Is routine chest radiograph necessary after chest tube removal?

Background

Obtaining a chest radiograph (CXR) after chest tube (CT) removal to rule out a pneumothorax is a universal practice. However, the yield of this CXR has not been well documented. Additionally, most iatrogenic pneumothoraces resulting from CT removal are atmospheric in origin, asymptomatic, and can be observed. Recently, we have begun to discontinue routine CXR for CT removal. We evaluated our experience with CT removal to clarify the usefulness of routine post CT removal CXR.

Methods

After IRB approval, a retrospective study was conducted on patients who had a CT placed in the past decade. Cardiac patients requiring a CT were excluded. Patient demographics, diagnosis, treatments, and outcomes were collected. Patients were divided into two groups, those with a CXR after CT removal (Group 1) and those without (Group 2). Percentages were compared with Chi square with Yates correction.

Results

462 patients were identified (group 1 = 327, group 2 = 135). Indications for CT included; empyema (n = 176), lung resection (n = 146), pneumothorax (n = 71), pleural effusion (n = 26), spinal fusion (n = 20), trauma (n = 16), and miscellaneous (n = 7). Seven patients (2.1%) in group 1 required reinsertion for pneumothorax (n = 4), empyema (n = 2), and pleural effusion (n = 1) compared to 1 patient (0.7%) in group 2 who required reinsertion for pleural effusion. This difference was not significant (P = 0.2).

Conclusions

In non-cardiac patients with a CT, tube reinsertion is uncommon and tube replacement is secondary to symptoms. Therefore, routine post CT removal CXR is not necessary. CXR in these patients should be obtained based upon clinical indications after CT removal.     

Is immediate chest radiograph necessary after central venous catheter placement in a surgical intensive care unit?

BACKGROUND: Current standard of care dictates that central venous catheter (CVC) insertion should be followed by an immediate chest radiograph to confirm appropriate position and rule out complications. We hypothesized that a subset of monitored intensive care unit patients exists that is at low risk for complications and might safely have radiographic evaluation of line placement deferred until the next scheduled radiograph. METHODS: Data regarding patient and procedural characteristics were obtained prospectively for 184 CVC placed between March 1, 1998, and June 30, 1999. Retrospective data regarding complications were obtained by chart review for an additional 174 CVC placed during the study period but for which data sheets were not completed. All procedures were followed by chest radiography. RESULTS: We documented a complication rate of 9% with the vast majority (25 of 31, 81%) of complications consisting of incorrect positioning. The number of needle passes was greater in the group suffering pneumothorax and arterial puncture than the uncomplicated group (5.6 versus 1.9, P = 0.008). "Straightforward" operator gestalt (P = 0.04) and number of needle passes <3 (P = 0.03) were factors correlating with the absence of complications. These factors had negative predictive values of 94% and 96%, respectively. CONCLUSION: Placement of CVC is safe in experienced hands. In monitored intensive care unit patients who undergo a "straightforward" procedure with <3 needle passes, chest radiograph can be safely deferred until the next scheduled examination.     

Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access?

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.     

Is this the end of the line for the moderate dyskaryotic smear?

OBJECTIVE: The British Society for Clinical Cytology has recently proposed that the terminology for cervical smear reporting is to be changed from a 3-tier system (mild, moderate, severe dyskaryosis) to a 2-tier system of low-grade and high-grade dyskaryosis. This modification eliminates the central category of moderate dyskaryosis which would be incorporated into the high-grade group. The aim of this study was to investigate the role of the moderate dyskaryotic smear in clinical practice. MATERIALS AND METHODS: A retrospective review of all women who were referred for colposcopy because of a moderate dyskaryotic smear was carried out for a 6-month period. Data collected included colposcopic impression, procedure performed and final histopathology. Two cytologists who were unaware of the original smear report were asked to reclassify these smears using the new 2-tier system. Their findings were compared with the documented colposcopic and histopathology results. RESULTS: One hundred women with moderate dyskaryotic smears were referred for colposcopy during the study period. Most of these were reclassified as high-grade dyskaryosis using the new system. Fifty-six (72%) of the moderate dyskaryotic smears which were correctly regraded as high grade by cytologist 1 were found to have cervical intraepithelial neoplasia 2/3 on final histopathology, whereas for cytologist 2, 66 (68%) were found to have high-grade cervical intraepithelial neoplasia. CONCLUSION: There is no clinical benefit in retaining the term moderate dyskaryosis. This study emphasizes the need for a uniform 2-tier system.     

Is the preoperative radiograph useful in predicting the outcome of a total hip replacement?

