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Vascular and Interventional Radiology |
1 From the Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710. From the 2003 RSNA scientific assembly. Received December 18, 2003; revision requested February 20, 2004; revision received May 12; accepted June 2. Address correspondence to T.A.J. (e-mail: jaffe002@mc.duke.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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MATERIALS AND METHODS: The institutional review board did not require approval for this study. In a survey conducted between November 2002 and February 2003, 493 questionnaires were sent to 193 academic and 300 private practice radiology departments in the United States. All recipients were informed of the study purpose. The survey included questions about departmental demographics, patient selection criteria for percutaneous abscess drainage (eg, abscess diameter at imaging, laboratory parameters such as white blood cell count, and clinical indications such as fever), use of analgesia or conscious sedation, drainage method, and imaging technique. The statistical significance of differences between respondent subgroups was analyzed with a Pearson or Mantel-Haenszel 
2 test.
RESULTS: Academic centers returned 95 questionnaires (49%), and private practice centers, 72 (24%). Percutaneous abscess drainage is performed by a fellowship-trained radiologist at 92 (97%) of 95 academic centers and 41 (79%) of 52 private practice centers (P < .001). Among 95 academic respondents and 52 private practice respondents, respectively, 56 (59%) and 33 (63%) do not perform drainage if an abscess has a diameter of less than 3 cm; 30 (32%) and nine (17%), if the white blood cell count is normal; and 16 (17%) and six (12%), if the patient is afebrile. Most (90 [95%] of 95 academic, 45 [87%] of 52 private practice) respondents use conscious sedation. A transabdominal approach and 8–12-F catheters are most frequently used by both groups. Academic respondents more frequently use transvaginal and transrectal approaches (54 [57%] and 51 [54%] of 95, vs 16 [31%] and 15 [29%] of 52 private practice respondents; P = .003) and 14-F catheters (69 [73%] of 95 vs 18 [35%] of 52; P < .001).
CONCLUSION: Percutaneous drainage is usually performed by fellowship-trained radiologists in abscesses of more than 3 cm in diameter, for appropriate clinical indications (multiple parameters above the established threshold), by using conscious sedation and 8–12-F catheters.
© RSNA, 2004
Index terms: Abscess, 70.21, 80.211 • Abscess, percutaneous drainage, 70.1263, 80.1263 • Catheters and catheterization, technology • Interventional procedures, utilization • Radiology and radiologists
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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While abundant data document the effectiveness of percutaneous abscess drainage and its recommended applications, the question remains, how much agreement is there among everyday practices of percutaneous abscess drainage? To our knowledge, there have been no studies that compared the practice patterns of academic and private practice radiologists with respect to percutaneous abscess drainage. In this study, our aim was to examine the current practice patterns in percutaneous abscess drainage at academic and private practice centers.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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The questionnaire included open-ended questions (with the instruction "fill in the blank"), most of which were in the demographics-related section, as well as closed-ended ones (with the instruction "choose from the following" or "select all that apply"). Our institutional review board does not require its approval for this type of study. All recipients of the questionnaire were informed of the study purpose.
Respondent Demographics
The recipients of the questionnaire were initially asked whether percutaneous abscess drainage was performed in their department. The respondents were then asked to indicate which division or group in the radiology department performed percutaneous abscess drainage, by selecting one of the following: vascular and interventional imaging, abdominal imaging, combination, or other. They also were asked how many radiologists were in the department, how many of them performed percutaneous abscess drainage, and of those who did so, how many were fellowship trained. There was no request to specify either the type of fellowship or the fellowship status of the respondents’ colleagues. Respondents also were asked to indicate the number of beds at their center and whether their center was affiliated with a Veterans Administration hospital. The respondents were asked whether percutaneous abscess drainage was performed in pediatric patients or performed "after hours" (between 5 PM and 7 AM on weekdays or at any time during the weekend). We did not ask respondents to provide identifying information or to indicate their age or sex.
