VOLUME

67 #{149}
APRIL

1981

#{149}
NUMBER

Pediatrics
Value of the Chest X-Ray as a Screening
for Elective Surgery in Children
Robert
From

A. Wood,
the

Department

Dentistry,

Rochester,

BA, and
of

Pediatrics,

New

chest

x-ray,

preoperative

screening,

elective

A. Hoekelman,

University

sur-

of Rochester,

of medical

costs
whether
be

on

information.
for

all

about

debate

about

screening
This
debate
hazards

or

ten
the

years

value

has

there
of

the

chest

been
x-ray

major
this

lyzed

the

1,000

healthy

routine
preoperative
procedure.2
resulted
from
concerns
about

has

of radiation

exposure

and

the

and

served
the

the

increasing

et

al2

larger

Barnes

consecutive

apolis

Childrens
They

the

demonstrated

Center

In 3.8%

postponement

technique
they

PEDIATRICS

Vol.

in pediatric
to

to
of

the

or

On
that

these

the

propatients

67

abnortotal

No.

sample)

significant

basis

routine

4 April

ab-

cancellation

a change

the

the

on

Minne-

a surgical

patients,

surgery,

date,

findings

for

of

1,500

resulted.
concluded

routine

study

unsuspected

of the
of

Both

that

7.5%

(4.8%

serious

one roentgenographic

63%

a totally

normality.

no

children.

justified

that

xof

admissions

Again,

admitted

Health

at least

all

radiographic

patients

these,

on

longest

the

reported

demonstrated
Of

not

in

Sa-

chest

as part

al concluded

were

1974,

routine

in these

et

al3 reviewed

cedure.

results,

Sagel

However,

1,500

Louis.

in 6%
abnor-

In

patients

St

City.

noted

skeletal

taken

on
clinic

York

were

of

detected

radiographs
et

thetic

in

were

taken

health

minor

x-rays

Hospital

et al and

x-rays

treatment.

pediatric

of chest

Sane

or

521

have

et al ana-

of New

results

con-

patients

Brill

chest
area

the

raised

patients.

in a preventive

reviewed

study

has been

1973,

were

can
medical

particularly

pediatric

required

remains

of

pediatric

In

most

on

yield

findings

none

taken

mality.
Received
for publication
June 12, 1980; accepted
July 30, 1980.
Reprint
requests
to (R.A.H.)
Department
of Pediatrics,
University of Rochester,
School
of Medicine
and Dentistry,
601 Elmwood Aye, Box 777, Rochester,
NY 14642.
PEDIATRICS
(ISSN
0031 4005).
Copyright
1981 by the
American
Academy
of Pediatrics.

of

of routine

patients;

and

rays

studies

radiographic

malities
gel

to

a low-income

Abnormal

its
been

problem.3
children

still
radiography

question

have

application

findings

patients.

much
as

Medicine

question
of

this
we

its

Three

Brill
chest
past

of

chest

basis

groups,

addressed

of

the

Although
age

cerned

that

The

preoperative

abnormalities

the

School

care.

routine

justified

to

gery.

Over

MD

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 preoperative 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 considered 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 performance
of routine
preoperative
chest
x-rays
on apparently
healthy
children
be discontinued.
Pediatrics
67:447-452,
1981;

Robert

Test

1 981

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in

anes-

of these
preopera-

447

tive

chest

cally

and

roentgenographic

examination

economically

justified

pediatric
patients.3
To
in study
results,
in 1979
tive study
that
compared
atric

patients,

chest

x-ray

one

This

enabled

ings

of

was

in

of

study

to

thought

it

the

chest

x-ray,

risk

used

altered

had

(1) the
in terms

preoperative

to assess

purpose

of

those

(2)

x-rays

who

of occurrence

operative

complications,

preoperative

temperature)

chest

and

tests
and

in

terms

the

was

eliminating

of

the

or post-

results

of

urinalysis,

indicated

nized

on

the

abnormality,

patients
Memorial

Hospital

the

and

by

reviewed

the

one

the

admitting
of

were

ing to one
third-party
date

used

of five
payer;

of admission;

missions;

urinalysis;

results

length

448

recorded.

