
Is Routine Postoperative Chest X-Ray Necessary after Fluoroscopic-Guided Subclavian Central Venous Port Placement?
Is Routine Postoperative Chest X-Ray Necessary after Fluoroscopic-Guided Subclavian Central Venous Port Placement? Jon R Brown, DO, Carol Slomski, MD, FACS, Andrew W Saxe, MD, FACS Two uncommon but serious complications after subclavian central venous port (SCVP) placement are pneumothorax (PNX) and malposition of the catheter. Chest x-rays (CXR) are commonly obtained after SCVP placement to identify these complications, but their use is controversial. STUDY DESIGN: We performed a retrospective review of SCVP placements to establish the incidence of PNX or catheter malposition identified exclusively by postprocedure CXR. RESULTS: Between July 1, 2001, and June 30, 2006, 205 patients underwent elective SCVP placement. Although 4 patients (2%) sustained a PNX, none was identified by routine postprocedure CXR. Postprocedure clinical symptoms (3 to 72 hours later) prompted repeat CXR, which identified the PNX. Five patients (2.4%) had catheter malposition recognized by intraoperative fluoroscopy and corrected intraoperatively. No malpositioned catheters were identified on postprocedure CXR. CONCLUSIONS: In our study, incidence of PNX after SCVP placement was low, and PNX was not detected by intraoperative fluoroscopy or by routine postprocedure CXR. We conclude that the practice of routine postprocedure CXR after SCVP placement is not necessary and should be replaced with diagnostic chest radiography only if symptoms develop. (J Am Coll Surg 2009;208:517–519. © 2009 by the American College of Surgeons) BACKGROUND:
Two complications that can occur after subclavian central venous port (SCVP) placement are pneumothorax (PNX) and catheter malposition. A postprocedure chest x-ray (CXR) is generally obtained to detect PNX. To reduce incidence of catheter malposition, intraoperative fluoroscopy is used to confirm placement of the catheter tip within the superior vena cava. Postprocedure CXR is also used to document correct catheter placement. Recently, use of postoperative CXR has been called into question, and several studies have concluded that it is not necessary. Burn and colleagues,1 in a study of 3,844 patients, identified complications on only 1.4% of their postoperative chest x-rays, and in only 0.1% of patients was the complication not suspected on clinical grounds. Similarly, Janik and colleagues2 reported that PNX was identified in 1.6% of 824 patients undergoing 1,039 central venous
catheters and concluded that routine chest x-ray after catheter placement is not required unless clinical suspicion of a complication exists. We performed a retrospective review of our experience with SCVP placement to answer the questions: What is the incidence of PNX and catheter malposition and how often are these complications identified on intraoperative fluoroscopy and postoperative CXR?
METHODS We used billing code 36561 to identify adults who underwent SCVP placement between July 1, 2001, and June 30, 2006. Minors and prisoners were excluded. Ultrasonography was not used. Data collected included age and gender of patients, inpatient or outpatient status, number of needle passes, whether air was aspirated during the procedure, and catheter position and PNX assessed by both fluoroscopy and postprocedure CXR. Catheter malposition was defined as a catheter lying in the internal jugular or subclavian veins. Charts were reviewed by the first author, and special attention was given to operative reports and to CXR reports. All CXR reports were dictated by board-certified radiologists.
Disclosure Information: Nothing to disclose. Received November 10, 2008; Revised January 12, 2009; Accepted January 24, 2009. From the Department of Surgery, Michigan State University College of Human Medicine, Lansing, MI. Correspondence address: Andrew W Saxe, MD, Department of Surgery, Michigan State University College of Human Medicine, 1200 East Michigan Ave, Ste 655, Lansing, MI 48912. email: [email protected]
© 2009 by the American College of Surgeons Published by Elsevier Inc.
