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Routine Chest Radiographs in Children After Image-Guided Central Lines Offer Little Diagnostic Value
Aaron J Cunningham1, Meredith B Haag2, Kristen V McClellan2
1Department of Surgery, Oregon Health & Science University, Portland, Oregon.
Insights
Routine postoperative chest X-rays (CXRs) after central venous line (CVL) placement in children provide minimal value. A clinical symptom-driven approach reduces CXRs without missing complications.
Area of Science:
- Pediatric Radiology
- Interventional Radiology
- Medical Imaging
Background:
- Central venous line (CVL) placement is common in pediatric patients.
- Postoperative chest radiographs (CXRs) are often performed after CVL placement.
- The utility of routine postoperative CXR after image-guided CVL placement requires investigation.
Purpose of the Study:
- To evaluate the effectiveness of postoperative chest radiographs (CXRs) following image-guided central venous line (CVL) placement in children.
- To compare a clinically driven approach to postoperative imaging versus routine imaging.
Main Methods:
- Retrospective review of 1080 tunneled CVLs placed in 915 pediatric patients (2010-2017).
- Subgroup analysis comparing clinically driven imaging versus routine postoperative imaging.
- Assessment of CXR sensitivity, specificity, and predictive values for detecting complications.
Main Results:
- Of 892 postoperative CXRs, 4.5% showed abnormalities, with low rates of false positives (1.3%) and false negatives (0.6%).
- CXR sensitivity for complications requiring intervention was 50.0%, with a negative predictive value of 99.6%.
- A clinically driven approach reduced CXR use by 41% without increasing missed complications.
Conclusions:
- Routine postoperative CXR after image-guided CVL placement in asymptomatic children has minimal value for detecting complications.
- A clinical symptom-driven approach to postoperative imaging is recommended, potentially reducing unnecessary radiographic procedures.
Background:
The aim of this study was to investigate the utility of postoperative chest radiograph (CXR) after image-guided central venous line (CVL) placement in children.
Methods:
A retrospective review was conducted of all tunneled CVLs placed at two pediatric institutions from 2010 to 2017. A subgroup analysis comparing a clinically driven approach to postoperative imaging against routine imaging was performed.
Results:
During the study period, 1080 lines were placed in 915 patients. There were 892 postoperative CXRs (82.6%). An abnormality was seen on 40 radiographs (4.5%, n = 891), with 16 false-positive (1.3%) and 5 false-negative (0.6%) CXRs. The sensitivity and specificity of CXR to identify complications requiring intervention were 50.0% (95% confidence interval [95% CI], 10.0-90.0) and 95.8% (95% CI, 94.5-97.1), respectively. Positive predictive value of CXR was 7.5% (95% CI, 0-15.7) with a negative predictive value of 99.6% (95% CI, 99.2-100). A clinically driven approach to postoperative imaging was associated with 41% decrease in CXR (P < 0.001) without increased incidence of missed complications. Only three complications requiring intervention (0.3%) were suspected on postoperative CXR alone, and all of those were symptomatic before intervention.
Conclusions:
Routine postoperative CXR offers minimal value in identifying technical complications requiring intervention after image-guided CVL placement in asymptomatic children. We recommend abandoning this practice in favor of a clinical symptom-driven approach to postoperative imaging.
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