Are routine chest radiographs still indicated after central line insertion? A scoping review

Abstract

Introduction:

Central venous catheters are increasingly inserted using point-of-care ultrasound (POCUS) guidance. Following insertion, it is still common to request a confirmatory chest radiograph for subclavian and internal jugular lines, at least outside of the operating theater. This scoping review addresses: (i) the justification for routine post-insertion radiographs, (ii) whether it would better to use post-insertion POCUS instead, and (iii) the perceived barriers to change.

Methods:

We searched the electronic databases, Ovid MEDLINE (1946-) and Ovid EMBASE (1974-), using the MESH terms (“Echography” OR “Ultrasonography” OR “Ultrasound”) AND “Central Venous Catheter” up until February 2023. We also searched clinical practice guidelines, and targeted literature, including cited and citing articles. We included adults (⩾18 years) and English and French language publications. We included randomized control trials, prospective and retrospective cohort studies, systematic reviews, and surveys.

Results:

Four thousand seventy-one articles were screened, 117 full-text articles accessed, and 41 retained. Thirteen examined cardiac/vascular methods; 5 examined isolated contrast-enhanced ultrasonography; 7 examined isolated rapid atrial swirl sign; and 13 examined combined/integrated methods. In addition, three systematic reviews/meta-analyses and one survey addressed barriers to POCUS adoption.

Discussion:

We believe that the literature supports retiring the routine post-central line chest radiograph. This is not only because POCUS has made line insertion safer, but because POCUS performs at least as well, and is associated with less radiation, lower cost, time savings, and greater accuracy. There has been less written about perceived barriers to change, but the literature shows that these concerns- which include upfront costs, time-to-train, medicolegal concerns and habit- can be challenged and hence overcome.

Introduction

Annually, countless central venous catheters (CVCs) are inserted worldwide, and increasingly this is facilitated by point-of-care ultrasound (POCUS).^1,2 While POCUS has changed how we insert CVCs, it has yet to have a similar impact on post insertion practise, namely, how we rule out complications and confirm line placement. It is still common to order a post-insertion chest radiograph (CXR) after internal jugular (IJ) or subclavian (SC) CVCs, at least in the Intensive Care Unit, and Emergency Department. ³ This scoping review examines (i) whether routine CXRs are still justified following thoracic CVCs, (ii) whether post-insertion confirmation could be improved using POCUS instead, and (iii) the perceived barriers to change.

The post CVC CXR is typically justified as a way to screen for complications and to confirm catheter tip placement. Alternatively, it may be little more than an unexamined habit or an anachronistic protocol. For example, even before the advent of POCUS, most practitioners were content to postpone CXRs after CVCs were inserted in operating suites (OSs), and when vasoactive infusions could not wait. This is because those CXRs rarely changed management and commonly caused delays. Importantly, the routine use of POCUS has made CVC line insertion safer still.^1–6 However, many are still ordering CXRs after CVC insertion even though thoracic CVCs are even less likely to be associated with pneumothorax (PTX) (<0.5%), catheter misplacement (<2.0%), or the perceived need for post-insertion catheter adjustment (<0.5%). ⁴ Moreover, those CXRs can still miss a small or loculated pneumothorax (PTX), especially in supine patients. ⁵

When it comes to confirming CVC placement after insertion, and screening for complications, POCUS offers many putative advantages over CXR. These include lower cost, less delay, less radiation, no need to move patients, no need to break the sterile field, and greater accuracy.^1–6 We therefore explore the evidence base surrounding POCUS confirmation after upper extremity CVC insertion^6–21 because it is less well known than that supporting POCUS during insertion, and because it may be time to forego the post insertion CXR.^{1,2,4,22–28} There has also been comparatively little discussion regarding resistance to change and therefore this is reviewed too. Overall, we explore the benefits of foregoing the routine CXR, and switching to POCUS, a technology that is (quite literally) already at hand.

Methods

This scoping review followed a comprehensive search of electronic databases including Ovid MEDLINE (1946-), Ovid EMBASE (1974-) using the MESH terms (“Echography” OR “Ultrasonography” OR “Ultrasound”) AND “Central Venous Catheter” and screened relevant articles, up until February 2023. We searched additional literature including clinical practice guidelines, and targeted literature, including cited and citing articles. We included adults (⩾18 years old) and limited to the English and French language. We included primary studies (RCTs, prospective and retrospective cohort studies), systematic reviews and surveys. We excluded case reports, case series, and articles that did not address ultrasound confirmation techniques, Lung-US, or US related to CVC insertion. We extracted data points onto Excel, grouped by type of technique: design, operators, technique, comparator, results, time to perform, feasibility, and reported barriers (Tables 1–3). All steps were performed in duplicate by two authors (JD, LM), with disagreements arbitrated by a third author (BB).

Table 1.

Primary studies regarding the use of ultrasound to screen for central venous line placement and complications.

