Routine CXRs Research Articles

Role of routine chest xrays and device checks in detecting peri-procedural complications associated with cardiac device implantation: a UK tertiary centre experience

Abstract Introduction Complications associated with Cardiac implantable electronic devices (CIEDs) are not uncommon, most of which occur in the perioperative phase. Until recently, guidance on implemented measures for early detection of peri-operative complications were lacking. The ESC guidelines on pacing recommend routine follow up of all newly implanted devices within 72 hours of implant. While the recently published EHRA expert consensus and practical guide on CIEDs recommend that a chest x-ray should be performed within 24 hours in all patients to rule out pneumothorax and document lead positions. Purpose At our tertiary centre for CIEDs, it is routine practice to perform CIEDs implantations on a day-case basis, targeting same day discharge for uncomplicated procedures. CXRs are performed 4 hours after the implant, and CIEDs are fully checked twice, once “on table” at the end of the procedure, and again after mobilisation and prior to discharge. In our analysis, we aimed to identify the yield of complications that could be detected early-on using these routine measures in all our implant procedures. Methods We performed a retrospective analysis of consecutive CIED implants performed between January and December 2019. The following information were collected; types and indications for device therapy, device checks reports, CXR reports, and clinical notes for documented symptoms or signs suggestive of peri-procedural complications. Results A total of 578 patients (Age 74±16 years, 68% male) were included in our analysis, for demographics see table. All patients had routine CXRs and 2 device checks. There were 16 (2.8%) peri-procedural complications associated with our device implants, 7 (1.2%) pneumothoraxes, 6 (1%) pericardial effusions, and 3 (0.5%) lead displacements. In 4 out of the 7 peri-procedural pneumothoraxes, the operator reported difficulty gaining access. 2 patients with pneumothorax reported chest pain, 1 patient reported shortness of breath and 1 had low O2 saturations. There were 2 asymptomatic cases of pneumothorax after reportedly straightforward procedures and were only detected on the routine CXRs, one of them required chest drain insertion and the other treated conservatively. 2 out of the 3 lead displacements were detected on both CXRs and pre-discharge pacing checks and didn't require intervention, while 1 case of lead displacement occurred after the pacing checks and CXRs were reported to be satisfactory, further pacing checks triggered by patient's symptoms and bradycardia on the monitor revealed lead displacement requiring intervention prior to discharge. Conclusion Routine post CIED implantation CXRs can detect early – otherwise clinically silent-periprocedural complications and appropriately remains a requirement for all CIED implants. While repeat post mobilisation device checks has low yield of detection of complications and can be reasonably abandoned provided that initial “on-table” checks are satisfactory. Funding Acknowledgement Type of funding sources: None.

A Quality Improvement Initiative to Reduce Unneeded Screening Chest Radiographs in a Pediatric Cardiovascular ICU.

Adult critical care and radiographical societies have recommended changing practice from routine screening radiographs to on-demand chest radiographs (CXRs) for stable mechanically ventilated adult patients. There are no similar recommendations for patients in the pediatric ICU. Reducing the frequency with which unneeded CXRs are obtained can decrease radiation exposure and reduce waste, a substantial contributor to rising health care costs. We aimed to reduce unneeded daily screening CXRs in a pediatric cardiovascular ICU (CICU) by 20% in 6 months. Criteria delineating which subjects in the CICU required daily screening CXRs were created and added to the daily rounding sheet for discussion for each subject. The primary goal of this study was to reduce CXRs in mechanically ventilated subjects as our previous practice had been to order daily CXRs. Respiratory therapists increased the frequency of evaluating and documenting endotracheal tube positioning prior to the initiation of this project. The outcome measure was the percentage subjects who received a daily screening CXR. The ratio of daily screening CXRs to the number of total CXRs ordered and unplanned extubations were followed as balancing measures. The number of subjects who received a daily screening CXR decreased from a baseline of 67% to 44% over the course of this project. There was no change in the ratio of daily screening CXRs to the number of total CXRs ordered or an increase in unplanned extubations. With an estimated cost of $268 per CXR, a reduction of 33% in routine screening CXRs saves an estimated $250,000 annually. A decrease in daily screening CXRs can be sustained through the development of specific criteria to determine which patients need screening radiographs. This can be achieved without an increase in CXRs obtained at other times throughout the day or an increase in unplanned extubations. This eliminates unneeded health care expenditures, improves resource allocation for radiology technicians, and decreases disruptive interventions for patients.

Chest radiography of contemporary trans-catheter cardiovascular devices: a pictorial essay.

