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Chest radiograph after fluoroscopic guided line placement: No longer necessary
Journal of Pediatric Surgery xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Chest radiograph after fluoroscopic guided line placement: No longer necessary Brian G.A. Dalton a, Katherine W. Gonzalez a, Michael C. Keirsy a, Douglas C. Rivard b, Shawn D. St. Peter a,⁎ a b
Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO Department of Radiology, Children's Mercy Hospital, Kansas City, MO
a r t i c l e
i n f o
Article history: Received 9 November 2015 Received in revised form 26 January 2016 Accepted 1 February 2016 Available online xxxx Key words: Central venous catheter Fluoroscopy Central line Cost benefit Chest radiograph
a b s t r a c t Purpose: 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. Methods: 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. Results: 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. Conclusion: After placement of central venous catheter under fluoroscopic guidance, a chest radiograph is unlikely to be helpful in an asymptomatic patient. © 2016 Elsevier Inc. All rights reserved.
1. Purpose It is a historical standard to obtain a chest radiograph after central line placement in the operating room. Recent retrospective studies, at our center and others have found these to be low yield [1–2]. After our retrospective investigation, we avoided routinely obtaining this exam. In this study, we examine the impact of our clinical change on chest radiograph utilization, adverse events, and cost benefit. 2. Methods We implemented a prospective protocol to avoid routinely obtaining chest films after central line placement on the basis of our previous retrospective study. Approval of the internal review board was obtained (IRB# 13,070,215) and we retrospectively reviewed those patients undergoing central venous catheter placement between January 2010 and July 2014. Catheters placed by the pediatric surgery or interventional radiology service were included. Catheters not placed under fluoroscopy ⁎ Corresponding author at: Children's Mercy Hospital, Department of Surgery, 2401 Gillham Rd, Kansas City, MO, 64108. Tel.: +1 816 983 6465; fax: +1 816 983 6885. E-mail address: [email protected] (S.D. St. Peter).
and peripherally inserted central venous catheters were excluded. Outcome measures included chest radiograph within 24 h of catheter placement, reason for chest radiograph, complication, and need for thoracostomy tube placement. Cost benefit was based on current charge of chest radiograph at our institution. 3. Results During the study period 622 central venous catheters were placed under fluoroscopy, and included for analysis. An oncologic diagnosis was the most common reason for line placement, present in 321 patients (51.6%). A chest radiograph was performed in 118 (19%) patients within 24 h of the line placement. Twenty five (4%) of these patients were symptomatic in the recovery room. The most common symptom was shortness of breath experienced in 12 patients (1.9%) followed by 8 patients with cough (1.3%) and 5 with pain (0.8%). Sixty one (9.8%) of these patients had radiographs for the specified purpose of line placement. The other 36 radiographs were obtained for reasons unrelated to the line placement. Chest radiographs are typically performed in an anterior–posterior view on inspiratory hold at our institution. Overall complication rate was 1.3%. One patient required chest tube for shortness of breath and pleural effusion, but no hemothorax was found.
http://dx.doi.org/10.1016/j.jpedsurg.2016.02.003 0022-3468/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Dalton BGA, et al, Chest radiograph after fluoroscopic guided line placement: No longer necessary, J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.02.003
2
B.GA. Dalton et al. / Journal of Pediatric Surgery xxx (2016) xxx–xxx
Four patients (0.6%) with shortness of breath were found to have a pneumothorax. None of these patients required chest tube placement as all pneumothoraces were small, symptoms abated and subsequent chest radiograph showed resolution of the pneumothorax. Two of these catheters were placed with cannulation of an internal jugular vein and the other 2 were catheters placed using a subclavian venipuncture. All pneumothoraces were discovered in the postoperative recovery area. No patients that were discharged returned with symptoms requiring a chest radiograph. Another patient needed evacuation of a port site hematoma, although the decision was based on physical exam. There were no re-operations because of mal-position of the catheter. One patient, needing dialysis access, was found to have bilateral brachiocephalic vein occlusion with multiple collaterals. This patient experienced an intrathoracic placement of the catheter. This malposition was because of perforation of a mediastinal collateral vessel. This complication was noted and treated intra-operatively fluoroscopic assistance, not requiring any subsequent procedure. In the 504 patients with no postoperative chest x-ray, there were no adverse outcomes. The current average charge of a portable single-view chest radiograph is $283 at our institution, thus a savings of $142,632 was produced for the study period without adverse events and a potential for further savings is evident. The pediatric surgery service placed 205 catheters while the interventional radiology service placed 417 catheters during the study period. Overall, ultrasound guidance was utilized in 79% of line placements (490 of 622). The interventional radiology service was significantly more likely to use ultrasound guidance during line placement, 93% vs 51% (p b 0.001). Interventional radiology also placed an internal jugular catheter in 87% of cases, while the internal jugular vein was used in 57% of cases performed by the pediatric surgery service (p = b 0.001). 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.