Study	Design and population	Operators	Technique	Comparator	Results	Time to perform	Feasibility	Barriers/Benefits
B-Mode Vascular and CVC tip identification
Bedel (2013)	Design: Prospective Cohort Monocentric Population: >18 years old Patients: 98 CVC: 101	Insertion: Attending (1) US: Attending (1) US training: US trained (1/1)	Insertion: USG and LM US: Guidewire detection and length measure in SC window. CVC tip identification in SC 4C window Lung US	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection (ITT): Sn 96% (90–98%) Sp 83% (44–97%) PPV 98% NPV 55% Malposition detection (PP): Sn 100% Sp 83% PPV 98% NPV 100% Complications: None	Measured post-insertion US: Mean 1.76 min ± 1.3 min CXR: Performed: 49 min ± 31 min Interpreted (radiologist): 103 min ± 81 min	Visualization: Catheters: 96% (97/101) Patients: 96% (94/98) Limitation: Poor windows	Technical (single operator required with right sterile setup). Patient (obesity, post abdominal surgery).
Dillemans (2020) Abstract	Design: Monocentric cohort Population: Critically ill patients Patients: 34 CVC: 34	Insertion: Not mentioned US: Not mentioned US training: Not mentioned	Insertion: Not mentioned US: Guidewire visualization in the right atrium Lung US for slide	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection: 70.6% PPV 100% NPV 9.1% Complications: no pneumothorax	Not mentioned US: Not mentioned CXR: Not mentioned	Visualization: 70.6% Limitation: 10 false negative TTE	Technical: Single operator, small sample size
Galante (2017)	Design: Prospective Cohort Monocentric Consecutive Population: >18 years old ICU CVC: 68	Insertion: IM resident (1) ICU residents (2) US: IM resident (1) ICU residents (2) US training: POCUS trained (3/3)	Insertion: USG for right IJ LM for right SV US: Guidewire detection/position adjustment in SC window. Alternate vascular site verification Lung US	Comparator group: Historical controls (92 consecutive LM technique patients) Comparator modality: CXR	Adequate position post-procedure: US: 86.7% (59/68 CVC) LM: 55.4% (51/92 CVC) Complications: Study group: 0 PTX Control group: 3 PTX	Measured post-insertion US: Mean 15 min. CXR: Interpreted (radiologist): Study group – mean 2.4 h Control group – unavailable	Visualization: 94% (64/58)	Technical – single operator feasible. Access to US easy now. False sense of security.
Bowdle (Jelacic) (2016)	Design: Prospective Cohort Monocentric Consecutive Population: >18 years old CV surgery Patients: 200	Insertion: Not mentioned US: Not mentioned	Insertion: USG RIJ US: Guidewire detection to brachiocephalic vein. Others: Pressure transducer	Comparator group: Same cohort as intervention Comparator modality: Not applicable.	Adequate position (brachiocephalic wire localization): 97.5% (195/200) No direct comparison to CXR.	Not mentioned	Visualization: 99% (198/200 brachiocephalic veins) Limitation: Obesity	Patient – Obesity, Pacemaker
Kebaili (2017)	Design: Prospective observational study Population: Pediatric intensive care unit patients Patients: 60 CVC: 60	Insertion: Not mentioned US: Not mentioned US training: Not mentioned	Insertion: USG US: Ultrasound tracking of CVC path and tip Lung US	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection: 100% Complications: No pneumothorax	Measured post-insertion US: Not mentioned CXR: 120 min (20–540)	Visualization: Catheter tip (72%) Limitation: Poor windows	Technical: Not mentioned Patient: Not mentioned
Kim (2016)	Design: Prospective Cohort Monocentric Population: >18 years old Orthopedic surgery Patients: 20	Insertion: Trained operator (1) (Anesthesia) US: Trained operator (1) (Anesthesia)	Insertion: USG supraclavicular Right SV US: Guidewire detection past RPA through supraclavicular SVC/RPA window	Comparator group: Same cohort as intervention Comparator modality: CXR Imaging review: CXR reviewer blinded.	Concordance (US/CXR): 100% Complications: None	US: Time to venipuncture: Mean 25 ± 5 min. Venipuncture to CVC placement confirmation: 1 min 05s ± 59s	Visualization: 90% (18/20) Limitation: Not mentioned	Technical – access to microconvex probe. More challenging in-place technique with microconvex probe.
Kim (2015)	Design: Prospective Cohort Monocentric Consecutive Population: >18 years old Elective surgery Patients: 48	Insertion: Trained operator (2) (Anesthesia) US: Trained operator (2) (Anesthesia)	Insertion: USG Right IJ US: Guidewire detection past RPA through supraclavicular SVC/RPA window	Comparator group: Same cohort as intervention Comparator modality: CXR TEE Intracardiac ECG Body-height formula Imaging review: CXR reviewer blinded, not for other methods.	Concordance (US/CXR): 100% Distance prediction (US/CXR): Difference 1.63 cm (−1.73–4.99 cm) Distance prediction (Peres/CXR): Difference 1.16 cm (−1.94–4.26 cm)	US: Time to venipuncture: 7 min 47s ± 30s Venipuncture to guidewire placement: 11 min ± 43s CXR: Start of procedure to radiologist read: 1h51min 06s ± 31min 39 s	Visualization: 91.6% (44/48) Limitations: Poor windows.	Technical – CVC tip not as well seen. Limited availability of microconvex probe. CXR not accurate compared to other techniques for placement. Rhythm limits application of ECG.
Kosaka (2019)	Design: Prospective Cohort Monocentric Population: ⩾20 years old External JV General anesthesia CVC: 63	Insertion: Anesthesia attending (1) US: Anesthesia attending (1)	Insertion: Unclear US: Guidewire detection at junction SVC/RPA through supraclavicular SVC/RPA window	Comparator group: Same cohort as intervention Comparator modality: CXR Peres formula Imaging review: Blinding not mentioned	Malposition detected (US/Total insertions): US − 6.5% (4/63). No direct comparison to CXR. Correlation coefficient (US/CXR): Kappa 0.73 (p < 0.001) Correlation coefficient (Peres/CXR): 0.27 (p = 0.03)	Not mentioned.	Visualization: 98.4% (62/63) Limitations: Poor window – obesity Other: 14/77 screened patients excluded as could not insert catheter	Technical – access to equipment. Training – Technical proficiency
Maury (2001)	Design: Prospective Cohort Monocentric Non-consecutive Population: Adult ICU Ward Patients: 81 CVC: 85	Insertion: ICU attending (3) US: US physician (3) US training: Trained for study (3)	Insertion: LM US: Bilateral IJV and SV Detection of CVC tip in SC 4C window Lung US.	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection (US/CXR): 90% (9/10 malpositions) Concordance (US/CXR): 98.8% (84/85) Complications: Arterial punctures (6) PTX (1)	Measured post-insertion US: 6.8 min ± 3.5 min CXR: 80.3 min ± 66.7 min	Visualization: 99.6% Limitations: Poor window – Obesity, COPD	Patient – obesity and COPD. Benefits – Mobile and can be used in any setting. Easily teachable technique.