There is a plethora of cardiovascular devices used for therapy and monitoring, and newer devices are being introduced constantly. As a result of advancement of medical technology and rapid development of such technology to address unmet needs across cardiovascular care, multiple conditions which were previously treated surgically or with medications now benefit from trans-catheter device-based evaluation and management. Moreover, innovation to existing technology has transformed the structural design of many traditional cardiovascular devices, making them safer and enabling easier deployment within the chest (catheter-based versus surgical). A post-procedure chest radiography (CXR) is often the first routine imaging test ordered in these patients. A CXR is a relatively inexpensive and noninvasive imaging tool, which can be obtained at the patient's bedside if needed. Commonly implanted cardiovascular devices can be quite easily checked for appropriate positioning on routine CXRs. Potential complications associated with mal-positioning of such devices may be life-threatening. Such complications often manifest early on CXRs and may not be readily apparent on clinical examination. Prompt recognition of such abnormal radiographic appearances is critical for timely diagnosis and effective management. Clinicians need to be familiar with new devices in order to assess proper placement and identify complications related to mal-positioning. This pictorial essay aims to describe the radiologic appearances of contemporary cardiovascular devices, review indications for their usage and potential complications, and discuss magnetic resonance imaging (MRI) compatibility.

Reducing chest radiography utilization in the medical intensive care unit.

Daily chest radiographs (CXRs) have long been a routine part of care. However, evidence as well as changing technology has promoted on-demand CXRs as beneficial to patient care. We found that a substantial number of routine daily CXRs were being ordered, with some of the orders staying active even after extubation. Within a 19-bed adult medical ICU, we prospectively utilized 3 intervention phases from October 1, 2014, to February 28, 2018, to reduce routine CXRs. Nurse Practitioners (NP) initiated this quality improvement (QI) project, aiming to reduce the number of unnecessary of CXRs. Interventions included staff survey, routine CXR order removal, duplicate alerts, visual reminders, and an electronic clinical decision support tool. Monthly education of appropriate CXRs and bedside ultrasound were facilitated by NPs. The outcome measures of interest include: the number of CXRs per patient-day, the number of routine and on-demand CXRs, mortality rate, ICU length of stay, and ventilator days, radiation and cost. Total number of CXRs per patient-day decreased by 36.1%. The proportion of routine CXRs decreased from 55.37% to 13.18%; on-demand orders increased, from 44.63% to 86.82%; and calculated radiation-exposure per census decreased, from 0.011 to 0.008 mSv. In addition, charges to patients for CXRs decreased by $7,750/month. ICU mortality and ventilator days per census remained stable. By an orchestrated process that included creating awareness and desire to change CXR ordering practices, we were able to decrease routine CXRs and increase on-demand utilization while maintaining counterbalance measures.

236 Utility of Chest Radiograph in Patients Admitted to a Pediatric Intensive Care Unit in Status Asthmaticus from a Pediatric Emergency Department

The NHLBI guidelines state that emergency department chest radiographs (CXRs) are not routinely recommended in asthma exacerbations unless a complicating cardiopulmonary process is suspected. Prior studies show a majority of CXRs performed in non-critical asthma reveal no evidence of pneumonia or air leak. There are limited studies that offer specific indications for CXRs in status asthmaticus. The literature suggests that new onset wheezing, fever, hypoxemia and an asymmetric exam are acceptable indications for CXRs. The aim of this study was to determine the utility of CXRs in patients admitted to a pediatric intensive care unit (PICU) in status asthmaticus from a pediatric emergency department (PED). This was a retrospective chart review of children with a diagnosis of asthma aged 2 to 18 between 2012 and 2017 who presented to the PED and were then admitted to the PICU in status asthmaticus, requiring a minimum of continuous albuterol. Patient demographics, physical examination findings and vital signs were collected in addition to imaging results and hospital management information. Patients with underlying disorders including prematurity, cardiac disease, sickle cell disease, cerebral palsy and cystic fibrosis and patients without previous CXRs in the electronic medical record were excluded. Patients were then stratified into two subject groups based on presence of fever, hypoxemia or an asymmetric exam. Routine CXRs were defined as a CXR obtained in the PED in the absence of fever, hypoxemia and asymmetric exam. Descriptive statistical analysis was performed using statistical analysis software. 343 patients were analyzed and 250 (80.6%) of these had CXRs in the PED. Of those 250 patients, 114 (45.6%) had fever, hypoxemia or an asymmetric lung exam. Of the remaining 136 (54.4%) patients, 95 (69.9%) of the routine CXRs were negative. 41 (30.1%) had abnormal CXRs; 5 (3.7%) had infiltrates, 23 (16.9%) had infiltrate vs. atelectasis and 13 (9.6%) showed atelectasis. All 5 (100%) patients with infiltrates and 16 (69.6%) of the patients with infiltrate vs. atelectasis were treated with antibiotics. Eight (8.4%) patients with normal CXRs received antibiotics during hospital admission. 69.9% of the routine CXRs obtained for status asthmaticus in this study were negative. 3.7% of the routine CXRs showed infiltrates, leading to further interventions. All of these patients were admitted to an ICU, where CXR could be obtained if symptoms indicating the need for a CXR were to develop. In this study, routine use of CXR in the evaluation of patients with status asthmaticus led to a high rate of unnecessary imaging.

