Scientific paper

Routine chest roentgenogram after central venous catheter insertion isnot always necessary

Alvaro Sanabria, M.D.a,*, Carlos Henao, M.D.a, Romulo Bonilla, M.D.a,Carlos Castrillon, M.D.a, Herman Cruz, M.D.a, William Ramırez, M.D.a,

Pablo Navarro, M.D.a, Mercedes Gonzalez, M.D.a, Abel Dıaz, M.Sc.b

aDepartment of Surgery, School of Medicine, University of Antioquia, University Hospital San Vicente de Pau´l, Apartado ae´reo 1226, Postal 229Ciudad Universitaria, Medellı´n, Colombia

bMedical Research Center, School of Medicine, University of Antioquia, University Hospital San Vicente de Pau´l, Ciudad Universitaria,Medellın, Colombia

Manuscript received May 17, 2002; revised manuscript November 2, 2002

Abstract

Background: To evaluate the usefulness of routine radiologic control after the insertion of a central venous catheter as a tool that mightmodify treatment of patients.Methods: A prospective study was made of 149 patients submitted to central venous catheter insertionResults: In 55% of the patients the roentgenogram showed an adequate placement of the catheter tip and in 3.6% it showed some abnormalfinding. Ten modifications were carried out based on the radiologic results. The prolonged partial thromboplastin time value and thesubjective degree of difficulty showed a statistical relation to the appearance of complications. The number of punctures above one relatedto abnormal radiologic findings.Conclusions: The results suggest that routine chest radiology after the insertion of a central venous catheter is not always necessary andthat it should be ordered selectively, according to the findings made during the procedure and the subjective degree of difficulty. © 2003Excerpta Medica, Inc. All rights reserved.

Keywords:Central venous catheter; Chest roentgenogram; Selective radiologic control

The insertion of central venous catheters is a commonprocedure in large medical attention centers of the world.The Food and Drug Administration [1] reports that nearly 3million central venous catheterizations are performed annu-ally owing to the extensive range of indications. This pro-cedure is not exempt from complications, however, such asincorrect positioning of the catheter, hemothorax, pneumo-thorax, arterial and venous laceration, perforation of medi-astinal vessels or of heart cavities, severe heart rhythmdisorders, and embolisms of the guidewire or the catheter.Nevertheless, the rate of these complications is low, withreports in the literature oscillating between 1% and 2.5%[2,3].

Several years ago, the FDA recommended obtaining achest roentgenogram after the insertion of the catheter [1].

That makes it possible to guarantee that the tip is neitherlocated intracardiacally nor in peripheral vessels and toreach an early detection of such complications as bleedinginto pleural cavities, widening of the mediastinum, and thesecondary presence of a pneumothorax after a puncture ofthe lung apex. This conduct should potentially diminish theglobal rate of mechanical catheter complications.

Considering the low complication rate and the capacityof experienced personnel to clinically detect complicationsduring the procedure by means of simple semiological ma-neuvers like the auscultation of lung fields and measuringthe pulse and arterial pressure after the procedure thatclearly suggest the presence of such adverse events andconsidering that control roentgenograms rarely generatetherapeutic changes [4,5], we decided to evaluate the use-fulness of routine radiologic control after the insertion of acentral venous catheter as a tool that might modify treat-ment of patients, and analyze the data of the patient, the

* Corresponding author. Tel.: �51-4-212-9912; fax: �51-4-212-9912.E-mail address:asanabriq@hotmail.com

The American Journal of Surgery 186 (2003) 35–39

0002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved.doi:10.1016/S0002-9610(03)00122-3

surgical procedure, and the operator that can predict theoccurrence of complications and could suggest a selectiveradiologic control.

Patients and methods

A prospective, descriptive study was carried out during aperiod of 16 months, beginning in October of 1999, in afirst-level university hospital. The research was approved bythe Ethics Committee of the hospital. The data obtainedcame from all patients who had central venous cathetersinserted by any of the members of the general surgery andtrauma services, including interns, residents, and specialists.Exclusion criteria were procedure performed by a serviceother than that of general surgery, insertion of catheterthrough peripheral vein, and change of catheter over theguidewire.

Having obtained an informed consent, the insertion ofthe catheter was performed through the subclavian or inter-nal jugular using Seldinger’s method with a standardizationof the technique that included the following: Trendelen-burg’s position; asepsis of the operating field; infiltrationwith lidocaine at 1%; infraclavicular puncture at the junc-ture of the medial one third and the lateral two thirds and ata 45-degree angle relative to a line perpendicular to theclavicle for the subclavian puncture or in the union of thesternal and clavicular shafts of the sternocleidomastoidmuscle at an angle of 30 degrees for the case of a jugularpuncture; entry in a sternoclavicular direction or toward theopposite nipple under constant aspiration until venous bloodwas obtained; passing of metallic guidewire, withdrawal ofpuncture needle, enlargement of puncture route, passing ofcatheter over the guidewire at an average distance of 17 cm,withdrawal of guidewire; confirmation of catheter positionby means of aspiration of venous blood; intravenous liquidadministration; confirmation of venous return by gravity;and fixation of catheter with nonabsorbable sutures [6].

