Are chest X-rays mandatory following central venous recatheterization over a wire?

Exchange of a central venous catheter (CVC) over a guidewire is a frequent clinical procedure, especially in surgical intensive care units. At most hospitals, a chest X-ray (CXR) is obtained routinely after recatheterization to confirm accurate catheter placement and to rule out complications such as pneumothorax. We hypothesized that the incidence of complications after central venous recatheterization over a guidewire is too low to justify automatic performance and the associated expense of a routine postprocedure CXR. Initially we undertook a retrospective study of a total of 295 patients with a Swan-Ganz catheter (SGC), of which 92 SGCs were exchanged over a guidewire for a CVC between July 1, 1994, and June 30, 1996, at a university-affiliated community hospital. Age, gender, duration of SGC placement, type of central catheter used for exchange with the SGC, and CXRs and their reports were noted. From July 1, 1996, to October 1, 1997, the study has been continued prospectively. Thus far, in this ongoing investigation, we have identified 505 patients (201 prospective) who had a SGC placed, 210 (116 prospective) of whom had their SGC removed electively, leaving the SGC introducer in place for advancement of a guidewire, and subsequent replacement by a CVC. Of all the patients with a SGC, 40 per cent had the SGC replaced with a CVC over a guidewire, and follow-up CXRs and their reports confirmed that all exchanged triple lumen catheter tips were appropriately positioned in the superior vena cava with zero complications. With the advent of managed care, a savings of $115/CXR (one view X-ray and reading cost at our hospital) would be gained without the added risk of radiation exposure to the patient if a CXR were not mandatory after an uncomplicated guidewire replacement of a central line. It appears from these data that a CXR is not justified as a routine study after replacement of all CVCs over a wire from the standpoints of both patient risk and expense. Conscientious physical examination together with good clinical acumen and judgement in evaluating patients after replacement of a CVC over a guidewire are likely to obviate the currently mandated postprocedure CXR, reserving its use for selected patients.