Preprocedural Work-up
Respondents were asked to indicate which imaging modalities were used to evaluate patients for intraabdominal fluid collections (computed tomography [CT], ultrasonography [US], or magnetic resonance [MR] imaging). They also were asked what imaging findings and clinical criteria would make the performance of percutaneous abscess drainage unlikely. Possible image-based exclusionary criteria included abscess size of less than 3 cm in diameter, fluid attenuation of more than 40 HU, absence of contrast material–enhanced margins, absence of trapped air in a fluid collection, absence of free intraperitoneal air, and presence of air without fluid in the abscess cavity. We chose a threshold diameter of 3 cm because the diameter of the pigtail in an 8-F catheter is more than 2 cm. Possible clinical exclusionary criteria included normal white blood cell count, normal temperature, normal blood pressure, absence of peritoneal signs, lack of relevant medical history (eg, inflammatory bowel disease, penetrating trauma, neutropenia, human immunodeficiency virus, or recent surgery), and do-not-resuscitate code status. We included questions about these clinical data because we were interested in knowing whether they were important exclusionary criteria to radiologists. Our goal was to ascertain what combinations of clinical and radiologic findings were considered to indicate that a patient would benefit from percutaneous abscess drainage or decline without it. We did not ask respondents by what means the patients were referred to the radiology department or what type of surgical support was available.
Regarding the preprocedural work-up, respondents were asked whether laboratory data were obtained, whether the procedure would be performed in spite of abnormal coagulation parameters, and whether and by whom informed consent was obtained.
Use of Analgesia or Conscious Sedation
The definition of conscious sedation given in the ACR practice guidelines for adult sedation or analgesia was clearly outlined in the questionnaire, and the respondents were asked whether they used conscious sedation in percutaneous abscess drainage and what other types of sedation and/or analgesia were used (12). If conscious sedation was not used, the respondents were asked to indicate why, given the following choices: lack of expertise, no interest, not comfortable administering narcotics or benzodiazepines, lack of nursing support during the procedure or postprocedural recovery, and no prior exposure to the technique. They also were asked whether they would be interested in learning conscious sedation techniques and in completing a CME course devoted to this topic.
Radiologists who indicated that they did use conscious sedation were asked to specify where they had received their education in the technique of conscious sedation, whether specific informed consent was obtained for administration of medications, and what type of monitoring patients underwent during the procedure. Whether patients were monitored after the procedure and the length of their recovery time also were documented.
Procedural Technique and Imaging Method
The respondents were asked to indicate which approaches they used for catheter placement, with the possible choices including transabdominal, transgluteal, transrectal, and transvaginal approaches. They also were asked what imaging modalities they used to guide the procedure—CT, CT fluoroscopy, conventional fluoroscopy, US, or MR imaging. Respondents were asked what types of protective barriers (eg, gown, gloves, mask) and what catheter sizes were used (range, 8–16 F). Other questions asked to elicit further details about the percutaneous drainage technique were the following: how access to the abscess was verified (aspiration vs imaging), whether the cavity was irrigated immediately after drainage, what type of drainage reservoir was used, and who applied the dressings to the catheter after the procedure (physician, nurse, or technologist). Respondents also were questioned about how the procedure was documented and were asked to choose from the following responses: imaging, dictation of a procedural note, and writing of a note in the patient’s hospital chart.
Postprocedural Care
The respondents were questioned about whether the patient was admitted to the hospital after percutaneous abscess drainage and by which service the patient was admitted. Respondents also were asked who was responsible for the postprocedural nursing orders (radiologist, referring service, or surgical service), and how often the drainage catheter should be flushed to maintain luminal patency.
Respondents were asked whether they monitored the clinical status of patients who had undergone percutaneous abscess drainage, and, if they did so, with what means (eg, daily rounds, hospital information system, nursing notes). Respondents also were asked whether they routinely performed repeat imaging of the patient after the drainage stopped, and with what modality. Finally, respondents were asked what criteria they used to determine the appropriate time for catheter removal, and who was responsible for removal (radiologist, referring service, surgical service, or support staff).