After finishing the procedure a portable chest roentgen-ogram was made, or one using standard techniques, in orderto verify catheter tip placement.

Variables were collected on a predefined form as fol-lows: age, sex, indication, diagnosis, classification of theAmerican Society of Anesthesia (ASA), prothrombin time(PT) and partial thromboplastin time (PTT), platelet count,access route and side, number of catheter lumens, operator,subjective degree of difficulty, number of punctures, causeof difficulty, intraoperative complication, radiologic place-ment of catheter tip, pathologic radiologic findings, thera-peutic change after radiology, and time of catheter perma-nence. The PT and PTT values and the platelet count wereassigned thus: PT � normal up to 13 s; PTT � normal upto 32 s; and platelets � low from 0 to 150,000, normal from150,001 to 400,000, and high �400,000. The decision toinsert the catheter without previous coagulation tests and

platelet counts depended exclusively on the surgeon’s cri-terion.

Intraoperative complications and radiologic findingswere defined thus: arterial puncture—evidence of a brilliantred bleeding of a pulsatile type during aspiration; impossi-bility of inserting catheter in the vein—impossibility ofvenous puncture after multiple attempts; embolization ofguidewire—loss of control of guidewire by its total intro-duction throughout the system; serious arrhythmias—ar-rhythmias that required specific pharmacological manage-ment or defibrillation; venous perforation—loss ofcontinuity of venous wall as shown through angiography;heart perforation—detected by angiography or during au-topsy; hemothorax— radiologic opacity of ipsilateral hemi-thorax; pneumothorax—ipsilateral extrapleural air; medias-tinal widening—mediastinum width over 8 cm; and death—derived directly from procedure.

The classification of the degree of difficulty was subjec-tively divided into three groups: easy, moderately difficult,and extremely difficult. The chest radiology result was tran-scribed literally from the report made by the radiologist thenon duty. Length of stay, therapeutic changes, evolution, andcomplications were obtained from patient follow-up duringstay in hospital. According to their degree of experience,operators were grouped subjectively as low level (interns,first- and second-year residents) and high level (third-andfourth-year residents and specialists). Patient diagnoseswere grouped into categories, according to their frequency.

Statistical analysis

Qualitative variables were presented by frequency tables,and quantitative ones by mean and standard deviation ormedian and quartile distribution in cases of nonnormal dis-tribution. Univariate analysis were made with the chi-squaretest and Fisher’s test for nominal variables and with theStudent t test and the Kruskal-Wallis test for numericalvariables, considering a value of P � 0.05 as statisticallysignificant. A logistic regression analysis was carried outwith those variables statistically significant. Because degreeof difficulty was a subjective variable, a correlation analysiswith number of punctures was carried out using Spearman’stest. The EPI INFO 6.0 and STATA 6.0 software wereutilized for these analyses

Results

Information on a total of 171 patients was collected, 22of whom were excluded because of the impossibility ofobtaining sufficient data, thus reaching an analyzable totalof 149 patients.

The mean age was 50 years � 23 (15 to 96). Of thepatients, 61% (91) belonged to the female sex. A widevariety of illnesses had indications for catheter placement.The most commons were intraabdominal diseases, hemato-

36 A. Sanabria et al. / The American Journal of Surgery 186 (2003) 35–39

logic malignancies, and trauma. All of them were predom-inantly related to the impossibility of achieving peripheralvenous access, parenteral nutrition, central venous pressuremeasurement, and deliverr of chemotherapy. In 115 patients(77%) the ASA classification score was III or less.

Hematologic values

In 33 patients (22%), the catheter was placed withoutprior PT and PTT measurements. In the others, the PT valuewas 14.1 s � 2.6 s (9.7 s to 27.3 s), while PTT was 31.7 s� 10.6 s (9.7 s to 99.9 s). Seventy patients (60%) hadprolonged PT values and 44 patients (38%) had prolongedPTT values. In 16 cases (11%) the catheter was installedwithout previous platelet count measurement; in the remain-ing cases this value was 259,894 � 172,383 platelets (1,000to 847,000). Forty patients (30%) had low counts.

