Routine chest X-ray is unnecessary after ultrasound-guided central venous line placement in the operating room

Accepted Manuscript Routine chest X-ray is unnecessary after ultrasound-guided central venous line placement in the operating room

David C. Woodland, C. Randall Cooper, M. Farzan Rashid, Vilma L. Rosario, Paul David Weyker, Joshua Weintraub, Stuart Bentley-Hibbert, Michael D. Kluger PII: DOI: Reference:

S0883-9441(18)30097-2 doi:10.1016/j.jcrc.2018.03.027 YJCRC 52896

To appear in: Please cite this article as: David C. Woodland, C. Randall Cooper, M. Farzan Rashid, Vilma L. Rosario, Paul David Weyker, Joshua Weintraub, Stuart Bentley-Hibbert, Michael D. Kluger , Routine chest X-ray is unnecessary after ultrasound-guided central venous line placement in the operating room. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yjcrc(2017), doi:10.1016/ j.jcrc.2018.03.027

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ACCEPTED MANUSCRIPT

Routine Chest X-Ray is Unnecessary After Ultrasound-Guided Central Venous Line Placement in the Operating Room.

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David C. Woodlanda , C. Randall Coopera , M Farzan Rashida , Vilma L. Rosarioa, Paul

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David Weykerb, Joshua Weintraubc, Stuart Bentley–Hibbertc, Michael D. Klugera

Affiliation: a. Columbia University Department of Surgery. b. Kaiser Permanente South

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San Francisco, Department of Anesthesiology, Divisions of Critical Care Medicine and

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Interventional Pain Management c. Columbia University Department of Radiology

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Corresponding Author: Charles Randall Cooper: [email protected]

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Address: 177 Fort Washington Avenue 7GS -313 New York, NY 10032

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Declaration of interest: None

ACCEPTED MANUSCRIPT Abstract: Background: 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

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patient management.

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Methods: 200 patient charts who underwent pancreaticoduodenectomy with central line placement and early line removal were reviewed for clinical complications related to

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central line placement as well as radiographic evidence of malpositioning. A cost analysis

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was performed to estimate savings if CXR had not been performed across routine

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surgical procedures requiring central access.

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Results: 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

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or hemothorax were identified and 30 (15.3%) of CVCs were improperly positioned.

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Only 1(0.5%) of these was deemed clinically significant and repositioned after the CXR

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was performed.

Conclusion: Routine CXR consumes valuable time and resources (≅$155,000 annually) and rarely affects management. Selection should be guided by clinical factors.

ACCEPTED MANUSCRIPT Introduction Central venous catheters (CVC) can be critical for peri-operative monitoring and medication delivery. Despite their utility, they are associated with infectious, thrombotic and mechanical complications. Complications can be grouped as early or late, and have

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been reported in 0.4-30% of patients1-5. Early complications are related to catheter

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insertion, including malpositioning, arterial puncture, pneumothorax, and hemothorax.6,7

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Late complications such as infection or thrombus occur as a result of extended duration of use. Routine post-insertion chest x-rays (CXR) have become the standard of care to

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help combat early complications.8-11

Due to advancement of devices and insertion techniques, complication rates have steadily

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declined. It is now recommended that CVCs be placed using ultrasound guidance,

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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

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CXR were found to have related complications during their hospitalization. Of the 434

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patients who had a follow-up CXR, pneumothorax was documented in 0.4% 19. Routine imaging following CVC placement consumes valuable healthcare resources20. Many

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critical care and interventional radiology studies have challenged the use of routine CXRs21,22 in the absence of clinical signs of complications.

Performing a CXR after an operation where a CVC was placed is the standard of care despite the CVC having been used throughout the operation 23. Most major complications would be noted after CVC placement due to clinical deterioration18,24. The utility of this

ACCEPTED MANUSCRIPT practice has not been investigated. Here early complications of pre-operative CVC placement with post-operative CXR were retrospectively reviewed in patients undergoing pancreaticoduodenectomy (Whipple) operations. It was hypothesized that CVCs placed under ultrasound-guidance do not require routine post-operative CXR to rule out

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complications.