Nikouyeh (2020)	Design: Prospective cross-sectional study Population: Dialysis and plasmapheresis patients Patients: 117 CVC: 117	Insertion: attending US: Sonographer US training: Not mentioned	Insertion: USG US: Catheter tip visualization	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection: 3/117 (2.6%) Complications: None	Not mentioned US: Not mentioned CXR: Not mentioned	Visualization: catheter tip (94.9%) Limitation: Poor windows	Technical: Not mentioned Patient: Not mentioned
Panda (2021)	Design: Cross-sectional observational study Population: Adult patients in ICU Patients: 80 CVC: 80	Insertion: Anesthesiologist US: Anesthesiologist US training: Not mentioned	Insertion: USG US: Subxyphoid, apical four chamber, PSSAX Lung US	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection: 9/80 CVC misplaced Sn 100% Sp 100% Complications: 2.5% arrhythmias 2.5% arterial puncture	Measured post-insertion US: 13.56 min (4.98) CXR: 70.3 min (3.56)	Visualization: 100% Limitation: Not mentioned	Technical: View adequacy not described or quantified Correct position described as no CVC in RA Patient: BMI 24.8 (±4.12)
Raman (2019)	Design: RCT Monocentric Population: ⩾18 years old MICU Patients: 60	Insertion: ICU attending ICU fellow US: ICU attending ICU fellow US training: Additional training for study.	Insertion: USG US: Guidewire detection/position adjustment in SC 4C window Lung US.	Comparator groups: Group A – CXR Group B – US Comparator modality: Two group comparison Imaging review: Insertion team blinded to protocol Insertion team not blinded to procedure	Complications: No PTX. No CLABSI. No CVC malpositioned. Reduction in CXR: 60%	Measured post-insertion US: Mean 25.0 min ± 30.8 min CXR: Mean 53.6 min ± 34.1 min No difference in insertion time between groups.	Visualization: 100% Limitations: Not mentioned.	None reported.
Zick (2017) abstract	Design: Prospective, blinded, observational study Population: ER patients Patients: 210 CVC: 210	Insertion: EM trained residents and faculty US: EM residents and faculty US training: Ultrasound course (24 h) and supervised scans	Insertion: USG for IJ, LM for SC US: Apical and subcostal cardiac, IJ and SC veins bilaterally, lung US	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection: 5/9 visualized US Sn 94% Sp 89% PPV 91% NPV 93% Complications: Pneumothorax (5/210) – 3 iatrogenic	Measured post-insertion US: 5 min (±3) CXR: 65 min (±74)	Visualization: 117 (55%) Limitation: 6/210 – died before CXR could be completed	Technical: Single operator for insertion and diagnosis. Does not assess for CVC tip in smaller central veins. Patient: Patients with abnormal chest structure had much lower specificity (64%), sensitivity (75%), PPV (75%), and NPV (64%)
RASS
Aherne (2017) abstract	Design: Prospective Cohort Monocentric Population: ER and ICU Patients: 91 CVC: 9	Insertion: EM trained residents and faculty US: EM residents and faculty US training: Trained by investigators	Insertion: USG US: Subxyphoid, parasternal long or apical four Lung US	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection: 1% Complications: None	Measured post-insertion US: 21 (IQR 10,25) CXR: 49	Visualization: 100% Limitation: Not mentioned	Technical: Not mentioned Patient: Not mentioned
Amir(2017)	Design: Prospective Cohort Monocentric Population: Adults OR ICU Patients: 137	Insertion: Not mentioned US: Not mentioned	Insertion: USG US: RASS in SC 4C or SC bicaval window Lung US	Comparator group: Same cohort as intervention Comparator modality: CXR	Concordance (US/CXR): 97.6% (121/124 CVC) Complications: None	Not mentioned	Visualization: 90.5% (124/137) Limitations: Poor window – obesity, sterile draping.	Technical – Sterile technique may limit optimal image acquisition in some cases. Some specific probes may be unavailable
Baviskar (2015)	Design: Prospective Cohort Monocentric Population: Adults SICU CVC: 119	Insertion: Senior attending US: Senior attending US training: Previously trained in ED US	Insertion: USG US: Agitated saline in SC 4C window Other: Endovenous manometry	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection: Sn 100% (80–100%) Sp 100% (80–100%)	Measured post-insertion US: Mean 45s ± 30–60 s CXR: Mean 20 min to >60min	Not mentioned (all patients analyzed)	None mentioned
Duran-Ghering (2015)	Design: Prospective Cohort Monocentric Convenience Population: >18 years old Patients: 50	Insertion: Not mentioned US: ED residents (2) US training: Previous 1 month rotation in US	Insertion: Not mentioned US: RASS in SC 4C view Lung US	Comparator group: Same cohort as intervention Comparator modality: CXR Imaging review: CXR reviewer blinded.	Malposition detection (US/CXR): 33% (1/3 CVC) Complications: PTX – 2 (all detected by US)	Measure post-insertion US: Mean 5 min (95% CI 4.2–5.9) CXR: Performed – Mean 28.2 min (95% CI 16.8–39.4) Radiologist – 294 min (203.5–384.5) Mean difference: 23.1 min (−34.5 to −11.8)	Visualization: 92% (46/50) Limitations: Poor windows.	Training – need specific training to the protocol used.
Gekle (2015)	Design: Prospective Cohort Monocentric Population: >18 years old ED Patients: 68	Insertion: ED physicians US: ED physicians US training: Not mentioned	Insertion: USG US: RASS in SC 4C or PLAX window Lung US.	Comparator group: Same cohort as intervention Comparator modality: CXR Imaging review: Blinded faculty review committee	Not applicable Complications: None.	Measured post-insertion US: 8.80 min (95% CI 7.46–10.14) CXR: ED physician read 45.78 min (95% CI 37.03–54.54) Average difference 36.98 min (p < 0.001)	Not mentioned	None mentioned
Korsten (2018)	Design: Prospective Cohort Monocentric Population: ⩾18 years old ICU Intermediate care Patients: 101 (reference and test cohort)	Insertion: Residents Senior residents US: Residents Senior residents US training: Teaching session 30–60 min.	Insertion: USG for IJ USG or LM for SV US: RASS in SC 4C or Apical 4C window	Comparator group: Same cohort as intervention Comparator modality: CXR Imaging review: CXR reviewed by radiologist (blinded) and operator (not blinded)	Malposition detection: Sn 100% (73.54–100%) Sp 94.32% (87.24–98.13%) PPV 70.59% (44.04–89.09%) NPV100% (95.65–100%) Correlation coefficient RASS/CXR for present vs delayed vs absent: Kappa 0.726 (0.488–0.964) Correlation coefficient RASS/CXR for present vs absent: Kappa 0.772 (0.533–1.0) Complications: PTX (1)	Measured post-insertion US: Reference cohort- Median 5 min (2-11) Test cohort – Median 5 min (1-28) CXR: Reference cohort – Median 59.5 min (21–130) Test cohort – Median 48.5 min (13–254) Difference time US/CXR: Reference cohort - p = 0.002 Test cohort – p < 0.0001 for shorter by US.	Visualization: 99% (100/101) Limitations: Poor windows – obesity	Patient – obesity. Technical – Most important limitation is image quality. Training – Minimal training sufficient. Benefit – cost saving.
