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Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access?
James E Janik1, C Clay Cothren, Joseph S Janik
1Department of Pediatric Surgery at The Children's Hospital, Denver, CO 80218, USA.
Insights
Routine chest x-rays after pediatric central venous catheter placement may not be necessary when intraoperative fluoroscopy is used. Fluoroscopy minimizes misplaced catheters and complications, with clinical signs often preceding radiographic findings.
Area of Science:
- Pediatric critical care medicine
- Vascular access procedures
- Radiological imaging in pediatrics
Background:
- Central venous catheter (CVC) placement is common in pediatric patients.
- Post-procedural chest x-rays (CXRs) are often performed to confirm CVC tip location and detect complications.
- Intraoperative fluoroscopy is increasingly used to guide CVC placement.
Purpose of the Study:
- To evaluate the necessity of routine post-procedural chest x-rays (CXRs) in pediatric patients undergoing central venous access.
- To determine if intraoperative fluoroscopy obviates the need for routine CXRs following central venous catheter (CVC) placement.
- To assess the incidence of CVC malposition and complications when intraoperative fluoroscopy is employed.
Main Methods:
- Retrospective chart review of pediatric patients undergoing subclavian or internal jugular CVC placement.
- Analysis of patient demographics, access site, procedural details, intraoperative fluoroscopy findings, and post-procedure CXR results.
- Correlation of CVC tip location and complications with the use of intraoperative fluoroscopy.
Main Results:
- A total of 1,039 CVCs were placed in 824 pediatric patients.
- Intraoperative fluoroscopy was associated with a significantly lower rate of misplaced central venous catheters (0.1% vs. 1.1%).
- Pulmonary complications (pneumothorax, hemothorax, effusion) occurred in 0.9% of cases, with clinical signs preceding CXR findings in all instances.
Conclusions:
- Intraoperative fluoroscopy effectively minimizes central venous catheter malposition in pediatric patients.
- Routine post-procedure chest x-rays may be unnecessary for pediatric patients undergoing central venous access with intraoperative fluoroscopy.
- Chest x-rays should be reserved for cases with clinical suspicion of complications following central venous catheter placement guided by fluoroscopy.
Purpose:
The aim of this study was to determine in a pediatric population whether a routine chest x-ray after central venous access is necessary when the central venous catheter is placed with intraoperative fluoroscopy.
Methods:
This was a retrospective review of the charts of all patients at Children's Hospital in Denver, Colorado who underwent subclavian or internal jugular central venous catheter placement from January 1, 1998 through December 31, 2001. Age, sex, primary reason for access, access site, number of venipuncture attempts, type of catheter, intraoperative fluoroscopy results, chest x-ray results, location of the tip of the catheter, and complications were analyzed.
Results:
There were 1,039 central venous catheters placed in 824 patients, 92.6% in the subclavian vein and 7.4% in the internal jugular vein. There were 604 (58.1%) children who had both fluoroscopy and a postprocedure chest x-ray, there were 308 (29.6%) who had only fluoroscopy, there were 117 (11.3%) who had only a postprocedure chest x-ray, and there were 10 (1.0%) who had neither fluoroscopy nor chest x-ray. On completion of the procedure, there were 12 (1.1%) children with misplaced central venous catheters, only 1 (0.1%) when intraoperative fluoroscopy was used. There were 17 (1.6%) complications; 9 (0.9%) were pulmonary (pneumothorax, hemothorax, or an effusion). All children with pulmonary complications experienced clinical signs and symptoms suggestive of the complication after their central venous catheter insertion but before their postprocedure chest x-ray.
Conclusions:
The number of complications encountered in children who had central venous access of the subclavian vein or internal jugular central vein with intraoperative fluoroscopy was infrequent, the number of misplaced catheters was minimized with intraoperative fluoroscopy, and all children with pulmonary complications showed clinical signs suggestive of pulmonary complications before postoperative chest x-ray. Therefore, children who have had central venous access of the subclavian and internal jugular vein with intraoperative fluoroscopy do not appear to require a routine chest x-ray after catheter placement unless clinical suspicion of a complication exists.