Rethinking routine chest radiography after central venous catheterisation: a rapid review of current evidence and alternatives

Background: Despite growing evidence supporting ultrasound (US)- and ECG-guided protocols, chest radiography (CXR) remains the most widely used method for post-procedural confirmation of central venous catheter (CVC) position in clinical practice. Methods: We conducted a rapid review of observational studies, randomised controlled trials, systematic reviews, and guidelines comparing CXR with US- and ECG-based confirmation modalities in adult patients across ICU, emergency, and perioperative settings. Systematic searches were performed in PubMed, Scopus, and Web of Science through December 2025. Outcomes of interest included diagnostic accuracy for tip position and complications, procedural time, and clinical and economic impact. Findings: Ninety-four studies were included, comprising more than 20,000 CVC placements. Evidence from meta-analyses, multicentre cohorts, and comparative studies suggests that US-based protocols – particularly those incorporating agitated saline (“bubble test”) and right-atrial visualisation – and intracavitary ECG (IC-ECG) can achieve high diagnostic performance for tip confirmation in appropriately selected patients, with several reports describing sensitivity and specificity of approximately 95% or higher. Across studies, bedside strategies enabled faster confirmation than CXR (often 15–40 min), avoided radiation exposure, and facilitated earlier detection of complications. Despite these findings, CXR remains predominant in many institutions, reflecting entrenched protocols, medico-legal considerations, and heterogeneity in training and governance. Interpretation: Routine CXR after CVC placement offers little incremental value where comprehensive US or ECG confirmation is available, implemented, and documented by trained operators. Wider adoption of US- and ECG-based protocols could improve safety, efficiency, and resource utilisation in acute care. Institutional inertia and educational gaps remain key barriers to implementation; addressing these will be crucial to aligning practice with current evidence. A pragmatic two-tier pathway – POCUS and/or IC-ECG as first-line confirmation, with selective CXR for unresolved uncertainty or high-risk scenarios – may balance efficiency with governance and medico-legal requirements.