VOLUME 67 #{149}APRIL 1981 #{149}NUMBER 4
Pediatrics
Value
of the Chest
X-Ray
as a Screening
Test
for Elective
Surgery
in Children
Robert
A. Wood,
BA, and
Robert
A. Hoekelman,
MD
From the Department of Pediatrics, University of Rochester, School of Medicine and
Dentistry, Rochester, New York
ABSTRACT. A retrospective study was conducted to
assess the value of the chest x-ray as a preoperative screening procedure in pediatric patients. Admissions for elective surgery were compared at two hospitals, one that required routine preoperative chest x-rays and one that did not. Our purpose was to determine the yield of the screening chest x-ray in detecting unknown abnormalities and to determine whether patients who had a preopera-tive chest x-ray taken experienced fewer anesthetic or postoperative complications than did those who did not.
In all, 1,924 cases were studied; in 749 a preoperative chest film was taken. Of those 749 cases, a previously
unsuspected abnormality was discovered in 35 (4.7%) patients. Nine (1.2%) of these abnormalities were consid-ered to be clinically significant and three (0.4%) resulted in cancellation of surgery. No differences in anesthetic or postoperative complications were noted between the two groups of patients. It is recommended that the perform-ance of routine preoperative chest x-rays on apparently healthy children be discontinued. Pediatrics 67:447-452,
1981; chest x-ray, preoperative screening, elective
sur-gery.
Over the past ten years there has been much debate about the value of the chest x-ray as a
screening or routine preoperative procedure.’’2 This debate has resulted from concerns about the hazards of radiation exposure and the increasing
Received for publication June 12, 1980; accepted July 30, 1980.
Reprint requests to (R.A.H.) Department of Pediatrics, Univer-sity of Rochester, School of Medicine and Dentistry, 601
Elm-wood Aye, Box 777, Rochester, NY 14642.
PEDIATRICS (ISSN 0031 4005). Copyright © 1981 by the American Academy of Pediatrics.
costs of medical care. The question still remains
whether routine preoperative chest radiography can
be justified on the basis of its yield of medical
information. Although this question has been raised
for all age groups, we have been particularly
con-cerned about its application to pediatric patients.
Three major studies of pediatric patients have
addressed this problem.’3 In 1973, Brill et al’ ana-lyzed the findings of routine chest x-rays taken on
1,000 healthy children in a preventive health clinic
that served a low-income area of New York City. Abnormal radiographic findings were noted in 6%
of the patients; most were minor skeletal
abnor-malities and none required treatment. In 1974,
Sa-gel et al2 reviewed the results of routine chest
x-rays taken on 521 pediatric patients as part of a
larger study of chest x-rays taken on all admissions to Barnes Hospital in St Louis. Again, no serious
abnormalities were detected in these children. Both Brill et al and Sagel et al concluded that routine
chest radiographs were not justified in pediatric
patients. However, in the longest study to date,
Sane et al3 reviewed the radiographic findings on
1,500 consecutive patients admitted to the Minne-apolis Children’s Health Center for a surgical
pro-cedure. They reported that 7.5% of these patients
demonstrated at least one roentgenographic abnor-mality. Of these, 63% (4.8% of the total sample) demonstrated a totally unsuspected significant
ab-normality. In 3.8% of the 1,500 patients, cancellation
or postponement of surgery, or a change in
anes-thetic technique resulted. On the basis of these
preopera-tive chest roentgenographic examination is
medi-cally and economically justified and essential in
pediatric patients.”3 To evaluate this discrepancy in study results, in 1979 we undertook a retrospec-tive study that compared two populations of
pedi-atric patients, one in which a routine preoperative chest x-ray was taken and one in which it was not.
This enabled us not only to analyze the x-ray find-ings of one group, but also to compare the two
groups in terms of important variables such as
anesthetic and postoperative complications.
Although our primary goal in conducting this
study was to assess the value of preoperative chest radiography in a “healthy” pediatric population, we
also thought it worthwhile to analyze three other
routine tests-the hematocrit, urinalysis, and tem-perature-because these measures, along with the
chest x-ray, are used most often to assess anesthetic risk preoperatively. The purpose of this study was
to determine: (1) the results of the x-rays and their significance in terms of cancellation of surgery or
altered surgical management, (2) whether patients
had preoperative chest x-rays taken differed
signifi-cantly from those who did not in terms of the
frequency of occurrence of either anesthetic or
post-operative complications, and (3) the results of the
other preoperative tests (hematocrit, urinalysis, and temperature) and their significance.