Evaluation of Chest Radiographs and Laboratory Testing during Melanoma Staging Procedures

Chest radiographs (CXRs) and laboratory testing have historically been performed as a part of low-risk melanoma (clinical stage 1/2) workup. This study evaluates the utility of routine CXRs and laboratory testing during the staging of clinical stage 1 and 2 melanoma patients. This study was approved by the Institutional Review Board at Wake Forest University. A database of sentinel lymph node biopsies performed for clinical stage 1 or 2 melanoma was used to identify early-stage melanoma patients. The medical records of patients with melanoma were reviewed and preoperative workup procedures were recorded. Four hundred sixty-three patients were reviewed. A total of 315 patients underwent a preoperative CXR, whereas 309 received some laboratory testing. After sentinel node biopsies, 168 patients had pathologic stage 1 disease, 103 stage 2, and 44 stage 3. None of the CXRs (0%) correctly identified metastatic melanoma. Suspicious locations on CXRs and laboratory testing did not lead to metastatic findings in any patient within a year. Metastatic melanoma was not found in any patient by screening with CXRs or laboratory testing during preoperative workup. We recommend not conducting CXRs or laboratory testing during workup for surgical melanoma patients because of charges and anxiety these tests can cause. CXRs, blood tests, and metabolic panels have historically been ordered for early melanoma patients, although debate remains on their efficacy. Surgical patient records were retrospectively reviewed for these tests and no benefit was found.

PS01.192: ROUTINE CHEST X-RAY AFTER REMOVAL OF CHEST TUBES IS NOT NECESSARY DURING THE POSTOPERATIVE COURSE OF ESOPHAGECTOMY

Abstract Background Chest X-rays (CXRs) are commonly performed after removing chest tubes post-esophagectomy. However, literature on cardiopulmonary surgical patients suggests that a CXR might safely be reserved for patients who develop clinical respiratory signs or symptoms. Omitting unnecessary CXRs can save costs, radiation exposure, and logistic challenges, which aids the optimization of the postoperative care pathway. Therefore, the aim of this study was to investigate the clinical relevance of routinely performing a CXR after chest tube removal following esophagectomy. Methods A single-center prospectively maintained database was used to select all patients who underwent esophagectomy with gastric conduit reconstruction between 2015 and 2017. Patients who received a routine CXR 4 hours after removal of at least one chest tube or thoracic Jackson-Pratt drain were included. The radiological reports of routine CXRs were retrospectively evaluated for mentioning of intrapleural air or fluid. Cases requiring re-insertion of a chest tube on the day of routine CXR or the day afterwards were identified. Furthermore, the patients’ vital parameters were retrospectively reviewed from clinical documentation. Results Some 118 patients were included and esophagectomy was performed by a minimally invasive transthoracic (78%), an open transthoracic (14%), or a minimally invasive transhiatal (8%) approach. A total of 231 routine CXRs were performed after the removal of chest tubes (70%) and Jackson-Pratt drains (30%). Intrapleural air was found in 78 cases (34%) and was a new finding ipsilateral to previous chest tube or drain removal in 33 cases (14%). Intrapleural fluid was mentioned in 87 cases (38), which was new and ipsilateral to previous chest tube or drain removal in 24 cases (10%). Re-insertion of a chest tube was performed in 7 cases (3%). The routine CXR prior to chest tube re-insertion had shown intrapleural air (n = 3, 1%), intrapleural fluid (n = 2, 1%), or no abnormalities (n = 2, 1%). Clinical respiratory signs or symptoms (i.e. anamnestic dyspnea, an increased respiratory rate, dropping saturation levels, or need for oxygen support) occurred in all 7 patients who required chest tube re-insertion. Conclusion In conclusion, clinical respiratory signs or symptoms can safely guide the decision on whether to perform a CXR after chest tube or drain removal. Disclosure All authors have declared no conflicts of interest.

The clinical value of routinely obtained postoperative chest radiographs in post-anaesthesia care unit patients seems poor-a prospective observational study.

