Ann Thorac Surg 1995;59:1150-1153
© 1995 The Society of Thoracic Surgeons
Assessment of the Value of the Immediate Postoperative Chest Radiograph After Cardiac Operation
Philip I. Hornick, FRCS,
Paul Harris, MB, BS,
Claire Cousins, FRCR,
Kenneth M. Taylor, FRCS,
Bruce E. Keogh, FRCS
Departments of Cardiothoracic Surgery and Radiology, Hammersmith Hospital, London, England
Accepted for publication January 18, 1995.
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Abstract
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The value of the immediate postoperative chest radiograph upon a patient's return to the intensive care unit after a cardiac surgical procedure is uncertain. This study represents a prospective analysis of the immediate postoperative radiograph in 100 consecutive adult patients undergoing cardiac operations. In 11 patients it was found that the routine postoperative radiograph was of value when it was necessary either to clarify or confirm clinical findings or to check the position of an intraaortic balloon catheter. For those chest radiographs that were deemed unnecessary, only one of 89 were found to be of clinical value. Furthermore, in those situations in which an emergency radiograph was obtained, the routine radiograph was not found to be contributory to patient management. We conclude that the policy of obtaining routine, immediate postoperative chest radiographs in the absence of a specific clinical indication provides virtually no additional clinical yield. Residents should therefore request radiographs only to check the position of an intraaortic balloon catheter, and to clarify or confirm a clinical diagnosis.
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Introduction
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See also page 1153.
After cardiac surgical procedures it is a common practice to routinely perform chest radiography upon return of the patient to the intensive care unit [1–3], but the contribution of this investigation to patient management needs to be assessed. Furthermore, at those times when a patient's hemodynamic or respiratory function, or both, subsequently deteriorate, another chest radiograph is usually obtained. Each chest radiograph increases the financial burden placed on the cardiothoracic unit. The purpose of this study was to assess the contribution of the first radiograph to patient management.
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Patients and Methods
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Between March 1993 and June 1993, 100 consecutive adult cardiac surgical patients were assessed clinically and by chest radiography immediately upon their return to the intensive care unit. There were 62 male and 38 female patients. The mean age of all patients was 63 years (range, 25 to 85 years). Operations were performed by either K.M.T., B.E.K., or P.I.H., and the patients underwent a variety of different adult cardiac surgical procedures (Table 1
). The average number of coronary artery bypass grafts per patient was 4.1, with a 92% use of the left internal mammary artery and a 3% use of the right gastroepiploic artery.
Figure 1 shows the methodology used to ascertain the clinical value of the immediate postoperative chest radiograph. Immediately upon the patient's return to the intensive care unit, a chest radiograph was obtained in all 100 patients. After this the resident (either P.H. or P.I.H.) made a full clinical assessment of the patient, which included a physical examination and assessment of hemodynamic, respiratory and renal function performed according to a strict protocol. The resident was then asked to record his findings and whether the patient's management should be altered, and, if so, the nature of the therapeutic change to be instituted. The resident was then asked whether he or she would like to see the chest radiograph that had been obtained. If the answer was affirmative, the reason for this was recorded (Results 1). Regardless of the decision made, the resident then recorded the chest radiograph findings for each patient. Information obtained from the chest radiograph was compared with that yielded by the resident's clinical assessment, and the contribution made by the radiograph to the patient's management was recorded (Results 2). Finally, if there was a need for an additional chest radiograph before chest drain removal, this was noted, together with the indication. The resident then assessed any contribution made by the first chest radiograph to the interpretation of the new radiograph (Results 3). A limitation of the study design was that, of necessity, the resident was not blinded as to the identity of the patients from whom the radiographs came. However, in an attempt to minimize any inherent bias, the chest radiographs of all patients were subsequently reviewed by a consultant radiologist (C.C.) and consultant cardiothoracic surgeon, independent of (and therefore blind to) the resident's findings. Finally, the consultant surgeon reviewed the clinical data (in the light of his and the radiologist's interpretation of the radiograph) to assess whether the clinical decisions made by the resident were appropriate.
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Fig 1. . Methodology used in the assessment of the immediate postoperative chest radiograph (CXR). (IABP = intraaortic balloon pump.)
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In this series atelectasis was defined as areas of subsegmental collapse, which is typically platelike or linear. Collapse was defined as obstruction of segmental or lobar airways with diminution of lung volume. Consolidation was characterized by an irregularly shaped increased density, ill-defined margins, a nonsegmental distribution, and the presence of an air bronchogram. Pulmonary edema encompassed both the radiologic forms of interstitial and alveolar edema. Any disparities in the interpretation of the radiologic studies and the management decided upon between the resident and the independent reviewer were recorded (Results 4).
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Results
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Results 1: Residents' Use of the Routine Immediate Postoperative Chest Radiograph
In 89 of the patients the resident deemed it unnecessary to view the immediate postoperative chest radiograph and considered the clinical assessment of the patient sufficient. In the remaining 11 patients whose studies the resident wished to see, this was done to confirm a clinical diagnosis in 2, to clarify the diagnosis in 5, and to check the position of an intraaortic balloon catheter in 4.