METHODS
After eliminating all cases in which a chest x-ray
was indicated on the basis of a previously recog-nized abnormality, we reviewed the charts of all
patients under 19 years of age admitted to Strong Memorial Hospital or Rochester General Hospital
for elective surgery during calendar year 1978. Dur-ing that year, all 699 patients admitted to Strong Memorial Hospital for elective surgery had a chest x-ray taken, whereas, of the 1,225 patients admitted
to Rochester General, 50 had one taken (only when specifically ordered by the admitting physician). Thus, we reviewed the records of 1,924 patients.
The following information was retrieved from each patient’s hospital record: age; sex; race; socio-economic status (determined by census tract; home
addresses were used to categorize patients
accord-ing to one of five general socioeconomic areas); third-party payer; diagnosis; surgical procedure; date of admission; length of stay; number of
read-missions; results of the chest x-ray, hematocrit, and
urinalysis; maximum preoperative temperature re-corded; anesthetic complications; postoperative complications; and maximum postoperative term-perature recorded. This information was sought to enable us to study each patient’s illness, admission, and hospital course in order to compare outcomes
for patients who did or did not have a preoperative
chest x-ray taken.
In addressing the purposes of this study, we were
able to gatxer complete data on the types of elective surgery performed, cancellations of surgery, anes-thetic complications, and postoperative complica-tions, as well as the age, sex, race, and socioeco-nomic status of the patients and the organ system
upon which their surgery was performed.
RESULTS
Of the 1,924 patients reviewed, 36% (699) were admitted to Strong Memorial Hospital and 64% (1,225) were admitted to Rochester General Hos-pital. Of the total, 39% (749) had a preoperative
chest x-ray taken; 61% (1,175) did not. Sixty percent
(1,151) were boys and 40% (773) were girls; 88%
(1,702) were white, 8% (153) were black, and 4%
(69) were of another race. Ages ranged between 15
days and 19 years and were fairly evenly distributed
by year of age within the sample, although slightly
over half of the children were between 3 and 9 years
of age. Approximately 77% were insured by Blue
Cross, whereas about 10% were covered by
Medi-caid. The rest either utilized other forms of insur-ance or were self-payers. Of the five socioeconomic groups, 33.6% of the patients were in the highest two categories, 56.6% were in the middle category, and only 9.8% were in the lowest two categories. The admissions were distributed evenly over all months of the year, with August having the most (196, 10.2%) and September the least (122, 6.3%). Just over 86% of the patients remained in the hospital for three or fewer days, 13.5% remained
from four to nine days, and 0.1% remained for ten
or more days.
The-organ systems upon which surgery was
per-formed are shown in Table 1. Of the total, 22% (432) underwent the placement of polyethylene tubes, either alone or in conjunction with another proce-dure, 43% (828) of the patients, including some with polyethylene tube placements, had a tonsillectomy, adenoidectomy, or both.
X-Ray Findings
Of the 749 preoperative chest x-rays taken, 35
(4.7%) demonstrated some unsuspected
abnormal-ity, nine (1.2%) showed a significant unsuspected
abnormality, and three (0.4%) were used as the
reason to cancel or postpone surgery on the basis of the roentgenographic findings. The findings that resulted in cancellation were: (1) left lower lobe
pneumonia, (2) atelectasis in the left lower lobe
combined with some inflammatory element, and (3)
35 radiographic abnormalities are listed in Table 2. In one patient reported as having pneumonia on
x-ray, surgery was cancelled because the patient had an upper respiratory tract infection, and the chest x-ray was read as normal by the attending surgeon. In another patient reported to have pneumonia on x-ray, a repeat chest x-ray was taken on the day of
surgery and it was decided that the pneumonia had cleared sufficiently to allow the operation to be performed.
The frequencies of abnormal x-ray findings were
similar for different races, age groups, socioeco-nomic groups, diagnoses, and months of admission. Abnormal findings, however, were about two times as frequent in boys as in girls.
