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<ul><li><p>Daily routine chest radiographs (CR) are com-monly performed in surgical ICU. UnnecessaryCR increase costs and expose the staff and thepatients to radiation risk. The goal of our stu-dywas to estimate the value of daily routine CR inthe ICU and to determine the correlation between CR and physical findings in surgical ICU pati-</p><p>ents. Prospective observational study was conductedduring period of two months at the ICU department atthe Clinic for Digestive Surgery, Clinical Center of Se-rbia, Belgrade. It included 97 consecutive patients whounderwent digestive surgery and stayed at the ICU forat least two days. During their ICU stay, CRs were ob-tained as a clinical routine or to monitor lung pathol-ogy. Patients were followed daily, and CRs (as the pro-portion of positive findings) were compared with phy-sical examination and clinical presentation. A total of717 CRs were obtained, median number per patientwas 4.0 (2.0-7.0). Proportion of positive findings wassignificantly higher comparing to auscultation untilthe sixth day of ICU stay. There was no difference inCR findings from day to day after the sixth day. The-rapeutic efficacy of CRs was low as only 56 (7.8%) re-sulted in a change of patient management. We conclu-de that daily routine CRs are justified in the first sixdays of ICU stay, and after that time they show no ad-vantages over clinical examination. </p><p>Key words: radiography, thoracic - intensive care unit -therapeutic efficacy - postoperative period</p><p>INTRODUCTION</p><p>Chest radiographs (CRs) are commonly performed insurgical intensive care units (ICUs). Some of themare obtained as dictated by protocols, after interven-</p><p>tions such as thoracotomy, central venous catheter pla-cement or intubation, and others for monitoring of</p><p>pulmonary pathology (pneumonia, atelectasis, pleuraleffusions, pneumothorax, etc).1</p><p>CRs are frequently made on a daily basis, as a part of asurgical ICU daily routine, irrespective of a patients cli-nical status and the clinical judgement of the intensivist.2</p><p>The main purpose of any CR is to reveal an abnormalitythat otherwise wouldnt be detected and help in diagnosticand therapeutic decision making. According to until re-cently valid recommendations of American College ofRadiology (ACR), routine daily CRs were indicated forpatients with acute cardiopulmonary problems and thosetreated with mechanical ventilation. Following of theserecommendations would include almost all ICU patients.However, this practice has become a subject of numerousdebates over the efficacy of CRs in ICU patients and thusthe value of routine daily monitoring. They resulted inchange of ACR guidelines which restrict the use of routi-ne daily CRs in patients with acute cardiopulmonary prob-lems and suggest follow-up CRs only when clinically in-dicated.3 CRs have high accuracy in detecting malpositionof medical devices used in critically ill patients such asendotracheal tubes, central venous lines and thoracicdrains.4 There are studies with findings that support dailyCRs in surgical ICU, in subpopulation of mechanicallyventilated patients and those with pulmonary artery cathe-ters.5,6 Many others advocate different strategy of obtain-ing on-demand CRs, when indicated and specifically re-quested by the intensivist. This approach is based on re-sults that showed low diagnostic and therapeutic efficacyof routine daily CRs, demonstrating that abandoning thispractice doesnt adversely affect clinical outcome of ICUpatients.7,8,9 Multiple studies have shown that daily CRsdont reveal new information, at the same time increasingcosts and exposing patients and the staff to radiation ri-sk.7,10</p><p>The practice of routine CRs in surgical ICU patients iswidespread in Serbia, and there were no studies to questi-on and confirm its value, specially in a limited resourcessetting.The aim of our study was to estimate the value ofdaily routine CRs in the surgical ICU and to determine theco-rrelation between CRs, clinical presentation andphysical findings.</p><p>. ........................................</p><p>Routine chest radiographs in the surgical intensivecare unit: Can we change clinical habits with noproven benefit?</p><p>Jelena V. Veli~kovi}1, Sanela A. Hajdarevi}1, Ivan G. Palibrk1,2,Nataa R. Jani}1, Marija Djukanovi}1, Bojana Miljkovi}1, DejanM.Veli~kovi}1,2, Vesna Bumbairevi}1,2 1Center for Anesthesiology and Reanimatology, Clinical Center ofSerbia, Belgrade2University of Belgrade, Faculty of Medicine, Belgrade </p><p>/STRU^NI RADUDK 617.3:616.24-073-7</p><p>DOI:10.2298/ACI1303039V</p><p>rezi</p><p>me</p></li><li><p>MATERIAL AND METHODS</p><p>We conducted a prospective observational study evalua-ting the clinical value of daily routine CRs during periodof two months. The study was performed at the ICU de-partment of the Clinic for Digestive Surgery, ClinicalCenter of Serbia, Belgrade which is a university-affiliatedteaching hospital, from November 2012 till January 2013.Its ICU is a 14-bed "open format" department with surgi-cal patients only and permanent physician staff consistingof one surgeon, one anesthesiologist and two residents. </p><p>The study included all patients expected to stay at theICU more than two days (after surgery or admission forother reasons) in whom CRs were performed according toICU protocol day after day. The ICU policy is to orderCR in all admitted patients soon after admission.