Weekes (2014)	Design: Prospective Cohort Monocentric Convenience Population: >17 years old IJ, SC, Femoral Patients: 142 CVC: 150	Insertion: ED residents (3) ED attending (2) US: ED resident (3) ED attending (2) US training: ED residents with 1-month long block Attending with previous US training.	Insertion: Unclear US: RASS in SC 4C window	Comparator group: Same cohort as intervention Comparator modality: CXR Imaging review: CXR reviewed by operator (not blinded) PI inconsistently blinded.	Malposition detection: Sn 75% Sp 100% PPV 100% NPV 99.24% Complications: No PTX.	Not mentioned	Visualization: 96.6% (142/147) Limitations: Poor windows.	Technical: Optimal placement as gold standard is problematic. Method doesn’t identify arterial placement, nor precise location in the SVC or innominate. Patient – Unclear for LCOS states.
CEUS
Che Rahim (2022)	Design: Prospective monocentric interventional Population: >18 years old Patients: 45 CVC: 45	Insertion: Trained medical officer US: Credentialed junior ICU and echocardiography fellow US training: Echocardiography credential	Insertion: USG US: Guidewire detection – RVI-PLAX D50 contrast	Comparator group: Same cohort as intervention Comparator modality: Ultrasound	Malposition detection: 33% Complications: Hyperglycemia	NR	Visualization: 0 J-wires visualized Limitation: only 75% of patients screened included in study due to RVI-PLAX view	Technical: 3 staff required for procedure Handheld US used Patient:
Corradi (2016) abstract	Design: Prospective Cohort Monocentric Population: Adults ICU CVC: 47	Insertion: ICU nurses US: ICU nurses	Insertion: Unclear US: CEUS Lung US	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection: Sn 100% Sp 98% Concordance (US/CXR): kappa 0.91, p < 0.01 Complications: PTX (1)	Measured post-insertion US: Mean 10 min ± 3 CXR: Performed – Mean 25 min ± 8	Not mentioned	Not mentioned
Cortellaro (2014)	Design: Prospective Cohort Monocentric Convenience Population: Adults ED Patients: 71	Insertion: ED attending (2) Anesthesia attending (1) Resident (1) US: ED attending (2) Anesthesia attending (1) Resident (1) US training: Previously trained	Insertion: USG US: CEUS in SC 4C or apical 4C window	Comparator group: Same cohort as intervention Comparator modality: CXR Imaging review: Operators blinded to CXR Radiologist blinded to CEUS	Malposition detection: Total: 9 CVC Sn 33% (0–71%) Sp 98% (95–100%) NPV 94% (89–100%) PPV 67% (13%−100%) Interobserver concordance: Kappa 0.65 (0.01–1)	Measure post-insertion US: Mean 4 min ± 1 CXR: Interpreted (radiologist) Mean 288 min ± 216	Visualization: 100% Limitations: None mentioned	Technical – poor sensitivity. Not mentioned as barriers, but talk about no need for technician, easily learned, more accurate for complications.
Tecchi (2021) abstract	Design: Single center Population: NR Patients: 99 CVC: 99	Insertion: NR US: NR US training: NR	Insertion: USG and LM US: Contrast-enhanced Apical four-chamber, subcostal short-axis, TEE	Comparator group: same cohort as intervention Comparator modality: TEE	Malposition detection: TTE subcostal 96% accuracy, Sn 96% Sp 98% TTE apical 69% Sn 18% Sp 97% CXR 77% accuracy Sn 38% Sp 94% Complications: NR	US: NR CXR: NR	Visualization: NR Limitation: Single center, no information on operator or provider available	Technical: TEE used as gold standard not CXR Intravascular and intracardiac position considered together Contrast type not specified
Wen (2014)	Design: Prospective Cohort Monocentric Consecutive Population: Adults IHD CVC: 219	Insertion: Experienced proceduralist US: Experienced proceduralist US training: Previously trained with basic knowledge	Insertion: USG US: CEUS in SC 4C window	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection: Total: 2 CVC Sn 100% Sp 100% Complications: None	Measured post-insertion US: Mean 3.2 min +-1.1 CXR: Performed – Mean 28.3 min ± 25.7	Not mentioned.	None mentioned. Benefits – reducing total cost, time saving, exposure to radiation, suitability in emergency situation.
Combined/integrated techniques
Ablordeppy (2019) abstract	Design: prospective Cohort Monocentric Population: ER and ICU Patients: 199	Insertion: NR US: Emergency medicine senior residents Critical care fellows US training: NR	Insertion: NR US: Pleural slide RASS Absence of turbidity in neck vessels	Comparator group: same cohort as intervention Comparator modality: CXR	Malposition detection: ED Sn 1.00 Sp 0.98 (0.96–1.01) ICU Sn 0.25 Sp 0.98 Complications: ED NPV: 0.951 ICU NPV: 0.98	Measured post-insertion US: 9.0 min (9-10) CXR: 55 min (38–72)	Visualization: NR Limitation: Incomplete ultrasound protocol in 65 patients	Technical: NR Training: NR
Al Qsous (2019)	Design: Prospective Cohort Monocentric Population: ICU Patients: 38 CVC: 38	Insertion: NR US: NR US training: NR	Insertion: NR US: Pleural slide RASS	Comparator group: same cohort as intervention Comparator modality: CXR	Malposition detection: NR Complications: 100%	Measured post-insertion US: NR CXR: 32 min to complete, 49 min prelim read	Visualization: 100% Limitation: None	Technical: NR Patient: NR Missing information on time to US vs CXR
Arellano (2014)	Design: Prospective Cohort Monocentric Population: >18 years old CV surgery Patients: 100	Insertion: Cardiac anesthesia attendings Senior anesthesia residents US: Cardiac anesthesia attendings (2) Medical students (novice) (2) US training: Novice: 10 patients scanned previously. Expert: NBME advanced perioperative TEE and 2 days TTE training.	Insertion: USG RIJV US: CEUS after needle puncture in SC 4C or apical 4C window Guidewire detection/position adjustment in SC 4C or apical 4C window	Comparator group: Novice between themselves and compared to expert. Comparator modality: Not applicable	Interobserver correlation: Novice vs novice: No difference RA: p = 0.24 CEUS: p = 0.27 Guidewire p = 0.06 Expert vs novice No difference: p > 0.25	Not mentioned	Visualization: RA: 94% (87–98%) CEUS: 91% (84–96%) Guidewire: 91% (84–96%) If RA seen CEUS: 97% Guidewire: 97% Limitations: None mentioned.	Patient – High BMI. Technical − 2 person needed, longer time to perform, sterility. Limited impact of sterility. Training – optimal amount of training required for proficiency.
