Procedural and Clinical Data plus Electrocardiographic Guidance Greatly Reduce the Need for Routine Chest Radiograph Following Central Line Placement To the Editor: We read with interest the article by Abood et al., 1 which addresses the prob- lems arising in relation to reducing the need of routine chest radiograph follow- ing central venous catheterization. In this elegant study, the investigators employed clinical judgments to correctly determine the appropriate placement of central ve- nous catheters and to exclude possible complications caused by the insertion pro- cedure. This approach was characterized by low sensitivity and specificity and was able to exclude the existence of mechan- ical complications in only 6% of the patients. In accordance with literature and our own experience, the presence of post-procedural complications was found to be most significantly related to the number of needle passes. However, we disagree with the conclusion that clinical judgment cannot reliably predict the presence of complications. Numer- ous studies have, in fact, supported the importance of clinical observations in predicting complications of central vein catheterization. 2 Moreover, several in- vestigators have questioned the need for routine chest radiograph and have already developed successful decision models with the goal of decreasing the procedural time and the cost of central vein catheter placement. 3,4 We believe that the clinical signs employed by Abood et al. were not sufficiently investigated to be able to exclude the presence of mechanical com- plications with high probability. Further- more, the present prediction model did not consider several important clinical signs. In our recently terminated study, which included 600 patients, we determined the procedural and clinical data that were more frequently associated with the pres- ence of post-procedural mechanical com- plications. The data were obtained from the first 200 patients and subsequently tested in the remaining 400 patients. These selected data, in association with the num- ber of needle passes required, were able to exclude the presence of major mechan- ical complications, such as pneumothorax, with a predictive value of 100%. The same approach also allowed us to exclude the pos- sible presence of minor mechanical compli- cations with a predictive value of more than 90% (data submitted for publication). Moreover, we believe that the proce- dural aspects employed by the author to predict the presence of misplacement were not sufficiently specific for this purpose. As we would expect, malpositioning was, in fact, identified in only 20% of proce- dures. In the past, electrocardiography (ECG)-guided methods have been pro- posed as a way to check the positioning of the central venous catheter during catheter introduction. Right atrial ECG in particu- lar is a simple, reliable, and rapid method of positioning of a central venous catheter, although the accuracy of the catheter tip placement is controversial. Several studies have, however, demonstrated that the catheter is accurately positioned by this technique, and it would virtually eliminate the major risk of death associated with major misplacements. 5–7 This technique was used in the group of 400 patients, and we were able to exclude the presence of life threatening, as well as non-life threat- ening, malpositioning with a predictive negative value ranging from 99.4 –100%. Our experience, therefore, emphasizes the idea that if the central venous is accessed at the first pass of the introducer needle, the negativity of selected clinical signs ensures the absence of mechanical complications. This approach also eliminates the impact caused by individual operator skills. Finally, the presence of a satisfactory catheter tip ECG, appropriate assessment of which can be learned by brief training, is a marker for correct placement of the central line. We, therefore, truly encourage the development of a decision model based on the association of procedural and clinical data and ECG guidance, which may greatly decrease the need for routine chest radiographs. We be- lieve this procedural approach to be appro- priate for a number of reasons. As well as being reliable, cost-effective, and timesav- ing, it may allow for a reduction in radiation exposure and an increase in hospital effi- ciency without decreasing patient safety. Vittorio Antonaglia, MD Giuseppe Ristagno, MD Giorgio Berlot, MD Cattinara University Hospital Trieste, Italy REFERENCES 1. Abood GJ, Davis KA, Esposito TJ, et al. Comparison of routine chest radiograph versus clinician judgment to determine adequate central line placement in critical ill patients. J Trauma. 2007;63:50 –56. 2. Bailey SH, Shapiro SB, Mone MC, et al. Is immediate chest radiograph necessary after central venous catheter placement in a surgical intensive care unit? Am J Surg. 2000;180:517–522. 3. Gray P, Sullivan G, Ostryzniuk P, et al. Value of postprocedural chest radiography in the adult intensive care unit. Crit Care Med. 1992;20:1513–1518. 4. Gladwin MT, Slonim A, Landucci DL, et al. Cannulation of the internal jugular vein: is postprocedural chest radiography always necessary? Crit Care Med. 1999;27:1819 – 1823. 5. McGee WT, Ackerman BL, Rouben LR, et al. Accurate placement of central venous catheters: a prospective, randomized, multicenter trial. Crit Care Med. 1993;21:1118 –1123. 6. Gebhard RE, Szmuk P, Pivalizza EG, et al. The accuracy of electrocardiogram-controlled central line placement. Anesth Analg. 2007;10:65–70. 7. Watters VA, Grant JP. Use of electrocardiogram to position right atrial catheters during surgery. Ann Surg. 1997; 225:165–171. Letter to the Editor The Journal of TRAUMA  Injury, Infection, and Critical Care 1146 April 2008