The clinical value of routinely obtained postoperative chest radiographs (CXRs) in post-anaesthesia care unit (PACU) patients is largely unknown. To determine the diagnostic efficacy and treatment impact of postoperative routinely obtained CXRs in a university hospital PACU. Observational study collecting the expectations of attending physicians, the findings on routinely obtained CXRs and actions based on the findings on these CXRs in postoperative PACU patients. A 22-bed PACU in a university hospital in the Netherlands. Patients admitted to the PACU during a 9-month period. The analysis was restricted to CXRs routinely obtained during the first PACU admission, i.e., CXRs obtained during later admissions were excluded. Diagnostic efficacy, defined as the percentage of CXRs showing any unexpected major abnormality; treatment impact, defined as the percentage of CXRs showing an unexpected major abnormality that triggered a predefined change in therapy. The analysis included 294 postoperative CXRs. Of them 94 showed a new and unexpected predefined major abnormality (diagnostic efficacy of 35%). Of these 94 CXRs, only 10 triggered an intervention (treatment impact of 4%). The diagnostic efficacy of routinely obtained postoperative CXRs in PACU patients is fair; the treatment impact seems low if we assume that all CXRs that showed an abnormality but were not followed by an intervention and did not require an intervention. Future research should focus on the safety and cost-effectiveness of abrogating routine postoperative CXRs.

Defining indications for selective chest radiography in the first 24 hours after cardiac surgery

ObjectiveIn the intensive-care unit (ICU), chest radiographs (CXRs) are frequently obtained routinely for postoperative cardiac surgery patients, despite the fact that the efficacy of routine CXRs is known to be low. We investigated the efficacy and safety of CXRs performed after cardiac surgery for specified indications only. MethodsIn this observational cohort study, we prospectively included all patients who underwent conventional major cardiac surgery by median sternotomy in the year 2012. On-demand CXRs could be obtained during the first postoperative period for specified indications only. A routine control CXR was performed on the morning of the first postoperative day for all patients who had not undergone a CXR before that time. The diagnostic and therapeutic efficacy values were calculated for all CXRs. Differences were tested using Fisher's exact test or χ2 analysis. ResultsA total of 1102 consecutive cardiac surgery patients were included in this study. The diagnostic efficacy of CXRs for major abnormalities was higher for the postoperative on-demand CXRs (n = 301; 27%) than for the routine CXRs taken the morning after surgery (n = 801; 73%) (6.6% vs 2.7%, P = .004). The therapeutic efficacy was higher for the on-demand CXRs, whereas the need for intervention after the next-morning, routine CXRs was limited to 5 patients (4.0% vs 0.6%, P < .001). None of these patients experienced a major adverse event. ConclusionsDefining clear indications for selective CXRs after cardiac surgery is effective and seems to be safe. This approach may significantly reduce the total number of CXRs performed, and will increase their efficacy.

Elimination of routine chest radiographs following off-pump coronary artery bypass surgery: A randomized controlled trial study.

Background:Post cardiac surgery routine chest radiographs (CXRs), ordered without any clinical and laboratory indications, is a standard obligatory practice in many cardiothoracic centers. Routine CXRs incur cost, manpower, and radiation. The objective of this study is to assess early outcome in off-pump coronary artery bypass (OPCAB) patients with postoperative routine versus clinically indicated CXR protocols.Materials and Methods:This study is a randomized clinical trial conducted on 231 OPCAB candidates in Afshar Cardiac Center, Yazd, Iran. Patients were categorized into two groups. All 118 patients in group A had routine postoperative CXRs. The 113 patients in group B were selectively exposed to CXR only on clinical indications. All patients were postoperatively followed up for 30 days. Data gathered from both groups were statistically analyzed.Results:Routine postoperative CXRs obtained in 118 OPCAB group A candidates showed abnormal findings in 20 patients that did not require new intervention. One month follow-up of these patients showed no complications. In 113 OPCAB candidates of group B, 7 on-demand CXRs were obtained on clinical evaluation that required added intervention. In a 1-month follow-up of this group, five patients presented with symptomatic complaints. On re-examination, none needed readmission, intervention, or paraclinical evaluation. No complications were observed due to CXR elimination.Conclusion:The study suggests that postoperative CXR selected on clinical grounds in place of routine CXR does not change early postoperative outcome of OPCAB procedure.