TABLE 1. Organ Systems Upon Which
gery Was Performed
El ective
Stir-System No. %
Ear, nose, and throat 976 50.8
Urogenital 590 30.6
Musculoskeletal 215 11.2
Eyes 98 5.1
Other 45 2.3
Total 1,924 100.0
TABLE 2. Abnormalities Detected in 749 Screening
Preoperative Chest X-Rays
Abnormality No. %
Lungs 16 2.1
Pneumonia* 4
Atelectasis* 2
Azygous lobet 3
Bronchiectasis* 1
Consolidation* (prominence ofright pe- 1 rihilar region)
Peribronchial thickening 1
Small right lower lobe infiltrate 1 Increased interstitial markings 1 Increased markings of right middle lobe 1
Slight hilar prominence 1
Cardiovascular 14 1.9
Slight-mild cardiomegaly 3
Cardiomegaly* 1
Prominent main pulmonary artery 3
Prominent pulmonary vein 1
Prominent vasculature 1
Absence of clearly defined aortic arch 1 Poor definition of cardiac border 1 Curious configuration of cardiac silhou- 1
ette
Cardiac silhouette upper normal limit 1
Right-sided aortic archt 1
Skeletal 4 0.5
Mild scoliosis 2
Pectus excavatum 1
Hypoplastic first rib 1
Other 1 0.2
Colon interposed between liver and dia- 1 phragm
* Clinically significant.
1-
May be considered as anatomic variants.Other Reasons for Cancellation of Surgery
Surgery was cancelled for 16 of the 80 patients
with a maximum preoperative temperature greater than 99.9 F, either because of the temperature or for another reason. The distribution of preoperative temperatures is shown in Table 3. Surgery was performed in 64 patients after a preoperative
tern-perature 100.0 F had been recorded. In three
cases, these temperatures were >102.4 F. Although
these patients were found in all age groups, 15.3% were 1 year of age, and 1 1.6% were 2 years old.
Preoperative hematocrit test results in 1,918 of the 1,924 patients studied are shown in Table 4. In only one patient was hematocrit noted as a reason for cancellation of surgery. This patient had a he-matocrit of 23% in addition to a clotting disorder; both of these findings were noted as contributing to the cancellation. In an additional three cases, the
hematocrit was noted as low (25%, 29%, and 32%)
in the discharge summary; in each case, it was
stated that the patient would be followed for
pos-sible anemia. In two other cases, a low hernatocrit
had been previously discovered and studied. In all other cases, however, including the eight with a hematocrit less than 30% and the three with a
hematocrit greater than 50%, surgery was per-formed with no mention of the finding made in the physician’s notes.
Preoperative urinalysis testing was performed on 1,859 (96.6%) of the 1,924 patients admitted for elective surgery. In 1,633 (87.8%) of these patients, the urinalysis was completely normal, and in 226
(12.2%), some abnormality was discovered. Of these,
TABLE 3. Recorded Preoperative Temperatures*
Age Temperature (F)
(yr)
<99.0 99.0-99.9 >99.9
<1 43 63 9
1 37 24 11
2 47 29 10
3-4 206 103 16
5-9 551 203 22
10-14 197 87 7
15-19 198 57 5
Total 1,279 (66.4%) 566 (29.4%) 80 (4.2%)
* n
=
1,924.TABLE 4. Preoperative Hematocrit Results*
Hematocrit No. %
23-29 13 0.7
30-35 452 23.6
36-40 1,134 591
41-45 273 14.2
46-50 43 2.2
51-60 3 0.2
131 showed what we considered to be a significant
abnormality, as shown in Table 5. Of these patients, 14 had been admitted for a urologic procedure and their findings on urinalysis were expected. In only one patient did a urinalysis contribute to a cancel-lation; in this instance, 2+ protein, 3+ blood, and
pyuria (8 to 10 WBC/high power field) were found. Finally, reasons for cancellation of the 28 surgical
procedures are shown in Table 6. In the seven
patients in whom temperature elevation alone was noted as the reason for cancellation, the tempera-tures ranged from 100.4 to 102.6 F. A significant difference in cancellation rates was demonstrated between the two groups of patients, that is, six (0.5%) of the patients who did not have a preoper-ative chest x-ray taken had their operations can-celled, compared with 22 (2.9%) of the patients who did have x-rays taken (P < .001). However, only
three of the x-rayed group had surgery cancelled on the basis of the x-ray results.
Anesthetic and Postoperative Complications
Anesthesia records revealed that anesthetic corn-plications or abnormal reactions occurred in 25
(1.3%) of the patients. Most common among these
complications were laryngospasm during intubation or extubation, coughing, and increased secretions. None, however, was considered to be significant
TABLE 5. Significant Abnormalities Found on Preop-erative Urinalysis*
Abnormality No.