Statistical Analysis
The data were collected and entered into a database by the principal investigator (T.A.J.). The department statistician (D.M.D.) analyzed the data by using software (SAS, version 8.2; SAS Institute, Cary, NC). The statistical significance of differences between respondent subgroups in responses to specific questions was analyzed with the Pearson 2 test or the Mantel-Haenszel 2 test. A P value of less than .05 was considered to indicate a statistically significant difference.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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Vascular and interventional radiologists perform percutaneous abscess drainage at 54 (57%) of the 95 academic centers, abdominal radiologists perform the procedure at 25 (26%), and both groups of radiologists perform the procedure at 15 (16%); at one (1%) of the 95 academic centers, the procedure is performed by individuals other than vascular and interventional and abdominal radiologists. Among the private practice centers that perform percutaneous abscess drainage, the procedure is more commonly performed by both radiologist groups combined (26 [50%] of 52 for both radiologist groups vs 11 [21%] for vascular and interventional radiologists alone, seven [13%] for abdominal radiologists alone, and eight [15%] for others). The difference between academic and private practice centers is statistically significant (P < .001). Percutaneous abscess drainage is performed by a fellowship-trained radiologist at 92 (97%) of the 95 academic centers and 41 (79%) of the 52 private practice centers.
The number of radiologists in each respondent’s department varies greatly among both academic and private practice centers, with an average of 25 and 12 and a maximum of 80 and 34, respectively. The number of radiologists who perform percutaneous abscess drainage in the department ranges from one to 17, with an average of six in both academic and private practice settings. The number of hospital beds also varies greatly, with an average of 549 beds for academic centers and 294 beds for private practice centers. Twenty-eight (29%) of 95 academic centers and only one (1%) of 72 private practice centers are affiliated with Veterans Administration hospitals.
Seventy-five (79%) of 95 academic centers perform percutaneous abscess drainage in pediatric patients (age range, 1–17 years), compared with 30 (58%) of 52 private practice centers (P = .006). Radiologists at centers of both types (at 94 [99%] of 95 academic centers and at 47 [90%] of 52 private practice centers) gave an overwhelmingly affirmative response to the question of whether percutaneous abscess drainage was performed "after hours."
Preprocedural Work-up
CT is the imaging modality of choice for diagnostic evaluation of fluid collections at all responding centers, but the specific CT protocols were not explored. Both academic and private practices commonly use US (91 [96%] of 95, and 45 [87%] of 52, respectively) and less frequently use MR imaging (32 [34%] of 95, and 11 [21%] of 52, respectively) for detection and characterization of fluid collections.
Both respondent groups apply a range of image-based criteria in deciding which abdominal fluid collections should not be drained: Fifty-six (59%) of 95 academic respondents and 33 (63%) of 52 private practice respondents would not drain a fluid collection with a diameter that was smaller than 3 cm. High-attenuation (more than 40 HU) abscesses would not be drained at five (5%) of the 95 academic centers and eight (15%) of the 52 private practice centers. The lack of enhancing margins would obviate percutaneous abscess drainage at six (6%) of 95 academic centers and seven (13%) of 52 private practice centers. Neither group would forgo drainage of an abdominal fluid collection because of an absence of air in the abscess, and one (1%) of the 95 academic respondents and none of the private practice respondents indicated that the absence of free intraperitoneal air would militate against drainage. None of the differences between respondent groups with regard to these parameters were statistically significant. Seventeen (18%) of 95 academic radiologists and 36 (69%) of 52 private practice radiologists would not drain an abscess cavity that contained air without fluid (P < .001).
Clinical factors are also important criteria for determining the appropriateness of drainage, according to both academic and private practice respondents. Thirty (32%) of 95 academic respondents and nine (17%) of 52 private practice respondents indicated that a normal white blood cell count would obviate drainage of abdominal fluid collections. A normal temperature would militate against drainage for 16 (17%) and six (12%) of academic and private practice respondents, respectively. Neither group indicated that blood pressure measurements or peritoneal signs were used as clinical criteria. A small number of respondents (three [3%] of 95 academic, three [6%] of 52 private practice) consider the lack of pertinent medical history when deciding whether to perform percutaneous abscess drainage. Do-not-resuscitate code status is considered a clinical indication for exclusion of abscess drainage by 11 (12%) of 95 academic respondents and 12 (23%) of 52 private practice respondents. None of the differences between respondent groups are statistically significant.