Significant changes in the practice of chest radiography in Dutch intensive care units: a web-based survey

BackgroundICU patients frequently undergo chest radiographs (CXRs). The diagnostic and therapeutic efficacy of routine CXRs are now known to be low, but the discussion regarding specific indications for CXRs in critically ill patients and the safety of abandoning routine CXRs is still ongoing. We performed a survey of Dutch intensivists on the current practice of chest radiography in their departments.MethodsWeb-based questionnaires, containing questions regarding ICU characteristics, ICU patients, daily CXR strategies, indications for routine CXRs and the practice of radiologic evaluation, were sent to the medical directors of all adult ICUs in the Netherlands. CXR strategies were compared between all academic and non-academic hospitals and between ICUs of different sizes. A comparison was made between the survey results obtained in 2006 and 2013.ResultsOf the 83 ICUs that were contacted, 69 (83%) responded to the survey. Only 7% of responding ICUs were currently performing daily routine CXRs for all patients, and 61% of the responding ICUs were said never to perform CXRs on a routine basis. A daily meeting with a radiologist is an established practice in 72% of the responding ICUs and is judged to be important or even essential by those ICUs. The therapeutic efficacy of routine CXRs was assumed by intensivists to be lower than 10% or to be between 10 and 20%. The efficacy of ‘on-demand’ CXRs was assumed to be between 10 and 60%. There is a consensus between intensivists to perform a routine CXR after endotracheal intubation, chest tube placement or central venous catheterization.ConclusionThe strategy of daily routine CXRs for critically ill and mechanically ventilated patients has turned from being a common practice in 2006 to a rare current practice. Other routine strategies and an ‘on-demand only’ strategy have become more popular. Intensivists still assume the value of CXRs to be higher than the efficacy that is reported in the literature.

Significant change in the practice of chest radiography in Dutch ICUs

>We performed a survey under Dutch intensivists on the current practice of chest radiography in their departments. Chest radiographs (CXRs) are obtained frequently in ICU patients, despite the diagnostic and therapeutic efficacy of routine CXRs being known to be low. The discussion regarding specific indications for CXRs in critically ill patients and the safety of abandoning routine CXRs is still continuing [1].

Stating clear indications for chest radiographs after cardiac surgery increases their efficacy and safely reduces costs

We investigated the efficacy and safety of chest radiographs (CXRs) performed on specified indications only, directly after cardiac surgery. CXRs in the ICU are frequently obtained routinely for postoperative cardiosurgical patients, despite the fact that the diagnostic and therapeutic efficacy of these CXRs is now known to be low [1]. Routine CXRs may only be beneficial for certain indications and the discussion regarding these indications and the safety of abandoning routine CXRs is still continuing [2].

An audit on the documentation of the interpretation of chest radiographs following thoracic surgery

s / International Journal of Surgery 11 (2013) 589e685 614 ABSTRACTS Conclusions: Whilst discharge documentation has improved, significant deviation from local guidelines remains and is principally due to use of antiplatelet therapy after mitral repair. 0941: AN AUDIT ON THE DOCUMENTATION OF THE INTERPRETATION OF CHEST RADIOGRAPHS FOLLOWING THORACIC SURGERY Daron Nazari , Kapil Sugand , Martin Yates , Ian Hunt . 1 St George's University of London, London, UK; 2 Imperial College London, London, UK. Aims: All patients undergoing thoracic surgery at our institution undergo post-operative and post-drain removal chest radiographs (CXR). General Medical Council (GMC) Good Medical Practice guidelines state that the interpretation of all investigations should be documented by the requesting physician. The aim of this audit was to assess compliance with GMC standards. Methods: A prospective audit was carried out of all patients who underwent thoracic surgery between 1st November and 7th December 2012. Quality of documentation within the patient record was assessed by a single investigator for both the post-operative and the post-drain removal CXR's. For each CXR, basic demographics (date, patient details and physician identification) and the presence or absence of post-operative pulmonary complications were assessed. Results: During the period of study 63 patients underwent thoracic surgery. 49(78%) patients had documentation of post-operative and 46(73%) post-drain removal CXRs. However, more detailed clinical information was included in only 9(14%) and 12(19%) of records respectively. Conclusions: There is a suboptimal level of documentation of routine CXRs post-thoracic surgery. Improvement, therefore, is crucial in recording the presence or absence of radiographic post-operative complications in patient records. A pro forma for CXR documentation has been introduced and re-audit is currently in progress. 0982: THE EUROSCORE II IS A BETTER PREDICTOR OF MORTALITY THAN LOGISTIC EUROSCORE FOR PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE IMPLANTATION Ashok Kar, Daniel Moffat, Simon Kennon, Anne Malecki, Wael Awad. London Chest Hospital, London, UK. Objectives: Patient selection for transcatheter aortic valve implantation (TAVI) is critical because of proven efficacy for conventional aortic valve surgery (AVR). Currently available risk scoring systems are known to be inadequate; logistic Euroscore (LES) over predicts mortality for AVR. This study compared predictive ability of the new EuroSCORE II (ES2) with LES in patients undergoing TAVI. Methods: All patients undergoing TAVI (January 2009 September 2012) were identified from our registers. LES and ES2 scores were calculated and predicted mortalities for the 2 scoring systems compared with that observed. Results: 124 patients underwent TAVI: 3 cases were excluded due to insufficient data. Mean age of patients (n1⁄4121) was 81.9 years (75 e 91). Mean predicted LES was 21.6 12.6 compared to 7.7 6.2 for ES2; paired student t-test showed ES2 to be significantly lower (p 60kg. This may contribute to longer hospital admissions and more patients being discharged in AF. Other cardiac units should be encouraged to audit local practice and initiate change to guidelines. 1225: PRE-OPERATIVE TOPICAL ANTISEPTICS AND POST-OPERATIVE INFECTION RATES IN CARDIOTHORACIC SURGERY: META-ANALYSES OF PROSPECTIVE STUDIES Sudeep Das De. University of Cambridge, Cambridge, UK. Aim: To investigate the role of routine pre-operative topical antiseptic agents in cardiothoracic surgery. Background: Staphylococcus aureus is a major cause of post-operative infection after open-heart surgery, with the patient's endogenous flora as the principal source. However the routine use of pre-operative topical antiseptics in all cardiothoracic patients has not been established. In a meta-analysis, we quantitatively assessed the associations reported in prospective studies of routine use of preoperative topical antiseptics. Methods and Results: Studies were identified by computer-assisted searches of the published literature and scanning of relevant reference lists. The following was abstracted: size and type of cohort, mean age, mean duration of follow-up, and the relative risk ratio of developing a post-operative infection when using topical antiseptic agents. There were 5 studies reporting the use of pre-operative chlorhexidine and 4 studies on topical mupirocin. The combined relative risk ratio of developing a postoperative infection when using topical chlorhexidine versus the control armwas 0.47 (CI 0.39-0.63, p<0.05). The combined relative risk ratio when using topical mupirocin of developing an infection was 0.43 (CI 0.32-0.72, p<0.05). Conclusion: Published prospective studies provide good evidence to support the routine use of preoperative topical antiseptic agents.

