Cannulation of the internal jugular vein: Is postprocedural chest radiography always necessary?

Objectives: To determine whether clinical features can be used in a decisio n rule to prospectively identify a subgroup of internal jugular catheter pl acements that are correctly positioned and free from mechanical complicatio ns, thus obviating the need for routine postprocedural chest radiographs in selected patients. Design: Prospective cohort study. Setting: Tertiary care teaching hospital. Patients: A total of 107 consecutive patients who presented to our catheter service for internal jugular catheter insertion because of clinical indica tions between November 1995 and April 1996. Exclusion criteria were mechani cal ventilation, an altered mental status, an age of <15 years, and a heigh t of <152 cm. interventions. Right or left internal jugular vein catheter p lacement followed by a postprocedural chest radiograph. Measurements: The operating physician completed a detailed questionnaire fo r each catheter insertion, designed to detect potential complications and t o predict the necessity, or lack of necessity, for a postprocedural chest r adiograph. The questionnaire documented patient characteristics, the number of needle passes, difficulty establishing access, operator experience, poo r anatomical landmarks, number of previous catheter placements, resistance to wire or catheter advancement, resistance to aspiration of blood or flush ing of the catheter ports, sensations in the ear, chest, or arm, and develo pment of signs or symptoms suggestive of pneumothorax. After catheter inser tion, chest radiographs were obtained to assess for mechanical complication s and malpositioned catheters. Main Results: In 46 cases, the decision rule predicted either a complicatio n or a malposition and, thus, the need for a chest radiograph. In 61 cases, neither was predicted (no chest radiograph was needed). Radiographs confir med one complication (pneumothorax) and 15 catheter tip malpositions (nine in the right atrium and six in the right axillary vein). Among the 46 cases predicted to have a potential complication or malposition, there were one actual complication (pneumothorax) and six actual malpositions (three axill ary vein malpositions and three right atrial malpositions). The positive pr edictive value of this decision rule is 15%. Among the 61 cases predicted t o he free from complications or malpositions and not to require a postproce dural chest radiograph, there were nine unexpected malpositions (three axil lary vein malpositions and six right atrial malpositions). The negative pre dictive value is 85%. The overall sensitivity of the decision rule for dete cting complications and malpositions is 44%, and the specificity is 55%. Conclusions:ln experienced hands, internal jugular venous catheterization i s a safe procedure. However, the incidence of axillary vein or right atrial catheter malposition is 14%, and clinical factors alone will not reliably identity malpositioned catheters. Chest radiographs are necessary to ensure correct internal jugular catheter position.