Access was subclavian in 95% of the cases; on the rightside in 89% of the patients. A single-lumen catheter wasinstalled in 9% (13) of the patients; in 50% (75), a double-lumen catheter was installed, and in 41% (61), a triple-lumen catheter.

Distribution according to operator was divided thus: 3%(4) interns; 29% (43), first-year residents; 4% (6), second-year residents; 19% (28), third-year residents; 31% (47),fourth-year residents, and 14% (21), specialists.

Among the cases, 67% (100) were considered subjec-tively easy, 22% (32) moderately difficult, and 11% (17)extremely difficult. The number of punctures was 2.1 � 1.6(1 to 9). Among the patients, 49% (73) had more than onepuncture.

Spearman’s correlation analysis between the number ofpunctures and the subjective perception of degree of diffi-culty showed a rho of 0.83.

Of the 49 patients (33%) considered difficult duringinstallation, there were 2 patients for whom no informationregarding the cause of the difficulty was obtained; in 10cases there was more than one cause of difficulty, withresistance to passing being the most common of all. Distri-bution according to cause of difficulty can be observed onTable 1.

Intraoperative complications

There were 14 (9%) complications: 9 arterial punctures,3 cases in which it was impossible to insert the catheter, 1embolism of the guidewire, and 1 hematoma at the puncturesite. Two late complications occurred that were not detectedby control chest roentgenogram, a pneumothorax and ahemothorax 24 hours after the catheter insertion.

Radiologic findings

There were 5 instances of patients (3%) for whom nochest radiologic report was available. In one particular caseno roentgenogram was made, in spite of it having beenordered; however, the catheter was utilized during 4 dayswithout showing any evidence of complications. There wasanother patient with an incomplete radiologic report. The 3remaining patients died as a result of their main pathology,without any radiologic control having been possible. Table2 shows location in the remaining 145 patients, according toreports of radiologists then on duty. The normal location ofthe catheter tip was taken to be the superior vena cava, aswas the case in 79 patients (55%). Abnormal radiologicfindings were 4 cases of pneumothorax (3%) and 1 hemo-thorax (0.6%), for a total of 3.6% complications detected byradiology.

Therapeutic modifications

A total of 10 (7%) therapeutic modifications took place,9 of which directly derived from the radiologic result: 5chest tubes; 4 relocations of catheters that were previouslyin the internal jugular vein, right ventricle, subclavian vein,opposite subclavian vein and inferior vena cava; and 1extraction of guidewire by means of a endovascular inter-vention. Although 66 patients had an abnormal placementof the catheter tip, only 4 (6%) therapeutic changes wereperformed based on the radiologic results, and in the re-maining patients the catheter was utilized in spite of itsbeing abnormally located, with no evidence of complica-tions.

Table 1Cause of difficulty in passing the catheter

Cause Number %

Resistance to passing 13 28Obesity 8 17Deforming equipment 8 17Lack of patient collaboration 6 13Other 6 13Impossibility of recumbent position 1 2Shock 2 4Costoclavicular narrowness 3 6

Table 2Radiological localization of catheter tip

Location Number %

Superior vena cava 79 55Right atria 46 32Subclavian vein 4 3Jugular internal vein 5 3Right ventricle 3 2Other 8 5

37A. Sanabria et al. / The American Journal of Surgery 186 (2003) 35–39

Permanence of catheter

For 11 patients (7%) no information was obtained. In theother 138 cases, the length of catheter permanence was 13� 12.9 days (1 to 90).

Univariate analysis has found statistically significant dif-ferences between the global number of intraoperative com-plications and the value of prolonged PTT (P � 0.005, oddsratio [OR] 6.5 [1.4 to 33.3]), low platelet count (P � 0.005,OR 7.44 [1.6 to 37.9]), operator with a high degree ofexperience (P � 0.004, OR 7.5 [0.9 to 162.3]), difficultcatheterization (P � 0.001, OR 16.5 [2.15 to 347.9]), andnumber of punctures above 1 (P � 0.001, OR 35.3 [4.5 to750.4]).

The number of punctures above 1 during the process ofinserting the catheter had a statistically significant valuewith regard to pathological radiologic findings (P � 0.02,OR 5.1 [0.97 to 32.1]).

No statistically significant difference was found betweena catheter installation without a value of PT (P � 0.1), PTT(P � 0.1), and platelets (P � 0.1), and intraoperative com-plications. Since there were complications of a hemorrhagictype only in 2 cases (intraoperative hematoma and hemo-thorax), it was not possible to carry out analyses of sub-groups with prolonged PTT and low platelet counts.

Logistic regression analysis identified the value of PTTand the subjective degree of difficulty as the independentvariables for the development of complications.