>1+ bacteria 83
>10 WBC/high power field 32
>1+ occult blood or 10 RBC/high power field 18
>1+ protein 7
>1+ acetone 6
1+ glucose 2
Total 148
* n
=
131; 17 of the 131 patients had moreabnormality detected on urinalysis.
than one
TABLE 6. Reason for Cancellation of Surgical
Proce-dures*
Reason No.
Temperature only 7
Temperature and URI or sore throat 6
URIonly 6
X-ray report 3
Other 6
(one each for serous otitis media and cough,
chickenpox, elevated WBC count, elevated cre-atinine phosphokinase level, low hematocrit
and clotting disorder, and hematuria and
scheduling problems)
Total 28
a Abbreviation used is: URI, upper respiratory tract
in-fection.
clinically or related to the preoperative results of the chest x-ray, the temperature, the hematocrit, or the urinalysis.
A postoperative complication or an abnormality was noted by the attending surgeon in the discharge summary of 92 (4.8%) patients, as seen in Table 7. Of the conditions listed, only fever, bleeding, nau-sea, pneumonia, and upper respiratory tract infec-tion can be considered postoperative complications; of these, only fever, pneumonia, and upper respi-ratory tract infection could in any way be detected by using the preoperative tests we studied. Of the 22 patients in whom an elevated temperature was noted postoperatively, 17 had a normal preopera-tive chest x-ray. The remaining five had no preop-erative chest x-ray. In one of the patients without a preoperative radiograph, a postoperative chest x-ray taken in response to a temperature of 104.4 F demonstrated a right lower lobe pneumonia. One of the 22 patients had had a preoperative temperature of 101.0 F, whereas all others had had temperatures
99.6 F preoperatively.
The patient with pneumonia noted postopera-tively had a normal preoperative evaluation, includ-ing a normal chest x-ray. The patient who devel-oped an upper respiratory tract infection following surgery had not had a preoperative chest x-ray taken, although one taken postoperatively was nor-mal.
Of the 25 cases of postoperative bleeding, 23 followed tonsillectomy, adenoidectomy, or combi-nation of the two. Thus, 2.8% of the 828 such cases were complicated by postoperative bleeding while the patient was still in the hospital. Of these 23 patients, 15 were returned to the operating room for control of the bleeding and five required a
transfusion. Of the two remaining cases of postop-erative bleeding, one followed a circumcision and the other knee surgery.
Of the total, 21 (1.1%) patients were readmitted to the hospital or were seen in the emergency department with a complaint directly related to the surgery performed. Of these, nine involved
postop-TABLE 7. Postoperative Complications and
Abnor-malities Noted in Discharge Summary
Complication or Abnormality No.
Surgical cancellation explained 28 Postoperative temperature elevation 22
Postoperative bleeding 25
Low hematocrit 3
Postoperative nausea 3
Abnormal urinalysis 2
Right upper lobe and right lower lobe 1
pneumonia
Upper respiratory tract infection 1 Other of no significance 7
erative bleeding-seven followed tonsifiectomy and adenoidectomy and two followed circumcision. The overall frequency of postoperative bleeding follow-ing tonsillectomy and adenoidectomy, therefore,
was 30/828 or 3.6%.
Of the remaining 12 patients in whom there was a related readmission or emergency department visit, four were due to fever, two to upper respira-tory tract infections, one to a wound infection, and five to other minor problems. All of these patients had had completely normal preoperative evalua-tions, including chest x-rays. No patients with fever or upper respiratory tract infection required read-mission. In one patient, a mild postoperative fever was noted by the attending physician in his dis-charge summary, but the patient was discharged as scheduled; three days later he came to the emer-gency department with a cough and a temperature of 102.2 F.
The distribution of maximum postoperative tern-peratures is shown in Table 8. Of the 610 patients in whom the temperature was >99.9 F, five had temperatures >104.6 F. Twenty-two postoperative fevers were noted by the physician in the discharge
summary; of these, eight were studied further: cul-tures (throat, wound, urine, and blood) and chest x-rays were taken, and discharge was delayed so that these patients could be observed. The occurrence
of postoperative fever was not influenced by race, sex, or socioeconomic status. There was some van-ation, however, among different age groups; only 19.4% of all 1-year-old patients had a maximum postoperative temperature >100.0 F, whereas 39.6% of all 15- to 19-year-old patients had temperatures
>100.0 F. It was also noted that 28.7% ofall patients who had a preoperative chest x-ray taken had a postoperative temperature >100.0 F, compared with 33.6% of those who did not have a preoperative chest x-ray.
