Is chest radiography necessary after uncomplicated insertion of a triple-lumen catheter in the right internal jugular vein, using the anterior approach?

STUDY OBJECTIVES: Chest radiographs are required in many institutions by protocol after the insertion of a right internal jugular vein triple-lumen catheter (TLC), even if the anterior approach is used. This study investigates whether correct placement can be predicted during insertion and whether a "routine" postprocedural chest radiograph can be safely omitted.

DESIGN: The operators included 18 first-, second-, or third-year medical residents, 3 pulmonary fellows, and a board-certified pulmonary medicine and critical care attending, with at least 1 certified physician present during the procedure. All operators were trained in the "seven number rule."

PATIENTS: One hundred consecutive patients who required central venous access. Patients with left internal jugular vein or subclavian catheters were excluded.

SETTING: Single institution, medical ICU, step-down unit, and floors.

INTERVENTIONS: Right internal jugular vein TLC insertion, anterior approach, with subsequent chest radiograph.

MEASUREMENTS AND RESULTS: Eighty-eight patients had uncomplicated insertions, as defined by fewer than four sticks with a 22-gauge pathfinder needle and fewer than four slides with the 18-gauge introducer needle. Ninety-eight catheters were in accurate position, 1 catheter was in the distal superior cava vein, and 1 catheter was in an S-shaped position.

CONCLUSIONS: It is safe to omit the routine chest radiograph after uncomplicated insertion of a TLC. i.v. treatment can be initiated early. However, if there is any doubt about the correct position, a chest radiograph should be obtained.