Objective: To find the ability of physicians to reliably predict in advance complications associated with insertion of temporary venous catheters (TVC), based on a clinical decision design to decide whether a X-Ray Chest (CXR) is warranted post procedure.
Study Design: Case series study
Place and Duration: Department of Nephrology, Pakistan Institute of Medical Sciences, Islamabad from March 01, 2009 to August 31, 2009.
Materials and Methods: This study included 518 consecutive catheterizations performed for hemodialysis, using either internal jugular vein (IJV) or subclavian vein (SCV) approaches. All procedures were performed using anatomical land mark technique without employing fluoroscopy and ultrasonography (USG) guidance. The procedures were categorized as Low or High Risk for complications depending upon intraoperative events. The operator was required to predict for complications of malposition and pneumothorax and thus need for CXR. A post procedure CXR was obtained in all placements.
Results: There were a total of 16(3%) mechanical complications, including 2(0.4%) pneumothorax, 1(0.2%) hemothorax and 13(2.4%) catheter malpositions. High risk group comprised 100 placements. Pneumothorax/Hemothorax were only observed in 3% of High Risk Group and 1.05% of SCV placements. The catheter malpositions, 6% in high risk and 1.67% in low risk did not have significant difference with SCV or IJV route. Prediction for the need or need not of CXR was correct in 98.5% and 96% of procedures in low and high risk groups respectively.
Conclusions: Routine CXR is of little benefit and may not be mandatory when correct size catheters are used and experienced physicians use the proper technique, clinical judgment and reasonable discrimination between low and high risk procedures while placing TVC for dialysis.
Key Words: Hemodialysis, Temporary Central Venous Catheters, Routine post procedure X-Ray Chest.

Introduction

Vascular access has a central role as the life line for hemodialysis (HD) therapy. The native arteriovenous fistula (AVF) is recommended as the access of first choice.¹ The most recent US Renal Data System (USRDS) Annual Data Report estimated the prevalence of Cath in incident HD patients at approximately 65%.2 Of the 70% incident dialysis patients on Catheter in DOPPS study, only 59% converted to permanent access in first year.³
The TVC continue to grow for short term and long term use in dialysis population because of being cheap and their ease of insertion at bed side without available support of such facilities as real time vascular ultrasonography (USG) and fluoroscopy in many of renal units. Routine post procedure CXR has been advised as mandatory before commencing dialysis therapy to identify procedure related immediate mechanical complications and particularly to ensure that Catheter is well positioned and no pneumothorax/hemothorax had resulted. Thus a considerable time delay may occur in initiation of therapy. The perception of time delay may prompt the resident staff to opt for a femoral access, with its attendant complications of infection, deep vein thrombosis and repeated need for further catheterizations. In addition an extra cost of radiography is added to hospital budget sources.
The value of post procedure CXR has remained controversial due to limited number of prospective studies in dialysis populations. Therefore the present prospective study sought to determine the ability of physicians to reliably predict in advance complications associated with insertion of TVC, based on a clinical decision design which is based on the procedure experience and patient’s symptoms and signs during the procedure to decide whether a CXR is warranted.

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