CHEST

of stay;
chest

x-ray,

X-RAY

SCREENING

and
was

study,

we

were

the

organ

system

performed.

chest

x-ray

61%

boys

(1,702)

were

white,

were

days

and

of

of age

half

and
within

of the

age.

the

whereas

were

were

about

from
sociohome

black,

evenly

10%

15

slightly

3 and

9 years

insured

were

4%

distributed

although

were

88%

and

between

between

77%

percent

girls;

ranged

fairly

Hos-

Sixty

were

sample,

children

Approximately

not.

Ages

were

were
64%

a preoperative

(773)

(153)

race.

19 years

did

40%

(699)
and

General

had

(1,175)
8%

of another

year

(749)

and

were

36%
Hospital

Rochester

39%

taken;

(1,151)
(69)

to

total,

by

covered

Blue

by

Medi-

caid.
The rest either
utilized
other
forms
of insurance or were self-payers.
Of the five socioeconomic
groups,
33.6%
of the patients
were
in the highest
two

categories,

56.6%

and
The

only
9.8%
admissions

were
in the lowest
were
distributed

of the

year,

and

10.2%)

were

with

in the

middle

September

category,

two categories.
evenly
over

August

having

the

the

least

Just
over
86%
of the
patients
hospital
for three
or fewer
days,
from
four to nine days,
and 0.1%

(122,

6.3%).

remained

in

13.5%

all

most
the

remained

remained

for

ten

days.
are

systems

shown

upon

in Table

which

adenoidectomy,
X-Ray

surgery

1. Of the

underwent
the placement
of
either
alone
or in conjunction
dure,
43% (828) of the patients,
polyethylene
tube placements,

when

areas);
procedure;

was

total,

22%

per-

(432)

polyethylene
tubes,
with
another
proceincluding
some
with
had a tonsillectomy,

or both.

Findings

Of
ity,

and

temperature

was

re-

sought

749

preoperative

demonstrated

nine

(1.2%)

abnormality,

reason

chest
some

showed
and

to cancel

to

ELECTIVE

pneumonia,

combined
pneumonia

(2)

with
with

(0.4%)

or postpone

in

the

perihilar

SURGERY

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on April 3, 2015

35

unsuspected
used

on the

as

left

infiltrates.

of
that
lobe

lower

element,

the

basis

The
findings
(1) left
lower

inflammatory

bilateral

taken,
abnormal-

were

surgery

findings.
were:

atelectasis

some

x-rays

unsuspected

a significant

three

the roentgenographic
resulted
in cancellation

admission,
outcomes

FOR

the

(4.7%)

of read-

hematocrit,

information

of this

patients

surgery

admitted

the

The-organ

complications;
postoperative
maximum
postoperative
termThis

a preoperative

accord-

number

each patients
illness,
in order
to compare

were
Of

formed

physician).

patients

(1,225)

or more

patients.

socioeconomic
surgical

preoperative

enable
us to study
and hospital
course

(only

was
retrieved
age; sex; race;
by census
tract;

categorize

general
diagnosis;

of the

corded;
anesthetic
complications;
and
perature

to

maximum

Strong
Hospital

1,924

have

1,924
patients
reviewed,
to Strong
Memorial

pital.

(196,

all

1978. Durto Strong

taken

records

The
following
information
each
patients
hospital
record:
economic
status
(determined
addresses

to

General

50 had

ordered
we

of

charts

admitted

their

Of the
admitted

months

elective
surgery
had a chest
of the 1,225 patients
admitted

General,

specifically

recog-

the

Rochester

for

x-ray

a previously

of age

or

a chest

during
calendar
year
699 patients
admitted

Memorial
Hospital
x-ray
taken,
whereas,
to Rochester

of

reviewed

19 years

for elective
surgery
ing that
year,
all

Thus,

basis
we

under

in which

not

purposes

of the

which

Cross,

significance.

all cases

the

status

upon

over

METHODS
After

or did

able to gatxer
complete
data on the types
of elective
surgery
performed,
cancellations
of surgery,
anesthetic
complications,
and postoperative
complications,
as well as the age, sex, race,
and socioeco-

by

signifi-

anesthetic
(3)

was

patients

differed

(hematocrit,

their

study

whether

not

of either

anesthetic

x-rays
and their
of surgery
or

taken

did

we
other

and temwith
the

this

did

RESULTS
this

three

often

taken.