</p><p>According to the study protocol, ICU physicians duringtheir morning round recorded patients clinical presentati-on and did the physical examination (inspection, ausculta-tion, thoracic percussion, etc). Afterwards, daily routineCRs were obtained in all mechanically ventilated patients,all patients with pulmonary pathology or thoracic surgeryand patients in whom chest recording was dictated by theprotocol of their surgical ward. Only routine CRs wereevaluated. Additional on-demand CRs, made later duringthe day, because of clinical deterioration or placement of anew device (ET tube, chest drain, central venous line, fee-ding tube) were not analyzed.</p><p>To evaluate the CRs, a formatted questionnaire was de-signed, including patients demographic data, diagnosis,surgery, indication for ICU admission and stay, as well asdata about comorbidities and preadmission CRs. Radio-logic section of the form contained radiologic findings,which were labeled for the sake of simplicity just as "posi-tive" or "negative". Radiologic positive findings were pre-defined as shown in Table 1. Physical examination resultswere also categorized as "positive" or "negative" on dis-cretion of the attending physician. It was also noticed ifCR finding influenced the change in patient managementplan and the physicians judgement about whether the CRwas clinically indicated. Therapeutic efficacy of CR wasexpressed as the ratio of CRs resulting in change oftherapy and the total number of CRs.</p><p>Data were prospectively collected and entered into adatabase (Microsoft Excel 2007). They are expressed asmean (+SD) or median (+IQR). CR findings (expressed asthe proportion of positive results) were compared withclinical presentation and physical findings. Data wereanalyzed with Cochrans Q test and differences werecompared with X2 test using statistical software (SPSSversion 19). P value &lt; 0.05 was considered statisticallysignificant.</p><p>RESULTS</p><p>During the two month study period, 97 patients wereevaluated through 108 ICU admissions (97 postoperativ-elly and 11 as ICU readmission). Since majority of read-missions were due to respiratory failure, for the sake ofcomparability, only postoperative admissions to ICU werefinally analyzed. A total of 717 daily routine CRs wereobtained (620 of them as routine daily control). The me-dian number of CRs per patient was 4.0 (IQR,2.0-7.0).Mean number of CRs taken prior to admission to ICU was</p><p>1.7(+ 1.1). The average length of ICU stay was 6.0 days(3.0-11.0) and the longest stay was 28 days. Mechanicalventilation was performed in 43 patients for at least oneday. Demographic and clinical patient characteristics arepresented in table 2.</p><p>The first evaluated routine daily CRs were done on thesecond day of patients ICU stay (first routine control). Of97 CRs obtained during that day, only 25(25.8%) revealeda predefined positive radiologic finding, while only15(15.5%) patients had a positive finding on auscultationand 14(14.4%) of them exhibited a clinical presentationindicating pulmonary abnormality (p=0.01). Proportion ofpositive findings on CRs was significantly higher com-paring to auscultation and clinical feature until the sixth</p><p>TABLE 1</p><p>PREDEFINED CR FINDINGS</p><p>Radiologic positive finding Comment</p><p>Pulmonary infiltrates Any type or size</p><p>Atelectasis Segmental or lobar</p><p>Pulmonary congrestion</p><p>Pneumothorax/Pneumomediastinum Any air collection</p><p>Pleural effusion</p><p>Mediastinal abnormalityMediastinal wideningor distension ofesophageal substituent</p><p>Device malposition</p><p>Central venous catheter Tip of the cahteter notin the superior vena cava</p><p>Tracheal tube </p></li><li><p>day of ICU stay, and after that there were no differencesuntil discharge from ICU, suggesting that a chest abnor-mality could have been detected similarly with CR andphysical examination (Table 3; Figure 1). There was nosignificant difference in CR findings from day to day afterthe sixth day (p&gt;0.05). </p><p>Total number of control CRs with positive findings was424 (out of 620; 68.4%) The most common CR abnorma-lities were pulmonary infiltrates, atelectases, severe pul-monary congestion, pleural effusion, malposition of endo-tracheal tube, malposition of chest drains, distension ofgastroplasty or coloplasty and pneumothorax. (Table 4)However, the therapeutic efficacy of CRs was very low asin only 56(7.8%) CRs positive finding resulted in a chan-ge of patient management (most commonly bronchosco-py, thoracocenthesis, thoracic drainage, administration ofantibiotics and diuretics).</p><p>Attending physicians considered that 401 out of 717CRs (55.9%) were unnecessary (not clinically indicated)and in just 6 cases those CRs resulted in a change of pati-ent therapy.