Results 2: Analysis of the Contribution to Patient Management Made by the Routine Postoperative Chest Radiograph
Of the 89 patients whose routine chest radiograph was deemed unnecessary by the resident, the information provided by this radiograph was found to be contributory to patient management for only 1 patient by revealing a malpositioned central line. In the remaining 11 patients, the routine chest radiograph was of use in clarifying or confirming clinical findings or in checking the position of an intraaortic balloon catheter. In these cases the routine chest radiograph had been deemed necessary by the resident. The results of the residents' analysis are summarized in Table 2.
Results 3: Assessment of the Value of the Routine Chest Radiograph When a Further Chest Radiograph Was Obtained Before Removal of Drains
In 15 patients it was necessary to obtain an additional radiograph before the removal of chest drains because of poor arterial blood gas levels or hemodynamic instability. In no patient was the routine postoperative chest radiograph found to be of value in the assessment of the newer radiograph, and the routine study was therefore deemed noncontributory to patient management.
Results 4: Independent Review of the Immediate Postoperative Radiograph and Clinical Management by a Consultant Radiologist and Consultant Cardiothoracic Surgeon
All immediate postoperative chest radiographs were reviewed retrospectively by a consultant radiologist and cardiothoracic surgeon. There was a 100% concordance in the specific radiologic abnormalities identified by both of them. There was an 89% concordance with the radiographic interpretation of the surgical resident. The results of the radiologist's and cardiac surgeon's interpretation for each abnormality taken in isolation are shown in Table 3. The most common abnormality observed was consolidation. No abnormalities were detected in 4 patients. In those 11 patients for whom there was discordance between the resident's interpretation of the routine radiographs and that of the independent reviewers (atelectasis, 5 patients; pleural effusion, 4 patients; lobar collapse, 2 patients), the clinical management of these patients recommended by the resident was, nonetheless, judged correct by the consultant cardiac surgeon.
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Table 3. . Radiographic Abnormalities Found on the Routine Postoperative Chest Radiographs by Consultant Radiologist and Consultant Cardiac Surgeona
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Comment
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The immediate postoperative chest radiograph obtained after a cardiac operation is a common practice but of uncertain value. Some units do not follow this practice [4, 5]. Furthermore, deterioration in a patient's condition frequently necessitates another chest radiograph (15% in this series).
Investigations performed routinely often have a limited impact on patient management. In this study the need for the immediate postoperative chest radiograph was evaluated by comparing the results of the clinical assessment and the patient management instituted both with and without the information furnished by this radiograph. In an attempt to eliminate any inherent bias and provide quality control in the resident's radiographic interpretation and decision regarding patient management, all data were subsequently analyzed by a consultant radiologist and a consultant cardiothoracic surgeon. In addition, the value of the immediate radiograph has been assessed from the standpoint of its providing baseline information for the evaluation of further chest radiographs obtained to identify the sources of hemodynamic instability or poor respiratory function.
The surgical resident deemed the routine postoperative chest radiograph to be of value in 11% of the patients. It was considered mandatory in patients who had an intraaortic balloon catheter to verify its position. This radiograph was also of clinical value when confirming the presence of a suspected pneumothorax. In this series the two pneumothoraces were suspected by the resident after clinical assessment, and confirmed by analysis of the chest radiograph. They would have been manifested before, or soon after, the patient's return to the intensive care unit. This radiograph would, however, have been of no value should they have occurred later. In addition, the routine radiograph was of value to the surgical resident in the 5 patients who required clarification of the clinical findings. In these 5 patients the radiographic diagnosis confirmed the presence of pulmonary edema.
The radiologic abnormalities observed after cardiopulmonary bypass encountered in our study differ from those reported by other authors [1–3, 5]. Postoperative atelectasis was not as common a finding as consolidation in these other studies.
The important finding of our study was that, of the 89 chest radiographs that were deemed unnecessary by the surgical resident, only one was found to alter patient management by detecting a malpositioned central line not suspected on the basis of the clinical assessment. Furthermore, in no patient in whom a second, later, chest radiograph was requested before drain removal was the initial chest radiograph helpful. The immediate routine postoperative chest radiograph is of value whenever the resident wishes to confirm or clarify the clinical findings noted at that time, or to check the position of an intraaortic balloon catheter. Our study findings demonstrate that, in the absence of a specific clinical indication, the immediate routine postoperative chest radiograph provides virtually no additional useful information and its omission would be a cost saving for any cardiothoracic unit.
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Footnotes
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Address reprint requests to Mr Hornick, Department of Cardiothoracic Surgery, Hammersmith Hospital, Du Cane Rd, London, England, W12 OHS.
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References
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- Gale GD, Teasdale SJ, Sanders DE, et al. Pulmonary atelectasis and other respiratory complications after cardiopulmonary bypass and investigation of aetiological factors. Can Anaesth Soc 1979;26:15–21.
- Goodman LR. Postoperative chest radiograph: II. Alterations after major intrathoracic surgery. Am J Roentgenol 1980;134:803–13.[Abstract]
- Wiener-Kronish JP. Postoperative pleural and pulmonary abnormalities in patients undergoing coronary bypass grafts [Editorial]. Chest 1992;102:1313–14.[Free Full Text]
- Chong JL, Pillai R, Fisher A, Grebenik C, Sinclair M, Westaby S. Cardiac surgery: moving away from the intensive care. Br Heart J 1992;68:430–3.[Abstract/Free Full Text]
- Aps C, Hutter JA, Williams BT. Anaesthetic management and postoperative care of cardiac surgical patients in a general recovery ward. Anaesthesia 1986;41:533–7.[Medline]
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Abstract
Introduction
