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VOLUME 67 #{149}APRIL 1981 #{149}NUMBER 4
PEDIATRICS Vol. 67 No. 4 April 1 981 447
Pediatrics
Value of the Chest X-Ray as a Screening Testfor 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 toassess the value of the chest x-ray as a preoperativescreening procedure in pediatric patients. Admissions forelective surgery were compared at two hospitals, one thatrequired routine preoperative chest x-rays and one thatdid not. Our purpose was to determine the yield of the
screening chest x-ray in detecting unknown abnormalitiesand to determine whether patients who had a preopera-tive chest x-ray taken experienced fewer anesthetic orpostoperative complications than did those who did not.In all, 1,924 cases were studied; in 749 a preoperativechest film was taken. Of those 749 cases, a previouslyunsuspected 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%) resultedin cancellation of surgery. No differences in anesthetic orpostoperative complications were noted between the twogroups of patients. It is recommended that the perform-ance of routine preoperative chest x-rays on apparentlyhealthy 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 theAmerican 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
results, they concluded that “the routine preopera-
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448 CHEST X-RAY SCREENING FOR ELECTIVE SURGERY
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 allpatients 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)
pneumonia with bilateral perihilar infiltrates. The
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ARTICLES 449
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 PerformedEl ective Stir-
System No. %
Ear, nose, and throat 976 50.8
Urogenital 590 30.6Musculoskeletal 215 11.2
Eyes 98 5.1Other 45 2.3
Total 1,924 100.0
TABLE 2. Abnormalities Detected in 749 ScreeningPreoperative Chest X-Rays
Abnormality No. %
Lungs 16 2.1
Pneumonia* 4
Atelectasis* 2
Azygous lobet 3Bronchiectasis* 1
Consolidation* (prominence ofright pe- 1rihilar region)
Peribronchial thickening 1
Small right lower lobe infiltrate 1Increased interstitial markings 1Increased markings of right middle lobe 1Slight hilar prominence 1
Cardiovascular 14 1.9
Slight-mild cardiomegaly 3
Cardiomegaly* 1
Prominent main pulmonary artery 3
Prominent pulmonary vein 1Prominent vasculature 1
Absence of clearly defined aortic arch 1Poor definition of cardiac border 1
Curious configuration of cardiac silhou- 1ette
Cardiac silhouette upper normal limit 1Right-sided aortic archt 1
Skeletal 4 0.5Mild 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 91 37 24 11
2 47 29 103-4 206 103 16
5-9 551 203 22
10-14 197 87 715-19 198 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 0.730-35 452 23.6
36-40 1,134 591
41-45 273 14.246-50 43 2.2
51-60 3 0.2
* n = 1,918.
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450 CHEST X-RAY SCREENING FOR ELECTIVE SURGERY
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 more
abnormality detected on urinalysis.
than one
TABLE 6. Reason for Cancellation of Surgical Proce-dures*
Reason No.
Temperature only 7Temperature and URI or sore throat 6
URIonly 6X-ray report 3Other 6
(one each for serous otitis media and cough,chickenpox, elevated WBC count, elevated cre-atinine phosphokinase level, low hematocritand clotting disorder, and hematuria andscheduling problems)
Total 28a 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 28Postoperative temperature elevation 22Postoperative bleeding 25Low hematocrit 3Postoperative nausea 3Abnormal urinalysis 2Right upper lobe and right lower lobe 1
pneumoniaUpper respiratory tract infection 1Other of no significance 7
Total 92
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ARTICLES 451
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 33 361 39 19 142 40 23 233-4 161 74 905-9 293 245 238
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.
CONCLUSIONSOn the basis of the low yield of significant infor-
mation derived from the chest x-rays we reviewed,
as well as the need to contain hospital costs and
eliminate unnecessary radiation exposure, we rec-
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452 CHEST X-RAY SCREENING FOR ELECTIVE SURGERY
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 ofResearch Resources, National Institutes of Health grantBRSG-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 andKathy Schafer for their assistance in the preparation ofthis 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 uponthe results of the study reported here.
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1981;67;447PediatricsRobert A. Wood and Robert A. Hoekelman
Value of the Chest X-Ray as a Screening Test for Elective Surgery in Children
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Value of the Chest X-Ray as a Screening Test for Elective Surgery in Children
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