x-ray

as

population,

results
of the
of cancellation

chest

frequency
other

such

analyze

management,

from

variables

who

chest

nomic

two

of preoperative
to

The

surgical

cantly

the

pediatric

most

preoperatively.

find-

compare

for patients
In addressing

not.

x-ray

hematocrit,
urinalysis,
these
measures,
along

are

to determine:
significance

to

value

worthwhile

routine
tests-the
perature-because

it was

the

complications.
goal
in conducting

in a healthy

radiography
also

to analyze

important

and postoperative
our primary
assess

in

preoperative

in which

also

anesthetic
Although
was

one

only
but

terms

a routine

and

group,

essential

evaluate
this discrepancy
we undertook
a retrospectwo populations
of pedi-

which

us not

one

groups

in

taken

is medi-

and

lobe

and

(3)
The

35

radiographic

In one
ray,

abnormalities

patient

reported

listed

are

as having

in Table

pneumonia

2.

had
respiratory
tract
infection,
and
the chest
read as normal
by the attending
surgeon.
patient
reported
to have
pneumonia
on

surgery

was

an upper
x-ray
was
In another
x-ray,

a repeat

surgery

and

cleared

sufficiently

cancelled

chest
it was

because

x-ray

was

decided
to

taken

that
allow

the

patient

on the

the

day

pneumonia

the

of
had

operation

to

be

performed.

The

frequencies

similar

for

nomic

groups,

Abnormal

different
findings,

Was

x-ray
age

and

Organ

findings

groups,

months

however,

in boys
1.

TABLE

races,

diagnoses,

as frequent

gery

of abnormal

were

two

Systems

Which

El ective

Stir-

throat

No.

976
590
215
98
45

50.8
30.6
11.2
5.1
2.3

1,924

TABLE
2.
Preoperative

Abnormalities
Chest
X-Rays

Detected

in

749

Surgery

Lungs
Pneumonia*
Atelectasis*
Azygous
lobet
Bronchiectasis*
Consolidation*
(prominence
ofright
perihilar
region)
Peribronchial
thickening
Small
right
lower
lobe infiltrate
Increased
interstitial
markings
Increased
markings
of right
middle
lobe
Slight
hilar
prominence
Cardiovascular
Slight-mild
cardiomegaly
Cardiomegaly*
Prominent
main
pulmonary
artery
Prominent
pulmonary
vein
Prominent
vasculature
Absence
of clearly
defined
aortic
arch
Poor
definition
of cardiac
border
Curious
configuration
of cardiac
silhouette
Cardiac
silhouette
upper
normal
limit
Right-sided
aortic
archt
Skeletal
Mild scoliosis
Pectus
excavatum
Hypoplastic
first rib
Other
Colon
interposed
between
liver and diaphragm

variants.

Preoperative
1,924 patients

matocrit

sible

of 23%

was

In

two

Screening

hematocrit

greater

the

surgery.

(25%,

in

a low

TABLE

some
3.

Recorded

Age
(yr)
<1

43
37
47
206
551
197
198

1
2
3-4
5-9
10-14
15-19
Total
n

1,279

4.

Hematocrit
23-29
30-35
36-40
41-45
46-50
51-60

0.2

on
for

patients,

and

in 226
Of these,

Temperatures*
(F)

99.0-99.9

566

per-

in the

performed
admitted

>99.9

63
24
29
103
203
87
57
(66.4%)

a
a

9
11
10
16
22
7
5
(29.4%)

80 (4.2%)

= 1,924.

TABLE
0.5

was

of these

Temperature
<99.0

In all
with
with

made

normal,
discovered.