Blans (2016)	Design: Prospective Cohort Monocentric Population: >18 years old Ward Patients: 53	Insertion: Attendings Residents US: Experienced operators (2) US training: Not mentioned.	Insertion: USG US: Ipsilateral IJ and SV scan CEUS in SC 4C or apical 4C view Lung US	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection: Total: 4 Sn 98% (89.4–100%) Concordance (US/CXR): 94.2% (49/52 CVC) Complications: None	US: Venipuncture to end Mean 17 min ± 8.6 CXR: Performed Median 24.5 min (IQR 8.1–45.3)	Visualization: 98.1% (52/53) Limitations: Poor window – obesity, abdominal surgery.	Technical – only people with US skills can perform. Patient -(obesity, abdominal surgery).
Da Hora Passos (2019)	Design: Prospective Cohort Monocentric	Insertion: Experienced operators (3) US: Experienced operators (3)	Insertion: USG US: CVC tip detection in SC 4C window CEUS in SC 4C window Lung US.	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection: Sn 100% Sp 100% Complications: None	Procedure US: Venipuncture to end Mean 23.4 ± 4.3 Lung US: Mean 2.4 min CXR: Performed Mean 60 min ± 6	Not mentioned.	Technical – risk of ischemic CVA. Training – require training.
Ghattas (2017) abstract	Design Monocentric cohort Population NR Patients: 36 CVC: 36	Insertion: Internal medicine interns & residents (IMIR) US: IMIR, critical care fellow supervision US training: Training in cardiac and thoracic ultrasound	Insertion: NR US Pleural slide pre and post insertion RASS	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection: 100% Complications: No pneumothorax, 1 malposition	US: NR CXR: NR	Visualization: 33/36 (91.7%) Limitation: none	Technical: First CVC insertion for all operators Missing information on time to US vs. CXR
Kamalipour (2016)	Design: Prospective Cohort Monocentric Consecutive Double-blind Population: Adults CV surgery Patients: 116	Insertion: Anesthesia resident US: Anesthesia resident anesthesia resident. US training: Theory teaching 2 days + 150 CEUS studies	Insertion: LM US: CEUS in SC 4C or epigastric window Axillary or IJV vascular scan if negative CEUS	Comparator group: Same cohort as intervention Comparator modality: CXR Imaging review: CXR and US reviewer blinded to other modality	Malposition detection: Total: 11 CVC Sn 98% Sp 69% PPV 95% NPV 85% Concordance (US/CXR): 93.3% (97/104 CVC) Kappa 0.72	Not mentioned	Visualization: 89.7% (104/116) Limitations: Poor windows.	Patient – Acoustic window.
Iacobone (2020)	Design: Prospective cohort monocentric Population: >18 years old Patients: 42	Insertion: Unclear US: Expert physician	Insertion: USG US: CVC tip location in SC 4C or apical 4C RASS or CEUS Lung US	Comparator group: Same cohort as intervention Comparator modality: CXR Imaging review: CXR unclear US by operator	Malposition detection: Total: 2 CVC	Not mentioned	Visualization: 41/42 Limitations: Acoustic window	Patient – BMI
Meggiolaro (2015)	Design: Cohort Monocentric Population: >18 years old OR Patients: 105	Insertion: Anesthesia attendings Anesthesia residents US: Anesthesia attending (1) US training: Not mentioned	Insertion: USG US: IJV and SV vascular scan CVC tip detection in SC 4C window CEUS in SC 4C view with evaluation of delay to visualization Lung US	Comparator group: Same cohort as intervention Comparator modality: CXR Imaging review: US independent review by two PI (not blinded) CXR review by radiologist (blinded)	Malposition detection: Direct visualization: Sn 48% Sp 95% CEUS all comers: Sn 50% Sp 100% CEUS – >500 ms delay: Sn 100% Sp 99% Concordance (US/CXR): Kappa 0.96 (p < 0.001) Complications: None	Measured post-insertion US: Median 5 min (5-10) CXR: Median 67 min (42–84)	Visualization: 100% (105/105) Limitations: None mentioned.	Technical – In preoperative setting, limited time to perform. Qualitative CEUS not sufficient in their study. Determination of what is malposition is unclear. Training – Significant amount of time and experience.
Parmar (2021) abstract	Design Prospective observational Population ER patients Patients: 100 CVC: 100	Insertion: NR US: NR US training: NR	Insertion: USG US Pleural slide RASS	Comparator group: same cohort as intervention Comparator modality: CXR	Malposition detection: No malposition Complications: No complications	Measured post-insertion US: 3.17 min (±1.34) CXR: 35.91 min (±17.23)	Visualization: 100% Limitation: NR	Technical: Number of operators and experience level not reported Patient: Patient characteristics not provided
Smit (2020)	Design: Prospective Cohort Monocentric Population: >18 years old CVC: 758	Insertion: Anesthesia ICU ED US training: NBME	Insertion: USG US: Bilateral IJV and SV scan RASS Lung US	Comparator group: Same cohort as intervention Comparator modality: CXR Imaging review: Same operator as insertion and US. CXR review by radiologist (blinded)	Malposition detection: Sn 0.70 Sp 0.99 PPV 0.76 NPV 0.99 LR + 92.5 LR- 0.31 4/5 clinically relevant malpositions detected by US	Not mentioned	Visualization: 91% (688/758)	Patient: Obesity
Vezzani (2010)	Design: Prospective Cohort Monocentric Population: ⩾18.y.o ICU Patients: 111	Insertion: ICU attendings ICU residents US: ICU attendings ICU residents US training: 15 h training	Insertion: LM US: Bilateral IJV and SV vascular scan CVC tip detection in SC bicaval window CEUS in SC bicaval window Lung US	Comparator group: Same cohort as intervention Comparator modality: CXR Other: Interobserver variability assessment	Malposition detection: Sn 96% Sp 93% LR + 13 Concordance (US/CXR): 95%, kappa 0.88 Interobserver concordance: 95% (19/20 evaluations) Complications detection: CXR: PTX (2) Intracardiac CVC tip (24) IJV misplacement (4) US: PTX (2) Intracardiac CVC tip (25) IJV misplacement (4)	Measured post-insertion:US: Mean 10 min ± 5 CXR: Mean 83 min ± 79	Visualization: 89% (99/111) Limitations; Poor windows: Abdominal wound (4) Obesity (4) Edema (3) Traumatic pneumopericardium (1)	Patient – Difficulty in obtaining windows due to patient factors. Technical – Optimal placement gold standard problematic. Unclear safety of CEUS.
Weekes (2016)	Design Prospective observational diagnostic cohort Population Adult ER patients Patients: 151 CVC: 151	Insertion: ER Physicians US: Study investigators US training: NR	Insertion: USG (140/151 – 92.7%), LM (11/151 – 7.3%) US Pleural slide RASS	Comparator group: Same cohort as intervention Comparator modality: CXR	Malposition detection: 147/151 – 97.4% Complications: No pneumothorax	Measured post-insertion US: 1.1 min (0.7 min) CXR: 20 min (30 min)	Visualization: 151/156 – 96.8% Limitation: CVC tip can only be visualized if at SVC/RA junction – innominate vein and higher SVC cannot be assessed	Technical: RASS is a surrogate test for CVC placement. More comprehensive assessment (tip and RASS) takes 10 min Only 2.6% of CVC were malpositioned Patient: Not mentioned