Preprocedural laboratory parameters are obtained at 67 (71%) of 95 academic centers and 39 (75%) of 52 private practice centers. Laboratory parameters include prothrombin time and partial thromboplastin time, white blood cell count (international normalized ratio), platelet count, and bleeding time. When asked whether they would perform percutaneous abscess drainage in a patient with abnormal laboratory values (eg, white blood cell count of more than 1.5 x 109/L, partial thromboplastin time of more than 35 seconds, and/or platelet count of less than 50 x 109/L), 64 (67%) of 95 academic respondents and 41 (79%) of 52 private practice respondents answered that they would, but only if the patient’s clinical status were critical. In such cases, at 94 (99%) of 95 academic centers and 47 (90%) of 52 private practice centers, the referring physician would administer platelets or fresh frozen plasma to the patient prior to the procedure. Of note, 12 (13%) of 95 academic respondents and eight (15%) of 52 private practice respondents would perform percutaneous abscess drainage only in patients with normal coagulation parameters.
Ninety-four (99%) of 95 academic radiologists and 51 (98%) of 52 private practice radiologists obtain informed consent prior to percutaneous abscess drainage. Only private practice radiologists (10 [19%] of 52) reported that referring physicians obtain consent.
Use of Analgesia or Conscious Sedation
Ninety (95%) of 95 academic and 45 (87%) of 52 private practice respondents use conscious sedation for percutaneous abscess drainage. Conscious sedation, as defined in the ACR practice guidelines, is sedation induced by pharmacologic agents that results in a minimally depressed level of consciousness, in which the patient has continuous and independent ability to maintain reflexes and a patent airway and to respond to physical and verbal stimulation (12). Respondents who do not use conscious sedation for percutaneous abscess drainage provided an array of explanations, including lack of interest, low comfort level, lack of available nursing support and recovery areas, lack of prior experience, and belief that conscious sedation is not necessary. Patient satisfaction was not addressed.
Most respondents who use conscious sedation received formal training in the administration of sedatives during their residency (46 [51%] of 90 academic respondents and 20 [44%] of 45 private practice respondents) or fellowship (20 [22%] and nine [20%]), at the current or prior institution (21 [23%] and 20 [44%]), or in a CME course (10 [11%] and three [7%]). More than 90% of respondents in each group (89 of 90 academic, 42 of 45 private practice) obtain specific informed consent for conscious sedation, and 70 (77%) of 90 academic respondents and 25 (56%) of 45 private practice respondents always obtain a history and perform a physical examination prior to administering conscious sedation. The respondents were not asked to describe the nature of the history and physical examination.
Among 95 academic respondents, 46 (48%) monitor vital signs in inpatients and 77 (81%) monitor vital signs in outpatients immediately after the procedure in the radiology department. Fewer private practice respondents monitor postprocedural vital signs: nine (17%) of 52, in inpatients, and 14 (27%) of 52, in outpatients (P < .001). The average duration of postprocedural observation for inpatients and outpatients, respectively, is 0.8 and 2.5 hours at academic centers and 2.1 and 2.8 hours at private practice centers.
Procedural Technique and Imaging Method
The transabdominal percutaneous approach is most commonly used, as was confirmed by 94 (99%) of 95 academic and 52 (100%) of 52 private practice respondents. Private practice radiologists are more likely to access a pelvic abscess transgluteally (44 [85%] of 52, vs 31 [33%] of 95 academic respondents; P < .001). Academic radiologists use transvaginal and transrectal approaches more commonly than do their private practice counterparts (54 [57%] of 95 vs 16 [31%] of 52 [P = .002], and 51 [54%] of 95 vs 15 [29%] of 52 [P = .003], respectively). CT is the imaging modality most frequently used for guidance of percutaneous abscess drainage (93 [98%] of 95 academic respondents, 52 [100%] of 52 private practice respondents). Academic respondents employ CT fluoroscopy and conventional fluoroscopy more frequently in percutaneous abscess drainage than do private practice respondents (38 [40%] and 44 [46%] of 95 vs 14 [27%] and 17 [33%] of 52), but the differences are not statistically significant. Ninety (95%) of 95 academic respondents also use US for guidance, compared with 37 (71%) of 52 private practice respondents (P < .001).