that a countrywide savings of $2.3 million per year could be found by using chest radiographs in only symptomatic patients after line placement. Based on 100 lines per year and the expanding number of pediatric centers to 184 as well as the increasing costs in healthcare the potential savings rise to $3.7 million with a conservative estimate of chest radiograph cost at $250. These data show that cost benefit ($142,632 at our center) can be accomplished without compromising patient safety, the foremost concern of all practitioners. The issue of outpatient central venous catheter placement is one of contention. Our data show that all 4 patients that had pneumothoraces discovered on chest x-ray were symptomatic in the recovery area immediately after the procedure. We believe that a patient eligible for discharge otherwise may be safely released from the hospital without a chest radiograph if fluoroscopy reveals no abnormalities and no symptoms develop in the postoperative recovery area. A recent randomized trial that showed higher success rate of initial vessel cannulation is achieved using ultrasound guided technique vs landmark technique. This study did not show a difference complication rate [5]. Our study shows that interventional radiology is more likely to use ultrasound guided technique than the pediatric surgery service, but no difference in complication rate was noted. This difference in choice of technique is most likely because of practitioner preference, but patient factors such as previous catheters and reason for catheter placement may also contribute. Ultrasound has also been used to detect pneumothoraces in the setting of trauma [6]. This technique is not routinely performed at our institution, and has not been well studied in children but is an area of potential future study. If ultrasound can be proven reliable in detection of pneumothorax in children this may mitigate some cost and risk incurred from fluoroscopy. The combination of ultrasound and fluoroscopy for central venous catheter placement has been shown to result in a low complication rate and ensure proper placement catheters [7]. The current study is an agreement with that with an overall complication rate of 1%, and no cases of reoperation for catheter malposition.
4. Discusssion 5. Conclusion 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. The vast majority of patients in this study had post-operative chest x-rays. In the current study less than 20% of the 622 patients had a post-operative chest radiograph. Of the more than 500 patients that did not have a post-operative chest radiograph none of these experienced an adverse outcome. This finding confirms that patients who are asymptomatic are very unlikely to have significant findings on chest x-ray after a central line placed under fluoroscopy. Proponents of routine post-operative chest radiograph argue that it is needed to confirm satisfactory line position. This line of reasoning is refuted by the fact that no patients in our series needed early revision of the catheter for malposition of the catheter. It is our practice to examine the final fluoroscopy image prior to skin closure and adjust catheter position if needed based on this image. Still, during the study period 61 chest radiographs were ordered for the purpose of line placement. Some of this is because of surgeon preference. However, often the surgery or radiology team is not the primary team caring for the patient and a chest radiograph is ordered by the primary team in order to confirm placement prior to use. Limited literature examines cost benefit of omitting chest radiograph after placement of central venous catheter in children. In the previous retrospective study from our center it was theorized
After placement of central venous catheter under fluoroscopic guidance, a chest radiograph is unlikely to be helpful in an asymptomatic patient. Chest radiography after fluoroscopic guided line placement should be reserved for symptomatic patients. References [1] Keckler SJ, Spilde TL, Ho B, et al. Chest radiograph after central line placement under fluoroscopy: Utility or futility? J Pediatr Surg 2008;43(5):854–6. http://dx.doi.org/10. 1016/j.jpedsurg.2007.12.027. [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(8):1199–202. [3] Caridi JG, West JH, Stavropoulos SW, et al. Internal jugular and upper extremity central venous access in interventional radiology: is a postprocedure chest radiograph necessary? AJR Am J Roentgenol 2000;174(2):363–6. [4] Oner B, Karam AR, Surapaneni P, et al. Pneumothorax following ultrasound-guided jugular vein puncture for central venous access in interventional radiology: 4 years of experience. J Intensive Care Med 2012;27(6):370–2. http://dx.doi.org/10.1177/ 0885066611415494. [5] Bruzoni M, Slater BJ, Wall J, et al. A prospective randomized trial of ultrasound- vs landmark-guided central venous access in the pediatric population. J Am Coll Surg 2013;216(5):939–43. [6] Soult MC, Weireter LJ, Britt RC, et al. Can routine trauma bay chest xray be bypassed with an extended focused assessment with sonography for trauma examination? Am Surg 2015;81(4):336–40. [7] Bowen ME, Mone MC, Nelson EW, et al. Image-guided placement of long-term central venous catheters reduces complications and cost. Am J Surg 2014;208(6):937–41 [discussion 941].