517
ISSN 1072-7515/09/$36.00 doi:10.1016/j.jamcollsurg.2009.01.020
518
Brown et al
Serious Complications after SCVP Placement
Abbreviations and Acronyms
CXR ⫽ chest x-ray PNX ⫽ pneumothorax SCVP ⫽ subclavian central venous port
RESULTS Charts of 291 patients were reviewed. Eighty-six patients were excluded (22 internal jugular access, 15 cutdowns, 3 catheter exchanges across a wire, 16 catheters placed without ports, 1 chart miscoded, and 29 charts with incomplete data), leaving 205 charts for inclusion. One hundred fifty-eight procedures (77%) were elective outpatient SCVP placements. The remaining 47 patients were admitted to the hospital either before operation for underlying medical conditions or after operations for observation, despite absence of symptoms of PNX or catheter malposition. Eleven patients did not receive a postoperative CXR, and none developed a PNX or symptomatic catheter malposition. Five patients had catheter malposition recognized by fluoroscopy and corrected intraoperatively. All malpositioned catheters were first noted to be in the internal jugular vein. No malpositioned catheters were identified on postprocedure CXR. Fluoroscopy and CXR reports differed on interpretation of catheter position in 51 patients (25%), eg, superior vena cava versus superior vena cava–right atrial junction. These differences were not believed to be clinically relevant. Four patients (2%) sustained PNX confirmed by CXR. None of the four patients had a PNX identified either by fluoroscopy or by routine postoperative CXR. In no patient with PNX was air aspirated during the venipuncture. In only one patient with PNX was more than one needle pass recorded. For those patients who sustained a PNX, the resident surgeon year was PGY1, PGY1, PGY2, and 1 procedure was performed by an attending surgeon. Each of the 4 patients with PNX underwent a planned outpatient SCVP placement for chemotherapy administration. Each had a negative postprocedure CXR. Patient 1 was discharged to home but returned to the emergency department 24 hours later with shortness of breath and left-sided chest pain. Patient 2 had an outpatient CT of the chest for additional evaluation for metastatic disease on the same day as SCVP placement. This demonstrated the SCVP catheter to be traversing the lung. Chest pain developed in this patient about 3 hours post-SCVP placement, and she was transferred to the emergency department. Chest pain and shortness of breath developed in patient 3 approximately 3 hours
J Am Coll Surg
postprocedure while still in the postanesthesia care unit, and a second CXR showed a PNX. Patient 4 had been home for 3 days when shortness of breath and left-sided chest pain developed, prompting return to the emergency department and a diagnosis of PNX. All four patients were treated with tube thoracostomy and were admitted to the hospital.
DISCUSSION Routine postoperative CXR has been a standard practice to document catheter tip placement and presence or absence of PNX after SCVP placement. Incidence of PNX has been reported to range from 1.3% to 1.6%.2,3 In light of this complication, Abood and colleagues4 have recommended that CXR be obtained routinely after SCVP placement. Burn and colleagues,1 in a retrospective study of 3,844 central line placements between 1994 and 1998, found a 1.4% PNX rate on routine CXR, and in only 0.1% was the finding occult and not suspected on clinical grounds. They concluded that routine postoperative CXR was not warranted. Janik and colleagues2 reported that PNX was identified in 1.6% of 824 pediatric patients undergoing 1,039 central venous catheters, and they concluded that routine CXR after catheter placement is not required unless clinical suspicion of a complication exists. Our study examined patients who underwent elective SCVP placement, usually for administration of chemotherapy for cancer, to see if our results and conclusions would be the same. Our findings are remarkably similar. Our rate of PNX was 2%, and all were detected on imaging done for symptoms well after the routine postoperative CXR. None of the PNX cases was recognized by either the intraoperative fluoroscopy or by immediate postoperative CXR. In each instance, clinical suspicion (shortness of breath, tachypnea, and pain) led to discovery of the PNX several hours postprocedure. In our series, clinically relevant PNX had a delayed evolution and was not found on the immediate, routine postprocedure CXR. We do not recommend delaying a routine CXR for several hours. The incidence is low, and, in our study, it was not possible to predict those who sustained a PNX. Requesting a routine stay in the postanesthesia observation unit for outpatients would place an untenable burden on the institution’s resources. Even a 3-hour period of observation would, in our study, have identified only half the patients with PNX. Indeed, patients admitted after line placement for observation (for a variety of reasons) did not experience symptom development or clinical suspicion of PNX.
Vol. 208, No. 4, April 2009
Brown et al
We also examined the potential complication of catheter malposition. We found postoperative CXR not to be necessary to identify catheter malposition, because our five cases of malposition were easily and quickly corrected intraoperatively under fluoroscopic guidance. Weaknesses of our study include its retrospective nature and relatively small size. In keeping with the retrospective nature of the study, 12% (29 of 234) of potentially eligible patients were excluded because of incomplete data. Also, central venous catheterization using ultrasonography guidance at the internal jugular is now replacing the subclavian approach. Despite these limitations, our findings showed that PNX is not readily detected by postoperative CXR; clinical symptoms more often lead to its discovery. Catheter position determined by fluoroscopy is accurate, and malpositions can be successfully resolved intraoperatively. We conclude that the practice of routine postprocedure CXR after SCVP placement is not necessary and should be replaced by a diagnostic CXR only if symptoms develop.