Both groups use a variety of protective barriers. The use of sterile gloves is almost universal (94 [99%] of academic and 52 [100%] of private practice centers). Gowns, shoe covers, hair covers, and masks are used with slightly higher frequency at academic centers than at private practice centers (Table 1). Both respondent groups answered affirmatively a question about whether they used catheters of standard sizes (8–12 F); academic respondents, however, use large-bore catheters (14 F and larger) more frequently than do their private practice counterparts (Table 2). All respondents use the Seldinger technique for placement of percutaneous drainage catheters, and 63 (66%) of 95 academic and 31 (60%) of 52 private practice respondents use the trocar technique when they consider it appropriate.
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Postprocedural Care
Most patients are admitted to the referring service after percutaneous abscess drainage (77 [81%] of 95 academic centers, 48 [92%] of 52 private practice centers), but postprocedural orders involving catheter care are mainly written by the radiologist (85 [89%] of 95, 48 [92%] of 52). The postprocedural management of catheters is similar in both groups; relatively equal numbers recommended flushing alone (46 [48%] of 95, and 22 [42%] of 52) versus combined flushing and aspiration (41 [43%] of 95, and 25 [48%] of 52). Follow-up by the radiology service is performed daily at 70 (74%) of 95 academic centers and 35 (67%) of 52 private practice centers, every other day at nine (9%) and seven (13%), and less frequently at 16 (17%) and 10 (19%). Follow-up is performed at more than half of all responding centers (59 [62%] of 95 academic, 35 [67%] of 52 private practice) by visiting the patient in the hospital room.
Twenty-nine (31%) of 95 academic respondents and 22 (42%) of 52 private practice respondents routinely perform repeat imaging after drainage stops, 63 (66%) and 29 (56%) sometimes do so, and two and one (2% in each group) never do so. Repeat imaging most often involves either CT or sinography, with the latter defined as a gentle injection of contrast material into the drainage catheter and subsequent fluoroscopic imaging with CT or radiography (93 [98%] of 95 and 49 [94%] of 52, CT; 53 [56%] of 95 and 25 [48%] of 52, sinography). Eighty-nine (94%) of 95 academic respondents and 46 (88%) of 52 private practice respondents send the patient home with a percutaneous abscess drainage catheter in place after "a reasonable inpatient stay," but the length of stay was not delineated in the questionnaire. Only three (3%) of 95 academic respondents and no private practice respondents send the patient home immediately after drainage. More than half of respondents in each group (56 [59%] of 95 academic, 36 [69%] of 52 private practice) stated that the drainage catheter can be removed when daily output decreases to less than 10 mL. Nineteen percent of respondents in each group (18 of 95 academic, 10 of 52 private practice) consider apyrexia and decreased catheter output prerequisites for catheter removal. More private practice radiologists than academic radiologists remove the catheters themselves (47 [49%] of 95 vs 37 [71%] of 52); academic respondents, however, more often have nurses and technologists to perform this task (14 [15%] of 95 vs 10 [19%] of 52).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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The questionnaire was sent to the 193 U.S. academic radiology departments that have an accredited radiology residency program. The response rates of 49% for academic centers and 24% for private practice centers were within our expectations and are similar to the rates for other questionnaire-based studies documented in the radiology literature (14–16).
In general, at both private practice and academic centers, percutaneous abscess drainage is performed by fellowship-trained radiologists. Percutaneous abscess drainage tends to be the responsibility of a specific division of radiologists at academic centers (vascular and interventional radiologists more frequently than abdominal imaging specialists), while it is more likely that this responsibility will be shared by various groups of radiologists in private practice settings. This finding is likely a function of throughput: It is easier to delineate where certain services are provided, and by whom, if there are more members of the group. It is also likely that the private practice radiologist, who is more oriented toward multitasking, is more apt to take on a procedure outside of his or her fellowship training, as there is more flexibility in the roles of the private practice radiologist on a daily basis. It is interesting that both groups affirmed that percutaneous abscess drainage was also performed after hours (after 5 PM and on weekends). This finding suggests that percutaneous abscess drainage is arguably now a nonelective therapy.