Preoperative

32%)

it was
for pos-

hernatocrit

surgery

(87.8%)

completely
abnormality
was

and

eight
three

finding

was

to
the

studied.

the
the

50%,

of the

disorder;

29%,

and

of

4. In

as a reason
had a he-

each
case,
be followed

including
30% and

1,633

1,918

as contributing
three
cases,

cases,

than

In

urinalysis

(12.2%),

1
1
4
2
1
1
1
1

low

other

no mention

in

physicians
notes.
Preoperative
urinalysis
testing
was
1,859
(96.6%)
of the
1,924
patients
elective

1.9

three

in Table

noted
patient

discovered

however,
less
than

1
1
1
1
1
14
3
1
3
1
1
1
1
1

as

previously

with

results

to a clotting

summary;
patient
would

other
cases,
hematocrit

was

F. Although

shown

were noted
an additional

noted

discharge
that
the

been

test
are

in addition

findings
In

100.0

3
1
1

In

>102.4

or

tern-

recorded.

were

was hematocrit
of surgery.
This

anemia.

had

2.1

temperature
of preoperative
3. Surgery

a preoperative

been

hematocrit
studied

one patient
cancellation

only

in the
stated

16
4

had

80 patients
greater

patients
were
found
in all age groups,
15.3%
1 year of age, and 1 1.6% were 2 years
old.

hematocrit

after

temperatures

both of these
the cancellation.

No.

16 of the
temperature

preoperative

100.0
these

these
were

for

cancelled

in 64 patients

perature
cases,

of Surgery

F, either
because
of the
reason.
The distribution
is shown
in Table

performed

significant.
as anatomic

was

than
99.9
for another
temperatures

the

for Cancellation

a maximum

formed

Abnormality

be considered

Reasons

with

for

Upon

Total

Clinically

times

as in girls.

System

1-May

socioeco-

Performed

Ear, nose,
and
Urogenital
Musculoskeletal
Eyes
Other

were

of admission.
about

Other

on x-

Preoperative

Hematocrit

Results*

No.

13
452
1,134
273
43
3

0.7
23.6
591
14.2
2.2
0.2

= 1,918.
ARTICLES

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449

131

showed

what

abnormality,
14 had been
their

we

considered

as shown
admitted

findings

on

to

urinalysis

were

one patient
did a urinalysis
lation;
in this instance,
2+
pyuria
Finally,

reasons

power

shown

in

Table

In

were

found.

of the

28 surgical

6.

the

In

the
the

only

to a cancel3+ blood,
and

field)

for cancellation

are

clinically

a significant

expected.

contribute
protein,

(8 to 10 WBC/high

procedures

be

in Table
5. Of these
patients,
for a urologic
procedure
and

or

to

the

sea,
tion

the

preoperative

temperature,

A postoperative
was noted
summary
Of the

seven

related

chest
x-ray,
urinalysis.

the

complication

results

of

hematocrit,

or an

or

abnormality

by the attending
surgeon
in the discharge
of 92 (4.8%)
patients,
as seen
in Table

conditions

listed,

pneumonia,
and
be considered

only

fever,

bleeding,

upper
respiratory
postoperative

can

7.

nau-

tract
infeccomplications;

patients
noted

in whom
temperature
elevation
alone
was
as the reason
for cancellation,
the tempera-

of these,
only fever,
ratory
tract
infection

tures

ranged

by using
the preoperative
tests
we studied.
Of the
22 patients
in whom
an elevated
temperature
was
noted
postoperatively,
17 had a normal
preopera-

difference
between
(0.5%)
ative
celled,
did

100.4

to

cancellation
two
groups

102.6

F.

rates
was
of patients,

A significant
demonstrated
that
is,

six

of the patients
who did not have
a preoperchest
x-ray
taken
had their
operations
cancompared
with 22 (2.9%)
of the patients
who
have

x-rays
taken
(P < .001).
However,
x-rayed
group
had surgery
cancelled
of the x-ray
results.

only
on

of the

three

the

from

in
the

basis

Anesthetic

and

Anesthesia
plications

(1.3%)

Postoperative

records
or abnormal

revealed
that
reactions

of the patients.

complications
or extubation,
None,

Most

was

Significant
Urinalysis*

cornin 25

among

during
increased

considered

5.

erative

anesthetic
occurred

common

were laryngospasm
coughing,
and

however,

TABLE

Complications

to

Abnormalities

these

be

>1+
>10
>1+
>1+
>1+
1+

power

83
32
18
7
6
2

field

148

Total
*

131;