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Methods

Consecutive records from a pancreatic surgery registry were retrospectively reviewed to

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identify patients undergoing a Whipple procedure with CVC placement after induction of

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general anesthesia. Patients were excluded if they remained intubated post-operatively, as this would be a confounding reason for CXR. Portable anterior-posterior radiographs

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were routinely performed post-operatively to document CVC tip position and rule-out

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complications, and read onsite by board-certified radiologists. CVCs are placed at the discretion of the anesthesiologist and whenever vascular repair or reconstruction is

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anticipated.

The primary outcome was the incidence of pneumothorax or hemothorax. The secondary

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outcome was CVC tip position. Catheters were considered appropriately positioned if the tip of the catheter projected over the superior vena cava from the junction with the brachiocephalic vein to the junction with the right atrium. Radiology reports were reviewed for each patient to determine incidence of the outcomes. Reports not specifically documenting the presence of a pneumothorax or tip position were independently reviewed for this study by an attending radiologist (S.B.H.). All relevant

ACCEPTED MANUSCRIPT data were contained within an electronic medical record, and this was reviewed for operative or interventional procedures related to CVC insertion such as repositioning, chest tube placement, repair of arterial injuries, or pseudoaneurysms.

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Statistic methods:

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A one-sided analysis at α=0.05 and =0.2 was performed to estimate an

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appropriate sample size. The authors recognize the limitations of performing such a

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calculation in an non-interventional investigation, but for the purposes of exploring the objectives and promoting generalizability, the calculation was performed. Given 18.7%

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of patients had a pneumothorax or malpositioned line in a recent meta-analysis of 15 studies involving ultrasound guidance, and a historical complication rate of up to 30% in

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the absence of ultrasound guidance, an overall sample of 200 patients was

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determined 25.

Patient characteristics including age, sex, height, weight, puncture site and catheter

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type were calculated with means, standard deviation and percentages as appropriate. The relative risk calculation for malposition was calculated for catheter type, sex, height and

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BMI. . Using Hanley’s formula, the confidence interval for the primary outcome hemothorax/pneumothorax was determined.26. These values were calculated using SPSS.

A cost-allocation analysis was performed to estimate the associated healthcare costs of routine CXR after perioperative CVC insertion. The cost data were acquired from the

ACCEPTED MANUSCRIPT Department of Radiology and hospital billing records. This study was approved by the Columbia University Institutional Review Board.

CVC Insertion Technique

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The placement of CVCs by anesthesiology staff (lines are placed by residents with

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attending anesthesiologists in the operating room,) follows standard sterile technique

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published by Provonost and associates27. Ultrasound guidance for CVC insertion became routine departmental policy in 2010. In brief, using real time ultrasound guidance to

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confirm proper insertion, the needle is visualized entering the vein, and the wire passed.

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An introducer catheter is inserted, the wire removed, and extension tubing connected to establish a fluid column, further confirming venous placement. Finally, the CVC is

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inserted, secured, re-cleaned with chlorhexidine, and a sterile chlorhexidine impregnated

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dressing is placed.

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Results

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Consecutive pancreaticoduodenectomy procedures were retrospectively reviewed to identify 200 consecutive patients with CVC placement (115 women, 85 men) between

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2010 and 2015 who were extubated post-operatively. Insertion sites included the subclavian (2) and internal jugular veins (198). Catheters were primarily inserted on the right (98.5%). Three catheter types were placed (152, 46 and 2, respectively): multilumen central venous access catheters with introducer (AK-21142; Teleflex Morrisville, NC), double (DL)-or triple-lumen (TL) central venous catheters (AK-25802; Teleflex

ACCEPTED MANUSCRIPT Morrisville, NC) and percutaneous sheath introducer catheters (AK-09803; Teleflex Morrisville, NC).

Post-operative CXRs were obtained in 198 of the 200 patients. It was unclear from the

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medical record why no orders were written to obtain CXRs in two patients. There were 26

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no pneumothoraces or hemothoraces observed on post-operative CXR (0±0.015) .