Serious Complications after SCVP Placement
519
Author Contributions Study conception and design: Brown, Slomski Acquisition of data: Brown Analysis and interpretation of data: Brown, Slomski, Saxe Drafting of manuscript: Brown, Saxe Critical revision: Brown, Slomski, Saxe
REFERENCES 1. Burn PR, Skewes D, King DM. Role of chest radiography after the insertion of a subclavian vein catheter for ambulatory chemotherapy. Can Assoc Radiol J 2001;52:392–394. 2. Janik JE, Cothren CC, Janik JS, et al. Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access? J Pediatr Surg 2003;38:1199–1202. 3. Yildizeli B, Lacin T, Batirel HF, Yuksel M. Complications and management of long-term central venous access catheters and ports. J Vasc Access 2004;5:174–178. 4. Abood GJ, Davis KA, Esposito TJ, et al. Comparison of routine chest radiograph versus clinician judgment to determine adequate central line placement in critically ill patients. J Trauma 2007;63: 50–56.
JACS ONLINE CME-1 PROGRAM EARN 4 CME-1 CREDITS EACH MONTH www.jacscme.facs.org
Two complications that can occur after subclavian central venous port (SCVP) placement are pneumothorax (PNX) and catheter malposition. A postprocedure chest x-ray (CXR) is generally obtained to detect PNX. To reduce incidence of catheter malposition, intraoperative fluoroscopy is used to confirm placement of the catheter tip within the superior vena cava. Postprocedure CXR is also used to document correct catheter placement. Recently, use of postoperative CXR has been called into question, and several studies have concluded that it is not necessary. Burn and colleagues,1 in a study of 3,844 patients, identified complications on only 1.4% of their postoperative chest x-rays, and in only 0.1% of patients was the complication not suspected on clinical grounds. Similarly, Janik and colleagues2 reported that PNX was identified in 1.6% of 824 patients undergoing 1,039 central venous
catheters and concluded that routine chest x-ray after catheter placement is not required unless clinical suspicion of a complication exists. We performed a retrospective review of our experience with SCVP placement to answer the questions: What is the incidence of PNX and catheter malposition and how often are these complications identified on intraoperative fluoroscopy and postoperative CXR?
METHODS We used billing code 36561 to identify adults who underwent SCVP placement between July 1, 2001, and June 30, 2006. Minors and prisoners were excluded. Ultrasonography was not used. Data collected included age and gender of patients, inpatient or outpatient status, number of needle passes, whether air was aspirated during the procedure, and catheter position and PNX assessed by both fluoroscopy and postprocedure CXR. Catheter malposition was defined as a catheter lying in the internal jugular or subclavian veins. Charts were reviewed by the first author, and special attention was given to operative reports and to CXR reports. All CXR reports were dictated by board-certified radiologists.
Disclosure Information: Nothing to disclose. Received November 10, 2008; Revised January 12, 2009; Accepted January 24, 2009. From the Department of Surgery, Michigan State University College of Human Medicine, Lansing, MI. Correspondence address: Andrew W Saxe, MD, Department of Surgery, Michigan State University College of Human Medicine, 1200 East Michigan Ave, Ste 655, Lansing, MI 48912. email: [email protected]
© 2009 by the American College of Surgeons Published by Elsevier Inc.
517
ISSN 1072-7515/09/$36.00 doi:10.1016/j.jamcollsurg.2009.01.020
518
Brown et al
Serious Complications after SCVP Placement
Abbreviations and Acronyms
CXR ⫽ chest x-ray PNX ⫽ pneumothorax SCVP ⫽ subclavian central venous port
RESULTS Charts of 291 patients were reviewed. Eighty-six patients were excluded (22 internal jugular access, 15 cutdowns, 3 catheter exchanges across a wire, 16 catheters placed without ports, 1 chart miscoded, and 29 charts with incomplete data), leaving 205 charts for inclusion. One hundred fifty-eight procedures (77%) were elective outpatient SCVP placements. The remaining 47 patients were admitted to the hospital either before operation for underlying medical conditions or after operations for observation, despite absence of symptoms of PNX or catheter malposition. Eleven patients did not receive a postoperative CXR, and none developed a PNX or symptomatic catheter malposition. Five patients had catheter malposition recognized by fluoroscopy and corrected intraoperatively. All malpositioned catheters were first noted to be in the internal jugular vein. No malpositioned catheters were identified on postprocedure CXR. Fluoroscopy and CXR reports differed on interpretation of catheter position in 51 patients (25%), eg, superior vena cava versus superior vena cava–right atrial junction. These differences were not believed to be clinically relevant. Four patients (2%) sustained PNX confirmed by CXR. None of the four patients had a PNX identified either by fluoroscopy or by routine postoperative CXR. In no patient with PNX was air aspirated during the venipuncture. In only one patient with PNX was more than one needle pass recorded. For those patients who sustained a PNX, the resident surgeon year was PGY1, PGY1, PGY2, and 1 procedure was performed by an attending surgeon. Each of the 4 patients with PNX underwent a planned outpatient SCVP placement for chemotherapy administration. Each had a negative postprocedure CXR. Patient 1 was discharged to home but returned to the emergency department 24 hours later with shortness of breath and left-sided chest pain. Patient 2 had an outpatient CT of the chest for additional evaluation for metastatic disease on the same day as SCVP placement. This demonstrated the SCVP catheter to be traversing the lung. Chest pain developed in this patient about 3 hours post-SCVP placement, and she was transferred to the emergency department. Chest pain and shortness of breath developed in patient 3 approximately 3 hours
J Am Coll Surg
postprocedure while still in the postanesthesia care unit, and a second CXR showed a PNX. Patient 4 had been home for 3 days when shortness of breath and left-sided chest pain developed, prompting return to the emergency department and a diagnosis of PNX. All four patients were treated with tube thoracostomy and were admitted to the hospital.