</p><p>DISCUSSION</p><p>The present study was undertaken to investigate the va-lue of routine daily CRs in a surgical ICU and to compareit to physical examination and clinical presentation.</p><p>The main findings of our survey can be summarized asfollows: 1) The ability of daily routine CR to reveal moreinformation than physical findings and clinical feature istime dependent and is higher at the beginning of ICU stayand 2) Daily routine CRs have low therapeutic efficacy inpostsurgery ICU patients.</p><p>Although physical examination, lung auscultation andchest radiography are the most commonly used methodsof bedside clinical evaluation of lung pathology, to date,only a few studies have compared their diagnostic perfor-mance in ICU patients. Lichtenstein et al. prospectivelystudied 32 patients with ARDS in order to compare diag-nostic efficacy of auscultation, CR and lung ultrasoundwith computed tomography, when diagnosing three enti-ties of lung pathology: pleural effusion, alveolar consoli-dation and alveolar-interstitial syndrome.11 They foundthat the diagnostic accuracy of auscultation was 61% for</p><p>pleural effusion, 36% for alveolar consolidation and 55%for alveolar-interstitial syndrome, while for bedside CR itwas 47%, 75% and 72% respectively. Lung ultrasoundappeared to be the most sensitive and specific methodwith accuracy over 90%, and was the only one that couldquantify the extent of lung injury. Graat and coworkersshowed an extremely low sensitivity (2.1%) of ICU clini-cians in predicting abnormalities on daily routine CRs intheir prospective observational study conducted in a 28-bed mixed medical/surgical ICU.(8) It is very much incontrast with results of Bhangwanjee and Muckart whofound that sensitivity of examiners in predicting signifi-cant changes on CRs was 93% and 97%.12 The authorsconcluded that clinical examination can effectively predictthe need for CR in ventilated ICU patients. The differencein findings of previous studies might be the result of diffe-rences in study populations and ICU setting as well as stu-dy design, since in study of Bhangwanjee and Muckart thethorough auscultation was performed in search for abnor-malities, while in survey of Graat et al. the prediction ofCR changes was based rather on general impression of theattending physician.</p><p> Our results showed that CR abnormality couldnt havebeen accurately predicted with auscultation or clinical fea-ture during the first six days of ICU stay. Abnormalitiesthat couldnt have been detected with clinical examinationduring that time in majority of cases were new or progre-ssive pulmonary infiltrates, atelectases (less than 2 lobes)and malposition of medical devices. In one case, pneumo-thorax that required chest drainage was missed. Pulmo-nary infiltrates have been shown to be the most frequentlyunrecognized lung abnormality on physical examinationin majority of studies, although their nature and clinicalrelevance havent been specified.7,8 Diverse etiologies areresponsible for pulmonary infiltrates in surgical ICU pa-tients. In only 30% they are due to pneumonia, anotherthird origin from lung edema, while acute lung injury andatelectases account for the remaining.13 In our study, anypulmonary infiltrate (even minor) was treated as positiveradiologic finding which possibly overestimated their in-cidence and since the majority of patients were admittedto the ICU after major elective surgery (with normal CR),it may explain why clinicians didnt suspect pneumonia oracute lung injury during the first six days. The most</p><p>TABLE 3</p><p>POSITIVE FINDINGS ON CHEST RADIOGRAPH, AUSCULTATION AND CLINICAL PRESENTATION</p><p>Day Number of patients Chest radiograph Auscultation Clinical presentation P value</p><p>2 97 25 (0.26) 15 (0.16) 14 (0.15) 0.01</p><p>3 74 28 (0.38) 22 ( 0.30) 19 (0.26) 0.02</p><p>4 58 36 (0.62) 31 (0.53) 25 (0.43) 0.002</p><p>5 42 35 (0.83) 35 (0.83) 30 (0.71) 0.062</p><p>6 36 34 (0.94) 30 (0.85) 28 (0.78) 0.042</p><p>7 34 30 (0.88) 29 (0.85 ) 28 (0.82) 0.3</p><p>8 22 21 (0.95) 21 (0.95) 19 (0.86) 1.35</p><p>9 17 17 (1.00) 16 (0.94) 14 (0.82) 0.97</p><p>Data are expressed as number (proportion) of patients with positive findings</p><p>Br. 3 Routine chest radiographs in the surgical intensive care: 41can we change clinical habit with no proven benefit?</p></li><li><p>probable cause of lung infiltrates at the beginning of ICUstay in our survey was lung congestion due to positivefluid balance after major surgery. </p><p>Malposition of medical devices (central venous cathe-ters, endotracheal tubes, chest drains) was the second mo-st common cause of unexpected radiographic findings inour study. Malposition of the tip of central venous cathe-ter (usually placed during surgery) was observed on 8% ofradiographs with positive findings, but in only two casesplacement of a new central venous line was necessary.Krner at coworkers in the observational study involving857 surgical patients in whom CRs were done after admi-ssion at the ICU, found that routine CRs had diagnosticefficacy of 13%, and that 60% of positive findings wasdue to malposition of invasive devices. Anyway, therape-u...</p></li></ul>