CVC: Central Venous catheter; USG: Ultrasound-guided; LM: Landmark; SC: subcostal; US: ultrasound; ITT: Intention to treat; PP: per protocol; Sn: Sensitivity; Sp: Specificity; PPV: Positive predictive value; NPV: Negative predictive value; min: minutes; CXR: Chest X-Ray; IM: Internal Medicine; ICU: Intensive Care Unit; POCUS: Point of care ultrasound; TEE: trans-esophageal echocardiogram; SV: Subclavian vein; SVC: Superior vena cava; RIJ: Right Internal Jugular; RPA: right pulmonary artery; JV: Jugular vein; 4C: four chamber; ED: Emergency department; RASS: Right atrial swirl sign; PLAX: Parasternal long axis view; IJV: internal jugular vein; CLABSI: Central line bloodstream infection; CEUS: contrast-enhanced ultrasound; PI: primary investigator; BMI: body mass index; COPD: Chronic obstructive pulmonary disease; AUC: Area under curve; LR+: positive likelihood ratio; LR-: negative likelihood ratio; PTX: pneumothorax.

Table 2.

Systematic reviews regarding the use of ultrasound to screen for central venous line placement and complications.

Study	Number of studies	# analyzed	Techniques	Outcome	Results	Time to perform	Feasibility	Barriers
Ablordeppey (2017)	15 Studies Adult	1469 CVC IJV, SV	Vascular view Cardiac view RASS CEUS Multimodality	CVC malposition (5) CVC malposition + PTX (10)	Malpositions: Incidence: 17.6% (258/1469) Sn: 0.82 (95% CI 0.77, 0.86, I2 = 81.0%) Sp: 0.98 (95% CI 0.97, 0.99, I2 = 77.1%) LR+: 31.12 (95% 14.72, 65.78, I2 = 51.4%) LR−: 0.25 (95% CI 0.13, 0.47, I2 = 83.2%) PTX: Incidence: 1.1% (12/1469) Sn: 100% Sp 100% Interobserver reliability: 94.5%	Average mean time US: 5.6 min CXR – performed: 63.9 min CXR – interpreted: 143.4 min	CVC position: 96.8% PTX detection: 100%	Training – Operator experience. Technical – Unclear definition of abnormal positioning
Chebl (2017)	5 Studies Adult	572 Patients IJV, SV	CEUS	CVC malposition (5)	Malpositions: Sn: 0.72 (95% CI 0.44–0.91) Sp: 1.0 (95% CI 0.99–1.00) OR: 5.53 (95% CI 4.34–6.73) AUC 0.971 PPV 0.921 NPV 0.985	Not mentioned	Not mentioned.	Technical – Limited ability to rule out malposition
Smit (2018)	25 Studies Adult Pediatric	2548 patients 2602 CVC IJV, SV	Vascular view Cardiac view CEUS RASS Multimodality	CVC malposition (25)	Malpositions: Incidence: 6.8% Sn 0.682 (95% CI 0.544–0.794, I2 = 75.5%) Sp 0.989 (95% CI 0.978–0.995, I2 = 83.3%) PTX: 1.1%	Average time US: 2.83 min (95% CI 2.77–2.89) CXR – performed: 34.7 min (95% CI 32.6–36.7) CXR – interpreted: 46.3 min (95% CI 44.4–48.2)	CVC position: 96.8%	Technical – Poor reference standard Training – Two operator sometimes required (avoidable). Technical – Unclear definition of abnormal positioning Benefits – Training easier than anticipated.

CVC: Central Venous catheter; USG: Ultrasound-guided; LM: Landmark; SC: subcostal; US: ultrasound; ITT: Intention to treat; PP: per protocol; Sn: Sensitivity; Sp: Specificity; PPV: Positive predictive value; NPV: Negative predictive value; min: minutes; CXR: Chest X-Ray; IM: Internal Medicine; ICU: Intensive Care Unit; POCUS: Point of care ultrasound; TEE: trans-esophageal echocardiogram; SV: Subclavian vein; SVC: Superior vena cava; RIJ: Right Internal Jugular; RPA: right pulmonary artery; JV: Jugular vein; 4C: four chamber; ED: Emergency department; RASS: Right atrial swirl sign; PLAX: Parasternal long axis view; IJV: internal jugular vein; CLABSI: Central line bloodstream infection; CEUS: contrast-enhanced ultrasound; PI: primary investigator; BMI: body mass index; COPD: Chronic obstructive pulmonary disease; AUC: Area under curve; LR+: positive likelihood ratio; LR-: negative likelihood ratio; PTX: pneumothorax.