Please cite this article as: Dalton BGA, et al, Chest radiograph after fluoroscopic guided line placement: No longer necessary, J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.02.003
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Chest radiograph after fluoroscopic guided line placement: No longer necessary Brian G.A. Dalton a, Katherine W. Gonzalez a, Michael C. Keirsy a, Douglas C. Rivard b, Shawn D. St. Peter a,⁎ a b
Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO Department of Radiology, Children's Mercy Hospital, Kansas City, MO
a r t i c l e
i n f o
Article history: Received 9 November 2015 Received in revised form 26 January 2016 Accepted 1 February 2016 Available online xxxx Key words: Central venous catheter Fluoroscopy Central line Cost benefit Chest radiograph
a b s t r a c t Purpose: 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. Methods: 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. Results: 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. Conclusion: After placement of central venous catheter under fluoroscopic guidance, a chest radiograph is unlikely to be helpful in an asymptomatic patient. © 2016 Elsevier Inc. All rights reserved.
1. Purpose It is a historical standard to obtain a chest radiograph after central line placement in the operating room. Recent retrospective studies, at our center and others have found these to be low yield [1–2]. After our retrospective investigation, we avoided routinely obtaining this exam. In this study, we examine the impact of our clinical change on chest radiograph utilization, adverse events, and cost benefit. 2. Methods We implemented a prospective protocol to avoid routinely obtaining chest films after central line placement on the basis of our previous retrospective study. Approval of the internal review board was obtained (IRB# 13,070,215) and we retrospectively reviewed those patients undergoing central venous catheter placement between January 2010 and July 2014. Catheters placed by the pediatric surgery or interventional radiology service were included. Catheters not placed under fluoroscopy ⁎ Corresponding author at: Children's Mercy Hospital, Department of Surgery, 2401 Gillham Rd, Kansas City, MO, 64108. Tel.: +1 816 983 6465; fax: +1 816 983 6885. E-mail address: [email protected] (S.D. St. Peter).
and peripherally inserted central venous catheters were excluded. Outcome measures included chest radiograph within 24 h of catheter placement, reason for chest radiograph, complication, and need for thoracostomy tube placement. Cost benefit was based on current charge of chest radiograph at our institution. 3. Results During the study period 622 central venous catheters were placed under fluoroscopy, and included for analysis. An oncologic diagnosis was the most common reason for line placement, present in 321 patients (51.6%). A chest radiograph was performed in 118 (19%) patients within 24 h of the line placement. Twenty five (4%) of these patients were symptomatic in the recovery room. The most common symptom was shortness of breath experienced in 12 patients (1.9%) followed by 8 patients with cough (1.3%) and 5 with pain (0.8%). Sixty one (9.8%) of these patients had radiographs for the specified purpose of line placement. The other 36 radiographs were obtained for reasons unrelated to the line placement. Chest radiographs are typically performed in an anterior–posterior view on inspiratory hold at our institution. Overall complication rate was 1.3%. One patient required chest tube for shortness of breath and pleural effusion, but no hemothorax was found.
http://dx.doi.org/10.1016/j.jpedsurg.2016.02.003 0022-3468/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Dalton BGA, et al, Chest radiograph after fluoroscopic guided line placement: No longer necessary, J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.02.003
2
B.GA. Dalton et al. / Journal of Pediatric Surgery xxx (2016) xxx–xxx
Four patients (0.6%) with shortness of breath were found to have a pneumothorax. None of these patients required chest tube placement as all pneumothoraces were small, symptoms abated and subsequent chest radiograph showed resolution of the pneumothorax. Two of these catheters were placed with cannulation of an internal jugular vein and the other 2 were catheters placed using a subclavian venipuncture. All pneumothoraces were discovered in the postoperative recovery area. No patients that were discharged returned with symptoms requiring a chest radiograph. Another patient needed evacuation of a port site hematoma, although the decision was based on physical exam. There were no re-operations because of mal-position of the catheter. One patient, needing dialysis access, was found to have bilateral brachiocephalic vein occlusion with multiple collaterals. This patient experienced an intrathoracic placement of the catheter. This malposition was because of perforation of a mediastinal collateral vessel. This complication was noted and treated intra-operatively fluoroscopic assistance, not requiring any subsequent procedure. In the 504 patients with no postoperative chest x-ray, there were no adverse outcomes. The current average charge of a portable single-view chest radiograph is $283 at our institution, thus a savings of $142,632 was produced for the study period without adverse events and a potential for further savings is evident. The pediatric surgery service placed 205 catheters while the interventional radiology service placed 417 catheters during the study period. Overall, ultrasound guidance was utilized in 79% of line placements (490 of 622). The interventional radiology service was significantly more likely to use ultrasound guidance during line placement, 93% vs 51% (p b 0.001). Interventional radiology also placed an internal jugular catheter in 87% of cases, while the internal jugular vein was used in 57% of cases performed by the pediatric surgery service (p = b 0.001). 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.