Is routine chest radiography indicated following chest drain removal after cardiothoracic surgery?

A best evidence topic was written according to a structured protocol. The question addressed was whether routine chest radiography is indicated following chest drain removal in patients undergoing cardiothoracic surgery. A total of 356 papers were found using the reported searches; of which, 6 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were mean duration of drains left in situ, timing of drain removal, pathology detected on chest radiographs (CXRs), interventions following imaging and clinical assessment, complications in patients not undergoing routine CXRs and the cost saving of omitting routine CXRs. One large cohort study reported the detection of pathology in 79% of clinically indicated CXRs in comparison to 40% of routine CXRs (P = 0.005). Ninety-five per cent of the non-routine CXR cohort remained asymptomatic and required no intervention. One large observational study reported the detection of new pneumothoraces in 9.3% of patients, 70.3% of which were barely perceptible. Intervention following CXR was required in 0.25% and only one medium-sized pneumothorax would have been potentially missed without CXR. Another large observational study reported intervention following CXR in 1.9% and the presence of relevant clinical signs and symptoms to be a significant predictor of major intervention (P < 0.01). A smaller observational study reported no pathology detected or intervention following CXR in 98% and the cost saving of omitting a single CXR at £10 000 per annum. Another small observational study reported only 7% of CXRs to be clinically indicated with a false-positive rate of 100%, and a false-negative rate of 7% in CXRs not clinically indicated. The smallest study reported no complications in the non-CXR cohort and only one patient undergoing intervention in the routine CXR cohort. We conclude that there is evidence that routine post drain removal CXR provides no diagnostic or therapeutic advantage over clinically indicated CXR or simple clinical assessment. The best evidence studies reported the detection of pathology on routine CXR ranging from 2 to 40% compared with 79% in clinically indicated CXRs (P = 0.005). Whilst the rate of intervention following routine CXR was as high as 4% in the smallest study, clinical signs and symptoms suggestive of pathology were a significant predictor of major re-intervention (P < 0.01).

Is Routine Postoperative Chest Radiography Needed After Percutaneous Nephrolithotomy?