Table 3.

Survey of practice norms and barriers to using pocus to confirm central line placement and complications. ³

Years of training		Training		Employment site		Frequency of US guidance		Routine confirmation practice
	% (95% CI)		% (95% CI)		% (95% CI)				% (95% CI)
Physicians ⩽ 5 years Physicians 6–10 years Physicians > 10 years Fellowship/residency training	52% (44.1–61.5) 26% (17.7–35.0) 22% (14–31.3) 88% (83.1–93.4)	Emergency Critical Care Anesthesiology Internal Surgery Emergency US Other	33% (26.9–40) 30% (23.5–36.6) 12% (5.6–18.6) 9% (3.0–16.1) 6% (0–12.6) 3% (0–12.6) 6% (0–10.1)	Academic Community Urban Suburban Rural	71% (64.3–79) 29% (21.7–36.3) 60% (47.4–72.4) 33% (21.1–46.1) 7% (0–19.8)	Never Sometimes About half the time Most of the time Always	0% (0–9.3) 7.3% (0–16.7) 8.1% (0–17.4) 47.8% (39.7–57.1) 36.8% (18.7–46.1)	Catheter position No other step US alone CXR alone US + CXR PTX exclusion No other step US alone CXR alone US + CXR	0% (0–9.0) 0% (0–9.0) 50.7% (42.6–59.7) 49.3% (41.2–58.3) 0.7% (0–9.3) 0.7% (0–9.3) 65.4% (58.1–74) 33.1% (25.7–41.7)
Barriers identified						Percentage (95% CI)
Policy or protocol requiring radiography after line placement						17% (11.5%–21.8%)
Political forces in hospital would opposite this as I would be in minority performing the US protocol						16% (11.2%–21.4%)
I do not feel adequately comfortable with my US skills to make this call						14% (9.2%–19.4%)
Medicolegal concerns						13% (7.8%–18%)
Inertia: I don’t think of it or it is just hard to change behavior and break habits						11% (5.8%–16.0%)
I lack sufficient ultrasound confidence to make this call						10% (4.8%–15.0%)
It is more convenient to get a chest radiography						7% (2.4%–12.6%)
I was not aware, or I did not appreciate that this was an option						4% (0%–9.2%)
Ultrasound is not as sensitive as chest radiography in evaluation of position or pneumothorax						2% (0%–6.8%)
No barriers, I currently use ultrasound and not chest radiography for confirmation						0% (0%–5.5%)
Lack of infrastructure to save images and report.						Unavailable
Adequate communication/documentation of good placement and exclusion of PTX						Unavailable

Reference: Ablordeppey EA, Drewry AM, Theodoro DL, Tian L, Fuller BM, Griffey RT. Current Practices in Central Venous Catheter Position Confirmation by Point of Care Ultrasound: A Survey of Early Adopters. Shock. 2018 Jul 25.

Results

General Search Results

Our search identified and screened 4071 articles, of which 117 full-text articles were accessed for eligibility (Figure 1).^{3,6–11,13,14,17–20,29–57} We retained 41 articles based on prespecified criteria for inclusion (Table 1). Regarding ultrasound guided placement and confirmation methods, 13 articles examined cardiac/vascular methods; 5 examined isolated contrast-enhanced ultrasonography (CEUS); 7 examined isolated rapid atrial swirl sign (RASS); and 13 examined combined/integrated methods (Table 1). We included three systematic reviews and meta-analyses (Table 2) and one survey (Table 3) in order to explore barriers to adoption (Table 3). Lastly, Table 4 outlines integrated lung/cardiac and vascular approaches.

Figure 1.

Search strategy regarding the use of ultrasound for central venous catheter placement and complications.

Table 4.

Integrated approaches regarding the use of ultrasound to screen for central venous line placement and complications.

Study	#CVC	Method	Cut-off CEUS	LUS	Test characteristics	Feasibility	# PTX identified	Time for imaging (min)	Notes
			RASS
Vezzani et al. (2010)	111	Vasc Card CEUS	2 s	+ve	Combined Sn 0.96 Sp 0.93 LR + 13	0.89	US: 4 CXR: 2	US: 10 ± 5 CXR: 83 ± 79	Intra-atrial considered malposition
Meggiolaro et al. (2015)	105	Vasc Card CEUS	0.5 s	+ve	Vasc/Card Sn 0.64 Sp 1.0 CEUS Sn 1.0 Sp 1.0 Acc > 99%	1.0	US: 0 CXR: 0	US: 10 (7-20) CXR: N/A	Intra-atrial not considered malposition
Smit et al. (2020)	758	Vasc Card RASS	2 s	+ve	Combined Sn 0.70 Sp 0.99 PPV 0.76 NPV 0.99 LR + 92.5 LR- 0.31 4/5 clinically relevant malpositions detected by US	0.91	US: 11 CXR: 5 Incidence of PTX US: 1.5% CXR: 0.7%	Not provided	Intra-atrial not considered malposition

Card: Cardiac; Vasc: Vascular; CEUS: Contrast-enhanced ultrasound; RASS: Rapid atrial swirl sign; Sn: Sensitivity; Sp: Specificity; Acc: Accuracy; US: Ultrasound; CXR: Chest X-ray.

In this table, LUS +ve indicates that LUS was performed to assess for PTX post-insertion.

Test characteristics are for catheter malposition.

Comparing CXR and POCUS after thoracic CVC insertion

Our literature review highlights three main metrics when comparing CXR and POCUS: (i) cost (ii) accuracy, and (iii) detection of the CVC tip. Regarding costs, Chang et al. ⁵⁸ estimated savings from foregoing CXR to be $34.58 per patient, or $39,559.52 in total, after a retrospective study of 572 internal jugular CVCs. For this expenditure only two PTXs were identified by CXR. Chiu et al. reported similarly impressive savings ($105,000–$183,000) in a retrospective study of 6875 CVC insertions. That expenditure diagnosed 23 PTX and 131 catheter misplacements, of which over 80% (107/131) were not repositioned. Similarly, Hirshberg et al. ⁵⁹ performed a retrospective analysis of 1483 supradiaphragmatic CVC and found an attributable annual CXR cost of $54,494. Our review confirms that the major concerns after CVC insertion are PTX, hemothorax, tamponade, and venous thrombosis. Regarding the detection of all four of these complications, US is more accurate than CXR.^60–63

Confirmation of the CVC tip by POCUS

Regarding detection of the CVC tip, POCUS also performs at least as well as CXR. For example, if we follow the recommendation that the tip should be between the lower third of the superior vena cava and the upper right atrium,^64,65 then CXR studies^4,24,28 identified 2% as misplaced, whereas US studies identified over 10%.^14,56 The important distinction between US and CXR however, is that US generally only permits indirect tip detection, unless that is, the wire or catheter is advanced deep into the super vena cava and/or right atrium, or is in a wayward structure. Bedel et al., ⁸ who insisted upon intra-cardiac detection of the US guidewire prior to vessel dilatation, reported a Sn of 96%, Sp of 83%, PPV of 98%, and NPV of 55% for misplacement.