17

abnormality

of

the

131

detected

patients

had

more

than

of 104.4

demonstrated
a right
lower
lobe pneumonia.
One
the 22 patients
had had a preoperative
temperature
of 101.0 F, whereas
all others
had had temperatures
99.6 F preoperatively.

of

taken

in response

The
patient
with
pneumonia
tively
had a normal
preoperative
ing

a normal

chest

6.

although
the

for

25

of Surgical

of

noted
postoperaevaluation,
includ-

The

patient

Proce-

who

tract
infection
preoperative

taken

cases

erative
bleeding,
the other
knee
to

Cancellation

one

preopwithout
chest
x-

devel-

following
chest
x-ray

postoperatively

was

postoperative

nor-

bleeding,

23

or combi828 such cases

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-

one

on urinalysis.

Reason

x-ray.

upper
respiratory
had
not
had

one
surgery.

Of the total,
the
hospital

department
TABLE

to a temperature

followed
tonsillectomy,
adenoidectomy,
nation
of the two. Thus,
2.8% of the
were
complicated
by postoperative

No.

bacteria
WBC/high
power
field
occult
blood
or 10 RBC/high
protein
acetone
glucose

ray

mal.
Of

on Preop-

Abnormality

no

taken,

significant

Found

tive chest
x-ray.
The remaining
five had
erative
chest
x-ray.
In one of the patients
a preoperative
radiograph,
a postoperative

oped
an
surgery

intubation
secretions.

pneumonia,
and upper
respicould
in any way be detected

surgery

21
or

with
performed.

followed

(1.1%)
were

a circumcision

patients
seen

a complaint

in

were
the

directly

Of these,

nine

and

readmitted
emergency
related

involved

to the
postop-

dures*
Reason
Temperature
Temperature
URIonly

X-ray

only
and

URI

No.

or sore

7
6
6

throat

(one

each

for

serous

otitis

chickenpox,
elevated
atinine
phosphokinase

and

clotting

scheduling

media

and

and

cough,

hematuria

and

problems)

28

Abbreviation

used

is: URI,

upper

respiratory

tract

in-

fection.

450

CHEST

X-RAY

SCREENING

FOR

in Discharge

ELECTIVE

Complications

and

Abnor-

Summary

or Abnormality

No.

explained
temperature
elevation
bleeding

28
22
25
3
3

cancellation

Abnormal

Total

Postoperative

Postoperative
Postoperative
Low hematocrit
Postoperative

WBC count,
elevated
crelevel,
low hematocrit

disorder,

Noted
Complication

Other

7.

malities

Surgical

report

TABLE

nausea

urinalysis

Right upper lobe and right lower

pneumonia
Upper
respiratory
tract infection
Other of no significance
Total

lobe

SURGERY

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2
1

1
7
92

erative

bleeding-seven

adenoidectomy

and

overall
frequency
ing tonsillectomy

was

30/828

two

followed

tonsifiectomy

and

Are the

followed

circumcision.

The

justified

on

mation?

Similar

of postoperative
and
adenoidectomy,

or

bleeding

followtherefore,

3.6%.

costs

tory
five

tract
infections,
to other
minor

one to a wound
infection,
and
problems.
All of these
patients

significant

had

had

tions,
including
chest
or upper
respiratory

preoperative

x-rays.
No patients
with
tract
infection
required

peratures
in whom
temperatures
fevers

were

noted

were

these

by the

of these,
(throat,

rays

of maximum

taken,

and

patients

be

fever

of all
>100.0

who

temperature

15- to

F. It was

had

was

tern-

also

x-

F, whereas

chest

x-ray

race,

>100.0
not have

39.6%

had

F, compared
a preoperative

x-ray.