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Review of electronic medical records further supported the imaging findings of no

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complications: no chest tube placements or vascular interventions were performed in any of these patients relating to CVC insertion. Thirty lines (15.3%) were improperly

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positioned; (95% confidence interval [CI], 10.1%-20.2%, P<0.001). The catheter tip was located at the level of the right brachiocephalic vein (17), in the right atrium (8), distal

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internal jugular vein (4), or directing in to the left brachiocephalic vein from a right

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subclavian access (1). Of these, only the latter was considered clinically significant and

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was repositioned after CXR in the post-anesthesia care unit. Lines were more commonly malpositioned in male and taller patients (Table 2). Not surprisingly, in taller patients

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(>170cm) with malpositioned lines, 83% (15 of 18) were too proximal. BMI and catheter

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type alone did not reach significance as risk factors for malpositioning.

Cost-Allocation Analysis An anesthesia administrative database was queried for CVC insertion during general surgery operative procedures. Thoracic, cardiac, trauma, transplant, vascular and reoperative procedures were excluded because indications for post-operative imaging differ. This review identified 1,204 instances over a 44-month period: more than one a

ACCEPTED MANUSCRIPT day for elective general surgery cases. According to institutional billing records, radiologic examination, chest; single view, frontal (CPT 71010) is billed at $474.17. Based on these estimates, the annualized cost allocation for CXRs following CVC insertion for elective general surgery cases was estimated at $155,700. The hospital may

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be reimbursed $7,543 considering 2017 Medicare reimbursement of $22.97 for this

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CPT28.

Discussion

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Performing a portable CXR is standard of care after central line placement in the

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operating room. Hospital records were reviewed to examine the incidence of early CVCrelated complications to ascertain the need for routine CXR, as well as the effect on cost.

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In 200 Whipple operations requiring perioperative central line insertion, no

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pneumothoraces or hemothoraces were identified.

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The rarity of these events is consistent with previous studies looking at ultrasound placed

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lines. In an investigation of 1,322 right IJ catheter insertions under ultrasound guidance in the ED, adult ICU and hospital ward, a pneumothorax rate of 0.1% was determined 29.

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Studies have looked at the role of CXR after lines placed under fluoroscopic guidance, finding routine CXR to be unnecessary. Keckler and associates looked at 237 central line catheters placed in OR under fluoroscopy. They found only 2 complications. Both were pneumothoraces, and one was observed and the other required a chest tube30.

ACCEPTED MANUSCRIPT We did find that 15% of central lines were malpositioned based on post-operative imaging. The only clinically significant line misplacement requiring adjustment was performed via the subclavian technique. Unless central access is needed for ongoing critical care, central lines are removed early in the post-operative period before late

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complications can occur. Therefore lines that were either proximal or distal to the ideal

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position at the superior cava-atrial junction were not repositioned. Based on our findings,

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patients taller than 170 cm were more likely to have misplaced lines. People with lower BMIs tended to have more misplaced lines, but this did not reach clinical significance.

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This indicates that individuals’ BMI and height be considered for optimal line placement.

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Based on previous studies the ideal depth for a right internal jugular line placement is 16cm ± 2cm31. As shown in the paper by Andrews et al., height correlated weakly with

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correct catheter distance, in fact, sex was more strongly correlated with correct insertion

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depth. Women were noted to have an average shorter insertion depth of 1.7cm. Given this information, we would recommend a right internal jugular placement with a depth of

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16cm.

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There are several limitations to the study. This is a retrospective chart review which is associated with data misclassification. Another limitation is that insignificant

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complications such as arterial punctures that were not documented in the medical record cannot be discussed; these were unlikely clinically relevant as they did not require intervention. Limitations regarding cost-allocation is that it only represents our institution and the impact may be more or less at different hospitals. Also, we cannot be sure that CXR in the cost allocation analysis was for other reasons than central line placement because we did not review those cases independently.

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Conclusions: -

Routine CXR after ultrasound guided right internal jugular central line placement is

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unnecessary, and consumes valuable resources. This practice should therefore be

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discontinued. Instead, post-operative CXR should be considered on a case-by-case

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cannot be drawn for subclavian line placement.