DISCUSSION
In analyzing the value of the routine preoperative
chest x-ray, one basic question must be answered:
TABLE 8. Recorded Postoperative Temperatures*
Age
(yr)
Temperature (F)
<99.0 99.0-99.9 >99.9
<1 46 33 36
1 39 19 14
2 40 23 23
3-4 161 74 90
5-9 293 245 238
10-14 91 94 106
15-19 70 87 103
Total 740 (38.4%) 575 (29.9%) 610 (31.7%)
a
=
1,924.Are the costs and possible hazards of this procedure justified on the basis of its yield of medical infor-mation? Similar questions should be asked of any preoperative procedure.
In our study, 749 children received a routine preoperative chest x-ray. A previously unsuspected
abnormality was discovered in 35 (4.7%) of these children. Nine of the abnormalities were considered significant and three resulted in cancellation of
surgery. When our two groups of patients were compared, no differences in anesthetic or postop-erative complications could be identified.
In comparison with similar studies, our data fall
between the contradictory results we have noted.’3 We detected a higher rate of roentgenographic ab-normalities not previously known than did either
Brill or Sagel and their gu’ but a lower rate than did Sane and his colleagues.3
The 749 chest x-rays cost $5,992 in 1978. We will not attempt a cost-benefit analysis of this figure, but refer interested readers to Neuhauser’stt
anal-ysis of the cost effectiveness of routine pediatric
preoperative chest x-rays based upon the data pre-sented by Sane et al. He concludes that their claim that such x-rays are “economically justified” is not
warranted.
Our analysis of routine preoperative measure-ment of hematocrits showed that in only one case
(of a total of 1,918) did the result of the hematocrit contribute to cancellation of surgery; in eight chil-then, elective surgery was performed even though their hematocrits were less than 30%.
Preoperative urinalysis results demonstrated some abnormality in 226 (1 1.7%) of 1,859 patients.
In 131 of these, the abnormality was deemed
sig-nificant by our standards, yet in only one case did results of urinalysis contribute to a decision to cancel surgery.
Before concluding, a word about the design of our study is indicated. The ideal study would be prospective rather than retrospective and would include a far larger sample population since the incidence of operative and postoperative complica-tions is quite small. Further, our methods of ana-lyzing postoperative complications were not ideal; a complete assessment of this variable would have required contacting each patient’s surgeon and pri-vate pediatrician to determine the true incidence of postoperative complications. Unfortunately, we were unable to do this.
CONCLUSIONS
On the basis of the low yield of significant
rec-ommend that the practice of performing
preopera-tive chest x-rays on apparently healthy children be
discontinued. We thus agree with Brill et al’ that preoperative chest x-rays should be performed on an individual rather than on a routine basis.
Chest x-rays are often routinely performed on
patients admitted for nonsurgical reasons at many hospitals and as a screening procedure in many nonhospitalized pediatric populations, for example,
as a prerequisite for entrance to college. We also
recommend that the need for chest x-rays among both of these groups be considered solely on an
individual basis.
We cannot recommend that routine urinalysis and hematocrit tests be similarly eliminated, but our results concerning these two tests do warrant attention. Both are of relatively low cost and ex-tremely low risk; therefore, their routine use for screening purposes has been much less
controver-sial than the use of chest x-rays. They are also fairly
productive, as we found, in their yield of medical information. However, we also found that the ab-normalities detected were of little consequence
vis-#{224}-visdecisions regarding surgical procedures, since they were seemingly ignored by attending
pediatri-cians and surgeons. The conclusions are obvious: if these tests are of value, their results must be scru-tinized more closely.
Finally, review of the reasons for cancellation of
elective surgical procedures reveals that a preoper-ative temperature elevation was the most common reason for cancellation, followed by upper
respira-tory tract infections; 21 of 28 cancellations were due
to either an elevated temperature or another finding on the preoperative physical examination. We con-dude, therefore, that a complete medical history and physical examination remain the most effective methods for screening surgical patients for potential operative and postoperative complications.
ACKNOWLEDGMENTS
This study was supported in part by the Division of
Research Resources, National Institutes of Health grant BRSG-RR-05403 and The Robert Wood Johnson Foun-dation General Pediatrics Academic Development
Pro-gram grant 4961.
The authors wish to thank Sydney A. Sutherland and Kathy Schafer for their assistance in the preparation of
this manuscript.
ADDENDUM
In June 1979, the use of routine preoperative chest x-rays for pediatric patients at the Strong Memorial
Hos-pithi was discontinued. This decision was not based upon
the results of the study reported here.
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