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1 All authors: Department of Radiology, University of Florida College of Medicine, 1600 S.W. Archer Rd., Gainesville, FL 32610.
Received May 7, 1999;
accepted after revision July 13, 1999.
Address correspondence to J. G. Caridi.
Abstract
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SUBJECTS AND METHODS. A prospective study of 937 consecutive central venous access procedures in interventional radiology using the internal jugular veins or upper extremities was performed from June 1995 through September 1997. Established interventional radiologic techniques were used to place various ports (n = 34) and tunneled (n = 670) and nontunneled (n = 233) catheters. All catheters were positioned using fluoroscopy and readjusted if necessary before termination of the procedure. Afterward, a chest radiograph was obtained with the patient upright to evaluate catheter position and possible procedural complications. Procedural complications and manipulations or interventions that resulted from the radiographic findings were noted. In addition, nursing time for acquisition of the chest radiograph was recorded.
RESULTS. We found seven procedural complications (four air emboli, two pneumothoraces, one innominate vein laceration) significant enough to alter the patient's treatment. These complications were apparent during the examination. Postprocedure chest radiography failed to reveal any unknown complications and revealed only one catheter sufficiently malpositioned to require manipulation. The amount of nursing time to acquire postprocedure chest radiographs ranged from 8 to 40 min (mean, 23 min) per patient.
CONCLUSION. When imaging guidance and interventional radiologic techniques are used for upper extremity and internal jugular central venous access, performing postprocedure chest radiography yields little benefit.
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With the advancement of interventional radiology, it became evident that the techniques used for other procedures could be applied to central venous access. Interventional radiologists used these techniques and imaging guidance, both sonographic and fluoroscopic, to refine the approach to central venous access; with time, interventional radiologists were able to perform central venous access more safely, accurately, and expediently and with greater convenience and less cost to the patient [4, 5, 6, 7, 8]. Although imaging is currently used by many interventional radiologists for access and catheter positioning, the tradition of obtaining a postprocedure chest radiograph persists in many institutions. In our anecdotal experience, review of chest radiographs did little to improve patient treatment. Furthermore, because patients undergoing venous access were sedated during the procedure, an inordinate amount of nursing time was usurped for the mandated monitoring of the patient during acquisition of the chest radiograph. In our busy central venous access practice, we noted that this use of nursing staff substantially affected the availability of the nursing staff for other procedures. Consequently, we prospectively evaluated the usefulness of obtaining a postprocedure chest radiograph.
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Before venous access, sonography was performed (Sonolayer SSH-140A, Toshiba America Medical Systems, Corrollton, TX; or SiteRite II, Dymax, Pittsburgh, PA) to assess both the size and viability of the desired vein. For peripherally inserted central catheters, either the basilic or cephalic veins above the antecubital fossa were used. For all other lines, the right internal jugular was the vein of choice. If this vein was unacceptable, the left internal jugular vein was chosen. Venous access was achieved with direct sonographic guidance using a 21-gauge needle (Micropuncture set; Cook Critical Care). This 0.018-inch wire was upsized to a 0.035-inch guidewire (Rosen wire; Cook Critical Care) and the venotomy dilated to the appropriately sized peel-away sheath (if necessary). As the Rosen wire was removed from the peel-away sheath, the distance from the right atrium—superior vena cava junction to the venotomy site was measured using two hemostats. This distance was used to determine the length of the catheter or subcutaneous tunnel or both depending on the type of catheter being used. We placed the more distal tip of a tunneled silicone rubber catheter from 1 to 2 cm into the right atrium depending on the patient's body habitus. In female and heavy-chested male patients, the catheter tip was inserted an additional 1-2 cm within the right atrium. This technique was also used for implantable ports. For stiffer polyurethane nontunneled catheters, we attempted to place the catheter tip at or above the right atrium—superior vena cava junction.
When a subcutaneous tunnel was required, a Hawkins blunt needle (MD-Tech, Gainesville, FL) was used. The obturator of the needle was removed and a Rosen wire was placed through the needle. The needle was then removed and an appropriately sized peel-away sheath was placed subcutaneously [9]. The catheter was then inserted through this sheath and the sheath was removed. We routinely positioned the Dacron (DuPont, Wilmington, DE) cuff of the catheter approximately 2 cm farther (centrally) within the tunnel than originally calculated. Consequently, if the catheter became kinked, it could be withdrawn slightly to reduce the kink without sacrificing optimal positioning of the catheter tip. The central placement of the cuff was also beneficial if catheter length had been underestimated. If a miscalculation had occurred, withdrawing, rather than advancing, a cuffed catheter was always easier. After the catheter was positioned subcutaneously, the patient was instructed to suspend respiration. The obturator was removed from the venotomy peel-away sheath and the central venous access catheter was immediately inserted. During this maneuver, the sheath was pinched in an attempt to prevent air embolus. Neither a subcutaneous tunnel nor a peel-away sheath was used for nontunneled catheters.
Before the catheter was secured, fluoroscopy was performed to assess the position of the catheter tip. If necessary, adjustments were made accordingly. Procedural complications were treated and recorded. The patient then underwent expiratory chest radiography, which was performed with the patient erect. Nursing assistance was also necessary for postsedation monitoring. The time required to accompany and monitor the patient was documented. Chest radiographs were evaluated for postprocedure complications and malposition. Malposition was defined as a catheter tip being positioned in the proximal superior vena cava or the mid to distal right atrium.
