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Iowa City, IA
Dr. van Beek is Professor of Radiology, Carver College of Medicine, University of Iowa.
Correspondence to: Edwin J.R. van Beek, MD, PhD, Professor of Radiology, Department of Radiology, Carver College of Medicine, University of Iowa, 200 Hawkins Dr, Iowa City, IA 52242-1077; e-mail: edwin-vanbeek{at}uiowa.edu
The insertion of central lines is now commonplace due to the increased use of IV feeding, the delivery of blood products and drugs, hemodialysis, and monitoring in intensive care situations in modern medicine. However, the exact method of insertion, the periprocedural care, and the assessment of adequate positioning is still a contentious issue. In this issue of CHEST (see page 220), an elegant study by Lessnau describes the situation of routine triple-catheter insertion in a large teaching hospital. The study demonstrates that one can virtually predict the adequate position of these lines, even if residents perform line insertion following training for this procedure.
Indeed, the insertion of central lines is currently performed by a range of health workers, including (junior) doctors from specialties ranging from radiology to anesthesiology as well as nurse specialists. One report,1 which is now 10 years old, estimated the insertion of central lines in the National Health Service of the United Kingdom at 200,000, or 3 lines per 1,000 inhabitants in the United Kingdom. Extrapolating this figure to the United States, where central lines are more frequently used, would result in an estimated 750,000 to 1 million central lines inserted per annum. This number highlights the importance of addressing the insertion of central lines, as any improvement or change in practice will obviously have a significant impact on patient care and on health-care economics. Thus, any improvement of the procedure or any cost saving (even if this seems relatively small, such as with a routine chest radiograph) will result in major savings at a macroeconomic level as well as have an effect on manpower planning (after all, many of these routine radiographs are obtained at bedside and/or out-of-hours).
Several routes may be used to insert central venous access lines. The most dangerous one is undoubtedly the subclavian approach, which is prone to pneumothorax. In fact, a confidential registry of central line insertion revealed one fatal pneumothorax per 3,000 inserted lines.2 Other complications of line insertion by any route include puncture of the adjacent artery, bleeding, and arteriovenous fistula. These complications are more common in higher risk patients such as those who are obese, children, those that require "acute" insertion, and those with clotting abnormalities. Furthermore, the femoral approach is probably more frequently implicated in these complications than the jugular vein approach.
In the report in this issue, Lessnau opted for an anterior jugular vein approach, using a so-called landmark technique. This technique uses anatomic knowledge to locate the course of the jugular vein. The authors suggest that this technique is safe, as long as several precautions are taken. This is in conflict with a report3 that highlighted some of the aspects of central line insertion, with a view toward issuing guidance on the use of imaging devices during line insertion. The report showed that the use of simple handheld ultrasound devices would reduce the failure rate of line insertion by > 85% and would result in a 57% reduction in the complication rate. Naturally, a reduction in the complication rate is one of the main aims, and the presented study would be unlikely to find significant differences with an ultrasound-guided approach due to the low a priori chance of significant complications.
The National Institute for Clinical Excellence report3 did not go into detail about the requirements for routine chest radiography. The approach to the routine use of chest radiographs varies widely from clinic to clinic and between various clinicians. One may take the approach that it is "better safe than sorry," but this would seem a rather defensive practice (and ultimately expensive). The author of the current study took a more pragmatic approach: "if the line goes in easily, without too many stabs, it is probably in a correct position." The fact that so few complications were seen in patients who had undergone uncomplicated line insertions suggests that routine chest radiographs are probably not required. However, one could still criticize the study for a lack of numbers. In this respect, a registry would be justified as it could help to gain information on the safety of line insertions and give further insight into those patients in whom routine chest radiographs can be omitted. Given the large number of lines inserted, it should be feasible to gain insight in a relatively short time period, especially if such action were to be undertaken under the auspices of one of the major organizations, such as the inverventional radiology associations in the United States and Europe or the Society of Critical Care Medicine, as these organizations will cover a significant proportion of the clinicians who routinely insert lines. It could also lead to a benchmarking exercise that subsequent clinicians can use to compare their own standards.
Improvements in the cost-effectiveness of procedures are vital for the financial welfare of many. Although the image-guided line insertion would result in a cost saving of approximately only $3 to $5 per procedure, the sheer number of line insertions is so high that this would still have an impact on the costs of health care. A similar view could be taken on the routine use of chest radiographs. Even at a relatively low cost of < $100 per postprocedure radiograph, the cost savings would be many millions of dollars and, indeed, much larger than with the introduction of ultrasound-guided line insertion. Where ultrasound-guided line insertion will have a significant impact on radiology manpower in the short term (until sufficient numbers of clinicians are adequately trained), the reduction of routine chest radiographs would have an immediate and long-term effect on the already time-stretched schedule of the radiologist and the use of similarly scarce support staff.
Apart from the obvious clinical important findings of the article by Lessnau, it also demonstrates the importance of auditing procedures in clinical practice. After all, the work described is not exactly a difficult research protocol but, rather, describes the outcome of a procedure in relation to patient safety and successful insertion of a triple-lumen catheter. Thus, it yields data that can easily be transferred to other centers, which can use the data to compare their own practice. However, measures will be needed with which a practitioner can compare his success, and a published audit is vitally important (in fact, this would also serve to underline the importance of a registry as a benchmark for interventional procedures). This type of basic performance research is often forgotten, as journals will tend toward the high-powered randomized trial as the ultimate proof of concept. However, one should not forget that most physicians are not involved in randomized trials, yet still have to perform a duty of care toward patients. Ultimately, it is clinical outcome by which the success of a clinician will be measured. The question of whether this can be achieved without a routine chest radiograph has to be answered affirmatively in my opinion.
References
This article has been cited by other articles:
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  J. Connell and N.S. Parekh Chest radiography and catheterization. Chest, February 1, 2006; 129(2): 499 - 499. [Full Text] [PDF]
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 CXR After Internal Jugular Line Placement Might Not Be Necessary Journal Watch Emergency Medicine, February 16, 2005; 2005(216): 2 - 2. [Full Text]
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