DISCUSSION
In analyzing

chest

the

x-ray,

TABLE

one

8.

value

basic

Recorded

<99.0

<1

must

Postoperative

Total

740
1,924.

preoperative

be

33
19
23
74
245
94
87
(38.4%)

575

answered:

Temperatures*
(F)

99.0-99.9

46
39
40
161
293
91
70

1
2
3-4
5-9
10-14
15-19

routine

Temperature

Age
(yr)

of the

question

of

these

considered

rate

studies,

our

fall

data

results
we have
of roentgenographic

noted.3
ab-

>99.9

36
14
23
90
238
106
103
(29.9%)

610

cost

effectiveness

chest
by Sane

such

analysis
of this
to Neuhauserstt

x-rays

et al. He

x-rays

are

of

based

routine

upon

concludes

pediatric

the
that

economically

figure,
anal-

data
their

preclaim

justified

is not

warranted.

routine
preoperative
measureshowed
that
in only one case
did the result
of the hematocrit

contribute
to cancellation
of surgery;
in eight
chilthen,
elective
surgery
was performed
even
though
their
hematocrits
were less than
30%.
Preoperative
urinalysis
results
demonstrated

temperatures
ofall
patients
taken

the

Our
analysis
of
ment
of hematocrits
(of a total
of 1,918)

so that

by

of

that

cul-

occurrence

influenced

had
28.7%

did

similar

contradictory
a higher

preoperative
sented

chest

delayed

>100.0

temperature
of those
who

with

attempt
a cost-benefit
refer
interested
readers

ysis

discharge

and

The

patients
noted
that

a preoperative

postoperative
with 33.6%
chest

19-year-old

(4.7%)
were

our

comparison

between
the
We detected

sex, or socioeconomic
status.
There
was some
vanation,
however,
among
different
age groups;
only
19.4%
of all 1-year-old
patients
had
a maximum
postoperative

35

abnormalities

three

When

In

fever
dis-

further:

blood)

not

routine

not
but

observed.

was

in

unsuspected

postoperative

studied

and

discovered

of any

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

in the

discharge

could

of postoperative

were

urine,

received

A previously

infor-

asked

was discharged
as
came
to the emerand a temperature

physician

eight

wound,

be

x-ray.

of the

and

should

children

procedure

of medical

resulted
in cancellation
of
two
groups
of patients
were
compared,
no differences
in anesthetic
or postoperative
complications
could
be identified.

is shown
in Table
8. Of the 610 patients
the temperature
was >99.9
F, five had
>104.6
F. Twenty-two
postoperative

summary;
tures

but the patient

days
later
he
with
a cough

Nine

surgery.

fever
read-

his

was

children.

evalua-

mission.
In one patient,
a mild postoperative
was noted
by the attending
physician
in
charge
summary,
scheduled;
three
gency
department
of 102.2 F.
The distribution

abnormality

of this

yield

questions

chest

preoperative

hazards

of its

procedure.
study,
749

12 patients
in whom
there
was
or emergency
department
to fever,
two to upper
respira-

normal

possible
basis

preoperative
In our

Of the remaining
a related
readmission
visit,
four were
due

completely

and
the

some
In

abnormality
131

of

nificant
results
cancel

by

in 226

these,

our

the

standards,

of urinalysis
surgery.

(1 1.7%)

abnormality

yet
contribute

of 1,859
was

in only
to

patients.

deemed

sig-

one

did

case

decision

to

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
tions
is quite
small.
lyzing
postoperative
a complete
assessment

and postoperative
complicaFurther,
our methods
of anacomplications
were
not ideal;
of this variable
would
have

required
contacting
each patients
surgeon
and
vate pediatrician
to determine
the true incidence
postoperative
complications.
Unfortunately,
were unable
to do this.

priof
we

CONCLUSIONS
On
(31.7%)

mation
as well
eliminate

the

basis

of the

derived
from
as the need
unnecessary

low

yield

the chest
to contain
radiation

of significant

infor-

x-rays
we reviewed,
hospital
costs
and
exposure,
we rec-

ARTICLES

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451

ommend
tive

that

chest

the

practice

x-rays

discontinued.
preoperative
an individual

on

of performing

apparently

healthy

children

be

We thus
agree
with
Brill
et al
chest
x-rays
should
be performed
rather
than
on a routine
basis.