POCUS achieves indirect detection by insonating the IJ and SC vein, the heart and/or by incorporating rapid injection of saline or an opacifying agent.^8–11 Zanobetti et al. ²¹ demonstrated that when POCUS is used to examine these major veins and atria post CVC insertion, it has a high sensitivity (Sn) and specificity (Sp) (94% and 89%, respectively), and 82% concordance with CXR. Similarly, Matsushima and Frankel ¹² reported a high accuracy (90%), positive predictive value (PPV) (91%) and negative predictive value (NPV) (83%) for detecting CVC misplacement with US.

As outlined, POCUS can indirectly detect the catheter tip using echogenic turbulence or following contrast injection. Rapid instillation of non-agitated saline can produce RASS on echocardiography, a finding exploited by Weekes et al.^18,19 In one prospective convenience sample of ICU and ED patients, Weekes et al. reported a Sn, Sp, PPV, and NPV of 75%, 100%, 100%, and 99.2% when using RASS to identify the catheter tip. Although non-agitated saline minimizes the risk of air embolism; it also reduces echogenicity, and therefore potential accuracy.^18,19,41

CEUS makes use of agitated saline or a lipid contrast agent. In one prospective observational study of using agitated saline, Cortellaro et al. ⁹ reported a Sn, Sp, PPV and NPV of 33%, 98%, 67% and 94% respectively. Baviskar et al. ⁷ found a SP (100%) and Sn (100%) in 25 non-consecutive patients. Although these results are promising, CEUS risks air embolism with inadvertent arterial placement or if there is a patent inter-atrial shunt. This is less likely when low volumes (<1 ml) of agitated saline are used. ⁶⁶ Another downside is that two practitioners are needed while maintaining the sterile field: one to obtain images and one to inject.

Integrated POCUS for CVC placement: The future?

Our review serves as a reminder that “a full confirmatory US” has five distinct steps: (1) Identify and cannulate the correct vessel in real-time, (2) visualize the wire in the correct place, (3) visualize the catheter, (4) rapidly instill non-agitated saline or agitated-saline with 0.5 ml air to opacify the endovascular cavity and infer the location of the catheter tip, and (5) use lung-US to exclude PTX.^{7,9,11,14,16–19,41} Practitioners may be reassured by combining confirmatory techniques; however, we only found three studies that included bilateral 2D vascular and cardiac imaging, plus agitated saline or CEUS, plus lung ultrasound (Table 4).^14,17,55

Discussion

Our review confirms that not only is there widespread literature support for POCUS during IJ and SC CVCs insertion,^22,67 there is also widespread literature support for using POCUS after CVC insertion; even if the latter is not as widely known or followed.^30,35,54 Overall, when used to confirm CVC placement and rule out peri-insertion complications, POCUS has superior Sn compared to CXR, and comparable Sn to computed tomography.^{6,7,9,11,13,14,16–19,21,41} When POCUS, rather than CXR, is used, it also means less radiation and shorter delays.^{4,5,9–11,17,20,25–27} POCUS added only 30 s to 10 min, whereas CXR added 20–83 min.^9,12,17–19 While there was no evidence that POCUS resulted in better clinical outcomes when compared to CXR, there were no reported downsides, and numerous putative benefits. In short, the routine post-CVC CXR increasingly looks like an anachronism left over from pre-POCUS days.

When comparing POCUS and CXR, POCUS was also superior in terms of cost, accuracy and ability to detect the CVC tip.^4,58,59 Moreover, three systematic reviews and a survey (Tables 2 and 3) have confirmed that there is robust support for US over CXRs.^30,35,54 Regardless, before adopting POCUS we need to identify and overcome potential barriers. These include patients with obesity, pulmonary disease, pacemakers, and chest wall abnormalities^{8,13,33,34,36,48,55}; though not cervical collars or open abdomens. ¹³ Notably, these same issues affect CXRs too. We also need skilled US operators and interpreters, though, again, this applies to CXRs too. Fortunately, for POCUS operators, less than 10 h of training usually delivers basic proficiency,^12,13,21 and the need to practise on patients can be avoided by using mannequins and simulation. ⁶⁸ In return for the upfront time investment the “payoff” is a significantly shorter time to confirmation with US: 5–11 min for cardiac/vascular studies.^12,13,21 Integrated approaches demonstrated a wider time interval of 1–20 min.^14,17,19 These longer intervals, while uncommon, could frustrate time pressured practitioners. Nonetheless, CEUS only added 30–60 s. ⁹ This compared to 65–75 min for CXR.^{12–14,17,21,55}

The remaining barriers center on medicolegal concerns, and change inertia. These should not be ignored, but can be challenged by our cumulative literature review. Firstly, in terms of safety, CVC insertion represented only 1.7% of 6449 claims over 30 years from the 2004 American Society of Anesthesiologists Closed Claims database. ⁶⁹ This low number was despite CVCs being one of the most common procedures, and came from a time before US made CVC insertion safer still. Others may assume that they have to do an XR to ensure that a SC CVC tip has not ended up in the ipsilateral IJ, or because patients are often intubated at the same time anyway (hence a single CXR can confirm both endotracheal tube placement and CVC placement). Again, though, this can all be done with POCUS by quickly insonating both the airway (via the front of the neck) and the veins (via the side of the neck). Finally, if practitioners and administrators still wish, or need, to have a radiologist’s review, then this can be done as easily with US images. This is because US images can now be easily stored and viewed remotely; just like the CXRs of old. In short, we humbly submit that the routine post CVC CXR is more ritual than rational.