To assess whether routine postoperative chest radiography (CXR) is required after percutaneous nephrolithotomy (PCNL) for the detection and possible management of hydropneumothorax. It is the standard for many urologists to obtain routine postoperative CXRs after PCNL to assess for hydropneumothorax. However, it has been our experience that in the few patients who develop hydropneumothorax, the CXR findings almost never affect the clinical management. A retrospective review was performed of 214 PCNL procedures acquired from 2007 to 2010. The data analyzed included patient demographics, operative data, postoperative CXR findings, and complications. We reviewed 214 PCNL procedures, 49% of the 164 patients were men, with a mean age of 48 years and a mean stone burden of 2.4 × 2.5 cm. Renal access was obtained by the urologists in 47% of cases. Renal access was obtained in the upper pole (51%), midpole (26%), and lower pole (23%) through the 11th-12th intercostal space (21%) and below the 12th rib (78%). Renal access was unsuccessful in 2.8%. All patients underwent postoperative CXR. Only 2 patients (1%) had a hydropneumothorax, and both had clinical symptoms. One patient's postoperative CXR findings were minimal pleural effusion only. Both patients were treated with tube thoracostomy. The mean hospital length of stay was 1.6 days, and the mortality rate was 0.5%. Routine postoperative CXR is not needed after PCNL. Obtaining selective CXR when a recognized intraoperative hydropneumothorax has occurred, the physical examination reveals an abnormality, or the patient experiences respiratory difficulties in the postoperative period is safe, cost-effective, and reduces unnecessary radiation exposure to the patients.

An integrated approach for prescribing fewer chest x-rays in the ICU

Chest x-rays (CXRs) are the main imaging tool in intensive care units (ICUs). CXRs also are associated with concerns inherent to their use, considering both healthcare organization and patient perspectives. In recent years, several studies have focussed on the feasibility of lowering the number of bedside CXRs performed in the ICU. Such a decrease may result from two independent and complementary processes: a raw reduction of CXRs due to the elimination of unnecessary investigations, and replacement of the CXR by an alternative technique. The goal of this review is to outline emblematic examples corresponding to these two processes. The first part of the review concerns the accumulation of evidence-based data for abandoning daily routine CXRs in mechanically ventilated patients and adopting an on-demand prescription strategy. The second part of the review addresses the use of alternative techniques to CXRs. This part begins with the presentation of ultrasonography or capnography combined with epigastric auscultation for ensuring the correct position of enteral feeding tubes. Ultrasonography is then also presented as an alternative to CXR for diagnosing and monitoring pneumothoraces, as well as a valuable post-procedural technique after central venous catheter insertion. The combination of the emblematic examples presented in this review supports an integrated global approach for decreasing the number of CXRs ordered in the ICU.

1944 IS ROUTINE POST-OPERATIVE CHEST X-RAY NEEDED AFTER PERCUTANEOUS NEPHROLITHOTOMY?

You have accessJournal of UrologyStone Disease: New Technology/SWL, Ureteroscopic or Percutaneous Stone Removal1 Apr 20111944 IS ROUTINE POST-OPERATIVE CHEST X-RAY NEEDED AFTER PERCUTANEOUS NEPHROLITHOTOMY? Marc Bjurlin, Michael Jordan, Naveen Divakaruni, Jed Robinson, Lindsey Lombardo, Sandra Goble, Patricia Vidal, Traci Beck, and Courtney Hollowell Marc BjurlinMarc Bjurlin Chicago, IL More articles by this author , Michael JordanMichael Jordan Chicago, IL More articles by this author , Naveen DivakaruniNaveen Divakaruni Chicago, IL More articles by this author , Jed RobinsonJed Robinson Chicago, IL More articles by this author , Lindsey LombardoLindsey Lombardo Chicago, IL More articles by this author , Sandra GobleSandra Goble Chicago, IL More articles by this author , Patricia VidalPatricia Vidal Chicago, IL More articles by this author , Traci BeckTraci Beck Chicago, IL More articles by this author , and Courtney HollowellCourtney Hollowell Chicago, IL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2125AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To assess whether routine postoperative chest radiography (CXR) is required after percutaneous nephrolithotomy (PCNL) for the detection and possible management of a pneumothorax. It has become the standard of care by many urologists to obtain routine postoperative CXRs after open nephrectomy to assess for the presence of a pneumothorax. However, at our institution, very few patients have developed a pneumothorax postoperatively, and, furthermore, the CXR findings almost never affected the clinical management. METHODS A retrospective review of 214 PCNL's acquired from 2004 to 2010. Data analyzed included patient demographics, operative data, postoperative CXR findings, and complications. RESULTS We retrospective reviewed 214 PCNL's, 50% were male, with a mean age of 48 years, and mean stone burden was 2.4 x 2.5 cm. Renal access was obtained by the urologists in 43%. Upper pole renal access was obtained in 50%, mid-pole in 26%, and lower pole in 22% through the 11–12th intercostals space in 46% and below the 12th rib in 53%. Renal access was unsuccessful in 2.8%. All patients underwent a postoperative CXR. Only two patients (1%) had a pneumothorax of which one patient's CXR findings were normal immediately after surgery. One patient was managed with a chest tube, the other with a percutaneous thoracic drain. Most common complications included anemia (6%), tachycardia (6%), and sepsis (1.4%). Mean hospital length of stay was 1.6 days and mortality was 0.5%. CONCLUSIONS Routine postoperative CXRs are not needed after PCNL. Obtaining a selective CXR when a recognized intraoperative pnumothorax has occurred, the physical examination reveals an abnormality, or the patient experiences respiratory difficulties in the postoperative period is safe, cost-effective, and decreases the radiation exposure to patients. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e777 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marc Bjurlin Chicago, IL More articles by this author Michael Jordan Chicago, IL More articles by this author Naveen Divakaruni Chicago, IL More articles by this author Jed Robinson Chicago, IL More articles by this author Lindsey Lombardo Chicago, IL More articles by this author Sandra Goble Chicago, IL More articles by this author Patricia Vidal Chicago, IL More articles by this author Traci Beck Chicago, IL More articles by this author Courtney Hollowell Chicago, IL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Clinical Value of Routine Chest Radiographs in the First 24 Hours After Cardiac Surgery