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The postprocedure chest radiograph did not expose any complications that were not already known at the time of the procedure. Furthermore, the evaluation of chest radiographs for the catheter tip placement led to the repositioning of only one catheter (0.1%); this catheter had been placed in a 2-month-old male infant who had undergone placement of a nontunneled line using a low right internal jugular vein approach. This catheter was replaced with a peripherally inserted central catheter using the basilic vein approach. None of the remaining catheters required additional manipulation. The amount of nursing time required to assist and monitor the patient for the postprocedure chest radiograph to be obtained ranged from 8 to 40 min per patient, with an average of 23 min per patient.
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With the advent of refined imaging and percutaneous techniques, central venous access procedures became more commonly performed by interventional radiologists [4, 5, 7, 8, 9, 14, 15]. Several authors have shown that interventional techniques in combination with imaging guidance can provide more accurate and expedient central venous access at a lower cost and with fewer acute and chronic complications [4, 5, 6, 7, 8]. Sonographic guidance using the right internal jugular approach expedites access and reduces the potential for pneumothorax and arterial puncture [7]. Using fluoroscopy with any one of a number of measuring techniques assists in the precise placement of central venous catheters. When these techniques are used by experienced interventionalists, the rate of procedural complications is minimal [4, 14]. In our practice, we found these assertions to be true so we placed little emphasis on, but continued to obtain, a postprocedure chest radiograph. Because all our central venous access patients received some degree of conscious sedation, department policy mandated that a nurse accompany these patients when chest radiography was performed. Whereas we might not have been aware of the additional cost for the chest radiograph to be obtained per patient, which Chang et al. [16] estimated to be $34.58 per patient, we did note the unavailability of nursing staff, who we determined were absent an average of 23 min for each central venous catheter placement, and raised the question of the necessity of a postprocedure chest radiograph. Therefore, we evaluated the necessity of obtaining a chest radiograph in this population during the next 27 months. Our methods were similar to those of Chang et al. in that we both used sonography and fluoroscopy for the placement of each central venous catheter and also reviewed the necessity of postprocedure chest radiography. Our protocol differed from that of Chang et al. in that we not only performed a prospective analysis but also included all accesses from the upper extremities and neck. Although Chang et al. did not include their experience with subclavian vein access, we have not performed any access procedures using this route for 5 years. Also, the impetus for our study was not cost savings, but time savings as measured by the loss of valuable nursing services. Because our ancillary services are limited, when nurses accompany our central venous access patients for chest radiography they are unavailable to perform other patient preparation services that are essential for time-efficient service. Furthermore, despite our initial motive, a cost analysis by our institution showed that the elimination of the postprocedure chest radiograph provides a savings of $38.45 in actual and indirect costs and an additional saving of an average of $25.72 in nurse and technologist time.
Chest radiographs obtained after various central venous access procedures in 937 patients disclosed one unexpected finding (0.1%) that led to additional treatment. All other complications were evident during the procedure. Three complications may have been avoided with more meticulous imaging. The rate of pneumothorax rate was 0.21% (excluding peripherally inserted central catheters), which is within the range of 0-2.5% reported by other authors using similar interventional radiologic techniques [4, 12]. During subsequent procedures, we used Trendelenburg's position and filled the peel-away sheath with saline while removing the obturator; as a result, our rate of air embolus decreased to 0%. Because we used the techniques noted previously and made minor adjustments to catheter position before fixation, only one patient had to return to the interventional suite for catheter repositioning. Similar results have been corroborated by other authors [16, 17].
The facts noted previously do not deny the observation of catheter migration when the patient is moved from the supine to the upright position for the chest radiograph. While placing central venous catheters, we assumed that at least 1-4 cm of migration might occur depending on the body habitus and sex of the patient. We adjusted the placement of the catheter tip depending on several variables. If the catheter was polyurethane and nontunneled, we placed it above the right atrium—superior vena cava junction to avoid atrial erosion and cardiac tamponade [18]. Tunneled Silastic catheters were typically placed 1-2 cm into the right atrium unless the patient was heavy or female. For these patients, we assumed retraction would be greater than in other patients and inserted the catheter another 1-2 cm into the atrium. We did the same for implantable ports because they are typically heavier than most catheters. As we stated in the Subjects and Methods section, we also calculated in 1-2 cm of latitude by initially placing the Dacron cuff more centrally than necessary within the subcutaneous tunnel. If the catheter tip was too deep, it could easily be retracted peripherally. Currently, no significant untoward events have precluded the placement of softer Silastic catheters within the right atrium. In addition, other than using peripherally inserted central catheters, we limited our access to the internal jugular vein to reduce the occurrence of malpositioning as well as acute and chronic complications that are more commonly associated with the subclavian route [3, 19, 20].
Since our series was completed, two studies have been published that support our experience regarding catheter migration. In one study, investigators concluded that catheter migration averages 3.2 ± 1.8 cm when the patient moves from the supine to the upright position [21]. In another study, authors found the potential for migration to be less likely from an internal jugular approach and more likely to occur in females and obese individuals [22]. If these facts are considered prospectively and appropriate adjustments implemented at the onset of and during the procedure, positional migration should not lead to malposition or nonfunction of the catheter. If imaging and interventional techniques can reduce malposition and unexpected complications, the clinical value of obtaining a postprocedure chest radiograph is questionable.
Arguments have been raised about the cost and charging policies for imaging guidance [23]. The necessity for conscious sedation and a nurse escort may also be debated. Irrespective of these arguments, we found the significance of the routine postprocedure chest radiograph as it relates to patient treatment to be inconsequential when central venous access is performed with prudent percutaneous and imaging techniques.
Obtaining a chest radiograph adds cost to the procedure and misallocates the use of nursing and technical staff. Consequently, it may be time- and cost-efficient to limit postprocedure chest radiography to only selective difficult or high-risk patients. Because of our results, we have eliminated the routine use of the postprocedure chest radiography in patients who undergo upper extremity or internal jugular central venous access if the catheter is placed using interventional radiology techniques.
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