The preoperative radiographs of 1015 patients undergoing 1163 total hip replacements for osteoarthritis were evaluated to determine if a relationship exists between the extent of osteoarthritis and the clinical results of a total hip replacement. Preoperative radiographs were graded with respect to the degree of cartilage space loss, direction of cartilage space loss (femoral head migration), and severity of osteophyte formation. Followup averaged 32.1 months (range, 6-93 months). Greater degrees of cartilage space loss correlated with lower hip scores preoperatively but were unrelated to preoperative pain. These patients had statistically less pain at 6 months and 1 year. Patients with superior cartilage space loss before surgery also had statistically less pain at 6 months. However, at 3 years and beyond, pain was independent of degree of preoperative cartilage space loss, osteophyte formation, or femoral head migration. In addition, hip scores at any followup were independent of the degree of osteoarthritis observed on the preoperative radiograph. These findings provide statistical support to the concept that greater degrees of joint space loss correlate with better relief of pain and less severe joint space loss correlates with less relief of pain within the first year after total hip replacement. At 3 years and beyond, hip and pain scores were independent of the degree of preoperative osteoarthritis.     

Chest radiograph after central line placement under fluoroscopy: utility or futility?

Background

Postoperative portable chest films are routinely performed after fluoroscopic placement of central venous catheters to evaluate positioning and to rule out significant complications (eg, pneumothorax). Emerging evidence in the literature has called this practice into question suggesting that routine postoperative chest x-ray is unnecessary. Therefore, we investigated our recent experience to examine the utility of these films, to examine the development of symptoms relative to therapeutic intervention, and to report a cost-benefit analysis.

Methods

After obtaining institutional review board approval, all charts of patients undergoing central venous catheter placement from January 2004 to December 2005 at our institution were reviewed. Outcome measures included whether or not there was a complication and whether or not that complication required an intervention. Peripherally inserted central catheters were not included.

Results

In the study population, 237 catheters were placed in the operating room. There were two complications, both pneumothoraces (0.085%). One patient required tube thoracostomy, whereas the other was asymptomatic and the pneumothorax resolved spontaneously. Fourteen patients had no postoperative chest film without adverse consequences. Total cost for portable chest films was $56,196.

Conclusions

For catheters placed under fluoroscopic guidance, postoperative chest films in asymptomatic patients add unnecessary cost. For this reason, we feel discontinuation of postoperative chest films in asymptomatic patients undergoing catheter placement with fluoroscopy is justifiable.     

How long should you wait for a chest radiograph after placing a chest tube on water seal? A prospective study

OBJECTIVE: The purpose of this study was to determine the optimal time interval for identifying a pneumothorax (PTX) on chest radiograph (CXR) after placing a chest tube on water seal. METHODS: One hundred nineteen chest tubes were placed on water seal according to a prospective, observational study protocol. After water seal, both an early (3.1 +/- 2.1 hours) and a late (17.6 +/- 8.0 hours) CXR was obtained. RESULTS: Thirty-one patients had a PTX on follow-up CXRs. There were 22 early and 9 late PTXs identified. Three patients in the early group had a clinically significant PTX or an increase in the size of PTX on follow-up CXR. None of the patients in the late group had a clinically significant PTX (any worsening of their PTX) or required further intervention. CONCLUSION: A normal chest radiograph obtained 3 hours after placing a chest tube on water seal effectively excludes development of a clinically significant pneumothorax.     

Is routine ultrasound guidance for central line placement beneficial? A prospective analysis

OBJECTIVE: Portable ultrasound devices have become more readily available in the intensive care unit setting, but their utility outside of controlled trials remains unproven. We sought to determine how the availability of ultrasound guidance affected the types and number of complications during central line placement. DESIGN: Review of a prospectively maintained database in a 20-bed combined intensive care unit. Procedure notes from all attempts at internal jugular vein access from 1996 to 2001 were recorded, and selected patient records were reviewed. Ultrasound guidance was available beginning in March 1998. RESULTS: From 1996 to 2001, there were 484 documented attempts at internal jugular central line placement. Most procedures (83%) were performed by first- or second-year residents. During this period, there were 47 complications for an overall complication rate of 10%. These included 1 pneumothorax (2%), 6 carotid punctures (13%), 2 hematomas (4%), and 34 unsuccessful attempts (72%). There was no significant difference in age, sex, body-mass index, or intubation status between those with and without complications or between the ultrasound and anatomic landmark groups. Ultrasound was used in 179 (37%) attempts. The overall complication rate with ultrasound was 11% versus 9% using anatomic landmarks (p = NS). The complication rate prior to the availability of ultrasound was 15 of 114 attempts (13%) versus 32 of 370 attempts (9%) after the introduction of ultrasound in our intensive care unit (p = NS). Analysis of the 370 procedures performed since ultrasound became available demonstrated a complication rate of 11% with ultrasound guidance versus 6% without (p = 0.09). There was no significant difference in complication rates by resident year group or department (surgery vs. other). However, procedures performed after-hours (1800 to 0800) were associated with a 15% complication rate versus 6% for procedures performed during the workday (p < 0.05). CONCLUSION: The availability and use of ultrasound guidance for central line placement by junior residents has not resulted in an improvement in procedure-related complications. The complication profile was not affected by ultrasound use, patient factors, or resident year in training. There was a higher complication rate associated with procedures performed at night that may be caused by resident fatigue or unavailability of senior supervision.     