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basis where there is a concern guided by clinical parameters. These conclusions

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Corresponding author: Charles Randall Cooper [email protected]

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177 Fort Washington Ave. 7GS-313 NY,NY 10032

200

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%

Total

Female

115

57.5%

Male

85

42.5%

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Patients

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Table 1.

Age (yrs)

67.28 ± 9.77

Height

166.36 ±10.28

(cm) Weight (kg)

75.28 ± 16.32

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27.23 ± 5.0

(kg/m2)

Puncture Site 198

99%

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Internal

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Jugular 1%

Right Side

197

98.5%

Left sided

3

1.5%

Double

152

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Subclavian 2

76%

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Lumen

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Catheter Type

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with Introducer

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Catheter

46

23%

2

1%

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DL

Catheter

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/TL

Catheter Introducer Catheter

Table 2.

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Total Malpositioned RR(95% CI)

Catheter Type DL with

150

20 (13.3%)

--

TLC/DLC 46

9 (19.6%)

1.47 (0.71 to 2.99)

Female

115

10 (8.7%)

Male

85

20 (23.5%)

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Introducer

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Catheter

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2.54 (1.24 to 5.16)

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Patient

(cm)

113

11

--

72

18

3.53 (1.62 to 7.69)

8

2 (25.0%)

1.41

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<170cm

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height

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>=170cm

BMI

--

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Sex

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Patient

(cm/m2)

<20

(0.38 to 5.25) 20-24.99

62

11 (17.7%)

--

25-29.99

68

8 (11.8%)

0.66

ACCEPTED MANUSCRIPT (0.29 to 1.54) 30-34.99

30

4 (13.3%)

0.75 (0.26 to 2.17)

>35

17

1(5.9%)

0.33

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(0.05 to 2.39)

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Reference group indicated by (--)

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care unit? Am J Surg. 2000 Dec;180(6):517-21; discussion 521-2.

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chest radiograph necessary after central venous catheter placement in a surgical intensive

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[22] Graat ME,ChoiG,WolthuisEK,etal.Theclinicalvalueofdailyroutine chest radiographs

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Venous Access. Anesthesiology. 2012 Mar;116(3):539-73.

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[24] Caridi JG, West JH, Stavropoulos SW, Hawkins IF. Internal Jugular and Upper Extremity Central Venous Access in Interventional Radiology. American Journal of

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Roentgenology. 2000;174(2):363-366. doi:10.2214/ajr.174.2.1740363. [25] Ablordeppey EA, Drewry AM, Beyer AB, et al. Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients. Critical Care Medicine. December 2016:1. doi:10.1097/ccm.0000000000002188. [26] Eypasch, Ernst, et al. "Probability of adverse events that have not yet occurred: a statistical reminder." BMJ: British Medical Journal 311.7005 (1995): 619.

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[29] Hourmozdi, Justin J., et al. "Routine chest radiography is not necessary after

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ultrasound-guided right internal jugular vein catheterization." Critical care medicine 44.9 (2016): e804-e808.

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[30] Keckler, Scott J., et al. "Chest radiograph after central line placement under

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fluoroscopy: utility or futility?." Journal of pediatric surgery 43.5 (2008): 854-856. [31] Andrews, Robert.,et al . How much guidewire is too much? Direct measurement of

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the distance from subclavian and internal jugular vein access sites to the superior vena

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cava-atrial junction during central venous catheter placement. Critical care medicine.

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Acknowledgements:

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2000;28:138.

Funding: This research did not receive any specific grant from funding agencies in the

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public, commercial or not-for-profit sectors

ACCEPTED MANUSCRIPT Research Highlights: - Routine CXR is unnecessary after uncomplicated right internal jugular placement of central venous catheters under ultrasound guidance prior to operations - 97% of “malposition” lines were deemed clinically insignificant

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- Reduced Chest X-Ray after general surgery cases can mean significant cost savings to

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an institution.

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Keywords: Central line placement; Chest X-Ray, Post-operative imaging, Whipple

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Procedure