Comments

Central venous catheterization is a common procedure insurgical services throughout the world, owing to its amplenumber of indications. In spite of being a relatively simpleprocedure, the seriousness of some complications is thereason why these patients need strict evaluation. Since1989, the FDA has recommended the utilization of routinechest radiology after the insertion of a central venous cath-eter in order to determine the position of the tip and to detectthoracic complications deriving from the procedure. Severalauthors had previously suggested that an abnormal cathetertip position was related to the development of mechanicalcomplications [7–10]. In these cases, a roentgenogramwould permit a quick identification of the abnormal positionand its correction. Secondarily, it would also show thepresence of hemothorax or pneumothorax, mediastinal wid-ening, or other thoracic findings suggesting complications.

Notwithstanding this recommendation, some surgicalgroups have tried to establish a more selective indication forradiology after central venous catheter insertion [5,11,12]based on a premise according to which other clinical toolsexist that provide easy detection of mechanical complica-tions and depend on some characteristics proper to thepatient, the procedure, and the experience of the operator. Itwas the objective of this study.

Some particular characteristics must be kept in mindwhen establishing comparisons with other populations, asfewer than 9% of the insertions took place during emergen-cies, which increases the risk of mechanical complications[13]. In univariate analysis, the factors showing statisticalsignificance for intraoperative complications were pro-longed PTT, low platelet count, subjective perception ofdifficulty, number of punctures above 1, and an operator’shigh degree of experience.

Although in the present study a prolonged PTT and a lowplatelet count are risk factors for any complication, it wasnot possible to show an association between these factorsand hemorrhagic complications. There are studies withsmaller sample sizes in which it is concluded that thrombo-cytopenia is not a risk factor for hemorrhagic complications[14]. Besides, the present study’s finding of an equal num-ber of complications in patients with and without coagula-tion tests prior to the procedure confirms the results ob-tained by other authors [15].

Although there is no concrete explanation for a majorrisk of complications after central venous catheterizationwhen peformed by operators belonging to the group withgreater experience, a relation was found between the oper-ator’s higher degree of experience and a low platelet count,suggesting that highly experienced operators perform alarger number of catheterizations in difficult cases. This is inopposition to reports in the literature, according to which theexperience of the operator diminishes the risk of complica-tions. There are even reports of an existing risk increasewhen the operator has performed fewer than 50 centralvenous catheterizations [16].

The subjective perception of difficulty had a correlationwith the number of punctures, a risk factor for complica-tions. This shows that, after having completed the proce-dure, the surgeon can determine its degree of difficulty andalso whether it is necessary to have a chest roentgenogramtaken. The most frequent among the causes of difficultywere resistance to passing and equipment deformation, in-traoperative findings that can suggest the convenience oftaking chest roentgenograms.

An intraoperative complication rate of 9% is high incomparison with that of other reports, but we includedartery punctures, which are usually unreported in publishedarticles [2,4,12,15,17–19]. Likewise, abnormal radiologicfindings requiring specific surgical management were ap-proximately 3%, similar to reports in the literature. Thisindicates that 97% of the roentgenograms showed no ab-normal findings and that among these only in 4 cases (3%)was a therapeutic change made regarding the placement ofthe tip. In the present study, 45% of the catheters wereabnormally located, a finding lying below the 59% reportedby Langston [17]. In spite of this, only in 4 cases was thelocation of the catheter changed. Those that were not relo-cated did not show a greater number of complications,which suggests that verifying the location of the catheter tipshould not justify doing routine radiologic control. Several

38 A. Sanabria et al. / The American Journal of Surgery 186 (2003) 35–39

patients in this study received treatment with catheters lo-cated in anomalous positions, without any secondary com-plication being found.

In spite of an early normal chest roentgenogram, two latecomplications were clinically detected in this study. Thisfinding reinforces the concept that it is the clinical follow-upof the patient that permits detection of these adverse events,since a normal initial roentgenogram does not necessarilydiscard them.

Based on the results of this study it can be concluded thatchest radiology after central venous catheterization as aroutine procedure is not fully justified. The clinical appre-ciation of the operator facilitates early detection of compli-cations, and the operator could selectively ask for the con-trol chest roentgenogram. In cases in which risk factorsintervene, such as alterations of coagulation tests (pro-longed PTT and low platelet count), number of puncturesabove 1, subjective perception of difficulty in making thecatheter pass, and intraoperative findings suggesting com-plications, a control chest roentgenogram would be indi-cated. Had this strategy been applied—having as the indi-cation for chest roentgenogram the finding of two or morepredicting factors—the number of roentgenograms wouldhave decreased by 40%, which represents a considerablesaving for the institution. A prospective comparative studyis necessary, however, in order to validate these risk factorsas predictors of the need for a control chest roentgenogram.

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