Is central sarcopenia a predictor of prognosis for patients with pathological fracture?

IntroductionWe aimed to investigate the relationship between central sarcopenia and survival in patients with pathological fracture.MethodsWe reviewed records of patients who were treated for pathological fracture of axial and appendicular skeleton in our clinic between 2011 and 2020. We used the psoas: lumbar vertebral index (PLVI) on axial computer tomographic evaluation to assess for central sarcopenia. A multivariate Cox algorithm was applied to recognize these factors independently associated with one month, six months, one year, and overall survival.ResultsA total of 147 patients [61 (41.4%) male and 86 (58.6%) female] were included, with an average age of 62.4 years. During the study, 108 (73.4%) patients died, and 39 (26.6%) were alive. The survival rates at 1 month, 6 months, and 1 year after surgery were 94.6%, 68.7%, and 53.1%, respectively. PLVI values ranged from 0.21 to 1.20 with a mean of 0.536 and a median of 0.520. According to the median value of PLVI, 68 patients with sarcopenia had low PLVI and 79 patients without sarcopenia had high PLVI. For the first month, only the preoperative albumin level was identified as a prognostic factor. Eastern Cooperative Oncology Group Performance Status (ECOG), American Society of Anesthesia (ASA) scores and primary malignancy (rapid grade) were strong predictor of poor survival. The PLVI was independent significant predictor of first month (HR, 0.083 [95% CI, 0.011–0.649], p = 0.018) and overall survival (HR, 0.129 [95% CI, 0.034–0.492], p = 0.003).ConclusionThe PLVI was a strong predictor of first year, and overall survival in patients with pathological fracture.     

Is a modified central bisegmentectomy a volume-saving operation for pediatric hepatoblastoma?

The authors report on an 11-month-old girl who presented with a hepatoblastoma. The tumor was located in Couinaud’s segments IV, V, VII, and VIII. She received adjuvant chemotherapy in accordance with the Japanese Study Group for Pediatric Liver Tumor Protocol-2, and the tumor thereafter showed a partial response, involving segments IV and VIII. She thereafter underwent a modified central bisegmentectomy (segments IV, VIII, and a part of V). The postoperative course was uneventful, and the patient is now doing well 22 months after the operation. The authors consider the central bisegmentectomy to be a volume-saving operation, and, based on a volumetric analysis, the estimated preserved volume of the functioning liver parenchyma was determined to be 87%. However, if using a right trisegmentectomy, the preserved volume was estimated to only be 44%. The authors consider a central bisegmentectomy to be a useful alternative operation for patients with centrally located hepatoblastoma to minimize both morbidity and mortality.     

Is ultrasonography a good screening test for intestinal malrotation?

Background

Early diagnosis of malrotation can prevent fatal midgut volvulus. Abnormal orientation of the superior mesenteric artery (SMA) and vein (SMV) on ultrasonography (US) has been described in malrotation. We aimed to determine the accuracy of this technique.

Methods

All children undergoing both upper gastrointestinal series (UGI) and US for possible malrotation over a 3-year period were reviewed. Patients were excluded if US did not include SMV/SMA orientation or if the duodenojejunal flexure was not visualized on UGI.

Results

Of 211 eligible patients, UGI and US were both normal in 62% and both abnormal in 15%. Forty-four had abnormal US and normal UGI (false positive, 21%), and 5 patients had normal US and abnormal UGI (false negative, 2%). Of these 5, none were found to have a short mesenteric base, which put them at risk for volvulus. Among abnormal ultrasounds, inversion of SMV/SMA and a “whirlpool” sign were more predictive for malrotation and volvulus than anterior/posterior orientation.

Conclusions

Ultrasonography is a good screening tool that effectively rules out malrotation at risk for volvulus. Children with an abnormal ultrasound should have an UGI or go to the operating room, depending on clinical findings.     

Is antero-posterior position superior to antero-lateral position for placement of electrodes for external cardioversion of atrial fibrillation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the antero-posterior position is superior to the antero-lateral position for the placement of electrodes for cardioversion of atrial fibrillation. Altogether 167 papers were found using the reported search, of which 5 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is no clinical difference between the two positions although if one position fails to convert the patient, the alternative position may still achieve success.