Comparison of routine chest radiograph versus clinician judgment to determine adequate central line placement in critically ill patients.

Background: Central venous catheterization (CVC) is routine in the management of critically ill patients. However, this procedure has complications, generally mandating a postprocedural chest radiograph (CXR) to confirm adequate position and to rule out procedure-related complications. We sought to determine whether clinician judgment could reliably predict complications and malpositioning after CVC placement, thus obviating the need for a postprocedural CXR on all lines placed.

Methods: Prospective observational study of patients undergoing central line placement in the trauma, surgical, and burn intensive care units during a 12-month period. After placement, a questionnaire addressing comorbidities and the technical aspects of the procedure was completed by the clinician placing the line. The clinical impression regarding line placement was then compared with the findings on a postprocedural CXR.

Results: In 147 patients, 209 CVCs were performed (mean age of 52 +/- 21 years). The population was 52% burn and 48% trauma or general surgery patients. The subclavian position was used in 78%. Ninety four percent of CVCs were without complication, whereas 3% were malpositioned and 2% resulted in pneumothorax (one delayed diagnosis at 24 hours). The incidence of complications was associated with level of training of the physician placing the line as well as the number of attempts necessary to access the vein. Clinical judgment correctly identified malpositioning in 20% of cases, and pneumothorax in 67% of cases. The person placing the line thought 68% of the CVCs were uncomplicated (corresponding complication rate 2.3%), whereas 25% thought they were technically difficult (corresponding complication rate 1%), and the remainder thought either they were associated with complications or technically not feasible, all with corresponding complications. Overall, clinical judgment had a sensitivity of 71%, specificity of 44%, positive predictive value of 97%, and negative predictive value of 6%, for an overall accuracy of only 70%.

Conclusion: Clinical judgment does not reliably predict malpositioning after CVC or the presence of postprocedural complications. Chest X-ray after CVC placement in the critically ill should remain the standard of care.