DISCUSSION Routine postoperative CXR has been a standard practice to document catheter tip placement and presence or absence of PNX after SCVP placement. Incidence of PNX has been reported to range from 1.3% to 1.6%.2,3 In light of this complication, Abood and colleagues4 have recommended that CXR be obtained routinely after SCVP placement. Burn and colleagues,1 in a retrospective study of 3,844 central line placements between 1994 and 1998, found a 1.4% PNX rate on routine CXR, and in only 0.1% was the finding occult and not suspected on clinical grounds. They concluded that routine postoperative CXR was not warranted. Janik and colleagues2 reported that PNX was identified in 1.6% of 824 pediatric patients undergoing 1,039 central venous catheters, and they concluded that routine CXR after catheter placement is not required unless clinical suspicion of a complication exists. Our study examined patients who underwent elective SCVP placement, usually for administration of chemotherapy for cancer, to see if our results and conclusions would be the same. Our findings are remarkably similar. Our rate of PNX was 2%, and all were detected on imaging done for symptoms well after the routine postoperative CXR. None of the PNX cases was recognized by either the intraoperative fluoroscopy or by immediate postoperative CXR. In each instance, clinical suspicion (shortness of breath, tachypnea, and pain) led to discovery of the PNX several hours postprocedure. In our series, clinically relevant PNX had a delayed evolution and was not found on the immediate, routine postprocedure CXR. We do not recommend delaying a routine CXR for several hours. The incidence is low, and, in our study, it was not possible to predict those who sustained a PNX. Requesting a routine stay in the postanesthesia observation unit for outpatients would place an untenable burden on the institution’s resources. Even a 3-hour period of observation would, in our study, have identified only half the patients with PNX. Indeed, patients admitted after line placement for observation (for a variety of reasons) did not experience symptom development or clinical suspicion of PNX.
Vol. 208, No. 4, April 2009
Brown et al
We also examined the potential complication of catheter malposition. We found postoperative CXR not to be necessary to identify catheter malposition, because our five cases of malposition were easily and quickly corrected intraoperatively under fluoroscopic guidance. Weaknesses of our study include its retrospective nature and relatively small size. In keeping with the retrospective nature of the study, 12% (29 of 234) of potentially eligible patients were excluded because of incomplete data. Also, central venous catheterization using ultrasonography guidance at the internal jugular is now replacing the subclavian approach. Despite these limitations, our findings showed that PNX is not readily detected by postoperative CXR; clinical symptoms more often lead to its discovery. Catheter position determined by fluoroscopy is accurate, and malpositions can be successfully resolved intraoperatively. We conclude that the practice of routine postprocedure CXR after SCVP placement is not necessary and should be replaced by a diagnostic CXR only if symptoms develop.
Serious Complications after SCVP Placement
519
Author Contributions Study conception and design: Brown, Slomski Acquisition of data: Brown Analysis and interpretation of data: Brown, Slomski, Saxe Drafting of manuscript: Brown, Saxe Critical revision: Brown, Slomski, Saxe
REFERENCES 1. Burn PR, Skewes D, King DM. Role of chest radiography after the insertion of a subclavian vein catheter for ambulatory chemotherapy. Can Assoc Radiol J 2001;52:392–394. 2. Janik JE, Cothren CC, Janik JS, et al. Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access? J Pediatr Surg 2003;38:1199–1202. 3. Yildizeli B, Lacin T, Batirel HF, Yuksel M. Complications and management of long-term central venous access catheters and ports. J Vasc Access 2004;5:174–178. 4. Abood GJ, Davis KA, Esposito TJ, et al. Comparison of routine chest radiograph versus clinician judgment to determine adequate central line placement in critically ill patients. J Trauma 2007;63: 50–56.
JACS ONLINE CME-1 PROGRAM EARN 4 CME-1 CREDITS EACH MONTH www.jacscme.facs.org