Chest radiographs (CXRs) are obtained frequently in the intensive care unit (ICU). Whether these CXRs should be performed routinely or on clinical indication only is often debated. The aim of our study was to investigate the incidence and clinical significance of abnormalities found on routine postoperative CXRs in cardiac surgery patients and whether a restricted use of CXRs would influence the number of significant findings. We prospectively included all consecutive patients who underwent cardiac surgery during a 2-month period. Two or three CXRs were performed in the first 24 hours of ICU stay. After ICU admission and after drain removal, a clinical assessment was performed before a CXR was obtained. All CXR abnormalities were noted and it was also noted whether they led to an intervention. For the admission CXR and the drain removal CXR, a comparison was made between CXRs clinically indicated by the physician and those not clinically indicated. Two hundred fourteen patients were included. The majority of patients underwent coronary arterial bypass grafting (60%), heart valve surgery (21%), or a combination of these (14%). In total, 534 CXRs were performed (2.5 per patient). Abnormalities were found on 179 CXRs (33.5%) and 13 CXR results led to an intervention (2.4%). The association between clinically indicated CXRs and the presence of CXR abnormalities was poor. For 32 (10%) of the 321 admission and drain removal CXRs, clinical indications were stated by the physician beforehand. If these CXRs would not have been performed routinely, 68 abnormalities would have been missed, of which 5 led to an intervention. Partial elimination of routine CXRs in the first 24 hours after cardiac surgery seems possible for the majority of patients, but it is limited by the insensitivity of clinical assessment in predicting clinically important abnormalities detectable by CXRs.

No Role for Routine Chest Radiography in Stage I Seminoma Surveillance

BackgroundAfter orchidectomy, the standard management options available for stage I seminoma are surveillance, adjuvant radiotherapy, or adjuvant chemotherapy. The optimal follow-up protocol for surveillance is yet to be determined but includes frequent chest radiography (CXR) and computed tomography (CT) scan of the abdomen and pelvis (CT-AP). ObjectiveThe purpose of this study was to identify the modality that first detected relapse and to assess the value of the CXR in this setting. Design, setting, and participantsFive hundred twenty-seven patients with histologically confirmed stage I testicular seminoma were managed with surveillance at our institution between 1982 and 2005. Routine CXRs were performed with each CT-AP and were done every 4–6 mo for 7 yr and annually thereafter. The median follow-up was 72 mo (range: 1–193). MeasurementsMeasurements included the 5-yr relapse rate, overall survival, and disease-free survival to determine the modality that first detected relapse disease. Results and limitationsThe 5-yr actuarial relapse rate for the 527 patients was 14%. The 5-yr disease-free survival and overall survival were 85.7% and 98.6%, respectively. Seventy-three patients (97.3%) had an abnormal CT-AP and a normal CXR at relapse. One patient (1.3%) had an abnormal CT-AP with pulmonary metastasis on CXR and CT chest scan, and one patient (1.3%) had a biopsy-proven inguinal node metastasis with a normal CXR. No patient had a normal CT-AP or physical examination with an abnormal CXR at relapse. This is a single-center retrospective study based on a relatively small number of relapses and may be subject to bias. Confirmation of these results from other studies would be useful for wider clinical applicability. ConclusionsAll except one relapse were detected by CT-AP with no relapses detected on CXR alone; therefore, CXR may be omitted as routine imaging in surveillance protocols.