that a countrywide savings of $2.3 million per year could be found by using chest radiographs in only symptomatic patients after line placement. Based on 100 lines per year and the expanding number of pediatric centers to 184 as well as the increasing costs in healthcare the potential savings rise to $3.7 million with a conservative estimate of chest radiograph cost at $250. These data show that cost benefit ($142,632 at our center) can be accomplished without compromising patient safety, the foremost concern of all practitioners. The issue of outpatient central venous catheter placement is one of contention. Our data show that all 4 patients that had pneumothoraces discovered on chest x-ray were symptomatic in the recovery area immediately after the procedure. We believe that a patient eligible for discharge otherwise may be safely released from the hospital without a chest radiograph if fluoroscopy reveals no abnormalities and no symptoms develop in the postoperative recovery area. A recent randomized trial that showed higher success rate of initial vessel cannulation is achieved using ultrasound guided technique vs landmark technique. This study did not show a difference complication rate [5]. Our study shows that interventional radiology is more likely to use ultrasound guided technique than the pediatric surgery service, but no difference in complication rate was noted. This difference in choice of technique is most likely because of practitioner preference, but patient factors such as previous catheters and reason for catheter placement may also contribute. Ultrasound has also been used to detect pneumothoraces in the setting of trauma [6]. This technique is not routinely performed at our institution, and has not been well studied in children but is an area of potential future study. If ultrasound can be proven reliable in detection of pneumothorax in children this may mitigate some cost and risk incurred from fluoroscopy. The combination of ultrasound and fluoroscopy for central venous catheter placement has been shown to result in a low complication rate and ensure proper placement catheters [7]. The current study is an agreement with that with an overall complication rate of 1%, and no cases of reoperation for catheter malposition.
4. Discusssion 5. Conclusion 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. The vast majority of patients in this study had post-operative chest x-rays. In the current study less than 20% of the 622 patients had a post-operative chest radiograph. Of the more than 500 patients that did not have a post-operative chest radiograph none of these experienced an adverse outcome. This finding confirms that patients who are asymptomatic are very unlikely to have significant findings on chest x-ray after a central line placed under fluoroscopy. Proponents of routine post-operative chest radiograph argue that it is needed to confirm satisfactory line position. This line of reasoning is refuted by the fact that no patients in our series needed early revision of the catheter for malposition of the catheter. It is our practice to examine the final fluoroscopy image prior to skin closure and adjust catheter position if needed based on this image. Still, during the study period 61 chest radiographs were ordered for the purpose of line placement. Some of this is because of surgeon preference. However, often the surgery or radiology team is not the primary team caring for the patient and a chest radiograph is ordered by the primary team in order to confirm placement prior to use. Limited literature examines cost benefit of omitting chest radiograph after placement of central venous catheter in children. In the previous retrospective study from our center it was theorized
After placement of central venous catheter under fluoroscopic guidance, a chest radiograph is unlikely to be helpful in an asymptomatic patient. Chest radiography after fluoroscopic guided line placement should be reserved for symptomatic patients. References [1] Keckler SJ, Spilde TL, Ho B, et al. Chest radiograph after central line placement under fluoroscopy: Utility or futility? J Pediatr Surg 2008;43(5):854–6. http://dx.doi.org/10. 1016/j.jpedsurg.2007.12.027. [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(8):1199–202. [3] Caridi JG, West JH, Stavropoulos SW, et al. Internal jugular and upper extremity central venous access in interventional radiology: is a postprocedure chest radiograph necessary? AJR Am J Roentgenol 2000;174(2):363–6. [4] Oner B, Karam AR, Surapaneni P, et al. Pneumothorax following ultrasound-guided jugular vein puncture for central venous access in interventional radiology: 4 years of experience. J Intensive Care Med 2012;27(6):370–2. http://dx.doi.org/10.1177/ 0885066611415494. [5] Bruzoni M, Slater BJ, Wall J, et al. A prospective randomized trial of ultrasound- vs landmark-guided central venous access in the pediatric population. J Am Coll Surg 2013;216(5):939–43. [6] Soult MC, Weireter LJ, Britt RC, et al. Can routine trauma bay chest xray be bypassed with an extended focused assessment with sonography for trauma examination? Am Surg 2015;81(4):336–40. [7] Bowen ME, Mone MC, Nelson EW, et al. Image-guided placement of long-term central venous catheters reduces complications and cost. Am J Surg 2014;208(6):937–41 [discussion 941].
Please cite this article as: Dalton BGA, et al, Chest radiograph after fluoroscopic guided line placement: No longer necessary, J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.02.003