Chest

x-rays

are

often

routinely

ACKNOWLEDGMENTS

preoperathat
on

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

recommend
both

of

these

individual

We
and

for

entrance

the

need

groups

be

that

to

for

college.

chest

We

x-rays

considered

also

recommend
tests
be

that
similarly

on

an

routine
urinalysis
eliminated,
but

our results
concerning
these
two tests
do warrant
attention.
Both
are of relatively
low cost and extremely
low risk;
therefore,
their
routine
use for
screening
purposes
has been
much
less controversial

than

the

use

of chest

productive,

as we

information.
normalities

However,
detected

#{224}-visdecisions
they

were

cians
these
tinized

review

reason
tory

for
tract

surgical
ignored

to either

an elevated

also

of the

by

452

since
pediatri-

reasons

cancellation

for

of

reveals
that a preoperwas the most
common
followed

by

upper

21 of 28 cancellations

temperature

X-RAY

abvis-

are obvious:
if
must
be scru-

for screening
surgical
and postoperative

CHEST

the

procedures,
attending

respirawere

or another

on the preoperative
physical
examination.
dude,
therefore,
that
a complete
medical
and physical
examination
remain
the most
methods
operative

fairly

of medical

conclusions
their
results

procedures
elevation

cancellation,
infections;

are

yield

we also found
that
were of little
consequence

and surgeons.
The
tests
are of value,
more
closely.

elective
surgical
ative
temperature

They

in their

regarding
seemingly

Finally,

x-rays.

found,

due

finding
We conhistory
effective

patients
for potential
complications.

SCREENING

The
Kathy

FOR

ELECTIVE

was

supported

in part

by

the

Division

of

grant
FounPro-

4961.

authors
Schafer

wish to thank
Sydney
A. Sutherland
for their assistance
in the preparation

and
of

manuscript.

ADDENDUM

among

solely

study

grant

gram

this

basis.

cannot
hematocrit

This

Research
Resources,
National
Institutes
of Health
BRSG-RR-05403
and The Robert
Wood Johnson
dation
General
Pediatrics
Academic
Development

In June
rays

1979, the use of routine

preoperative
chest
xfor pediatric
patients
at the Strong
Memorial
Hoswas discontinued.
This decision
was not based
upon

pithi
the results

of the study

reported

here.

REFERENCES
1. Brill PW, Ewing
ML,
Dunn AA: The value (?) of routine
chest radiography
in children
and adolescents.
Pediatrics
52:125, 1973
2. Sage! 55, Evens
RG, Forrest
JV, et al: Efficacy
of routine
screening
and lateral
chest radiographs
in a hospital
based
population.
N Engi
J Med 291:1001,
1974
3. Sane SM, Worsing
RA, Wiens CW, et al: Value
of preoperative chest x-ray examinations
in children.
Pediatrics
60:669,
1977
4. Taylor
LS: Inefficient
use of x-rays in diagnostic
radiology.
AJR 111:635, 1971
5. Rourke
AJJ: Are all those x-rays and tests really necessary?
ModHosp
118:106, 1972
6. Hahn
DR, Van Farrowe
DE: Misuse and abuse of diagnostic
x-ray. Am J Pub Health 60:250, 1970
7. Peters
ES: Mass x-ray surveys.
Med Serv J Can 22:922, 1966
8. Mackenzie
CJG: Non-tuberculous
chest disease
found in a
mass x-ray survey
in Vancouver,
B.C.
Can
Med
Assoc
J 94:
1257, 1966
9. Saenger
EL: Radiologists,
medical
radiation,
and the public
health.
Radiology
92:658, 1969
10. Mass survey
by chest radiography,
editorial.
Can Med Assoc
J 103:1081, 1970
11. Jarman
TF: Mass radiography.
Br Med
J 1:365,
1970
12.

Mackenzie

of persons
with
nonoperation
doorstep,
Vancouver,
Assoc J 103:1019,
1970
Neuhauser
D: Cost
effective
clinical
decision
making:
Are
routine
pediatric
preoperative
chest x-rays
worth
it? Ann
Radiol2l:80,
1978

tuberculous
13.

CJG:

A two-year

chest
disease
1964. Can Med

follow-up
found
at

SURGERY

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Value of the Chest X-Ray as a Screening Test for Elective Surgery in Children
Robert A. Wood and Robert A. Hoekelman
Pediatrics 1981;67;447
Updated Information &
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1981 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

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Value of the Chest X-Ray as a Screening Test for Elective Surgery in Children
Robert A. Wood and Robert A. Hoekelman
Pediatrics 1981;67;447

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/67/4/447

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1981 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

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