A number of imaging and clinical criteria are used to determine the indications for and expected effectiveness of image-guided percutaneous abscess drainage. Neither of our respondent groups would elect to perform percutaneous drainage in an abdominal abscess that is less than 3 cm in diameter. It is of note that the respondents were not asked whether they would perform simple needle aspiration in these small abscesses. There was a statistically significant difference (P < .001) between the two groups with regard to the drainage of abscesses that contain only air: Many more private practice respondents than academic respondents would forgo drainage in such abscesses (69% vs 18%). In our experience, this imaging finding is seen mostly in pericolonic collections, such as those in diverticular disease. The difference in response between the two groups likely reflects a difference in familiarity with this clinical manifestation, as well as in the level of aggressiveness of the referring surgeon. Imaging criteria deterred fewer responding academic radiologists than private practice radiologists from performing percutaneous abscess drainage; clinical criteria such as normal white blood cell count and temperature, however, deterred fewer private practice radiologists than academic radiologists. As has been noted in the literature, the clinical signs of infection (fever, leukocytosis, anorexia, peritonitis) may be absent in critically ill, elderly, and immunocompromised patients (13). The purpose of these questions was not to determine what the appropriate response would be; the purpose was to ascertain what parameters radiologists consider in deciding whether to attempt percutaneous abscess drainage. Although one could argue that this is not the way to establish practice guidelines, many physicians use anecdotal experiences as justification for their own appropriateness criteria. Indeed, the ACR and the Society of Cardiovascular and Interventional Radiology have stated in their practice guidelines that there are no absolute contraindications to percutaneous abscess drainage (11,13). Clearly, it is at the discretion of the radiologist to determine what imaging and clinical criteria obviate drainage.
The use of preprocedural laboratory data in nonvascular abdominal intervention has been previously studied and is well documented in the literature. In a survey of more than 2000 radiologists by Silverman et al (14), 81% of respondents said they routinely documented prothrombin time and 78% said they used partial thromboplastin time. These parameters are frequently (>75% of respondents) measured before percutaneous abscess drainage. These survey results roughly correlate with our findings in both academic and private practice centers. Silverman and colleagues noted that most respondents (64%) believed there should be written guidelines for the evaluation of patients prior to interventional procedures. Our survey did not include a question about this subject; if it had, we suspect that we would have received a similar response.
The application of conscious sedation is widespread, and several surveys in the literature detail the recent trends in conscious sedation in the field of radiology (12,15,16). Like the results of these previous surveys, our results show little difference between respondent groups in the application of conscious sedation for percutaneous abscess drainage, regardless of the type of practice or hospital affiliation. Most respondents had formal training in conscious sedation techniques. From this, we can surmise that conscious sedation is now widely applied for percutaneous abscess drainage.
The procedural technique used varies slightly between academic and private practices. Both groups use CT most frequently. Academic groups are more likely to use CT fluoroscopy and conventional fluoroscopy than are their private practice counterparts. This difference likely reflects the facts that CT fluoroscopy is more widely available in academic centers. Percutaneous abscess drainage is more likely to be performed by a vascular and interventional radiologist in academic centers than in private practice centers, and these academic radiologists have more immediate access to conventional fluoroscopy. Academic interventionalists are more likely than their private practice counterparts to perform drainage in a deep pelvic collection by using a transrectal or transvaginal approach. These approaches are arguably more difficult technically, and they require experience. In addition, these approaches frequently require more time and deeper sedation. The discrepancy in response rates most likely reflects a lack of experience and of a satisfactory comfort level with this technique in the private practice setting. Alternatively, this difference could represent a function of throughput, as the transgluteal approach tends to be a faster technique.
Protective barriers tend to be more elaborate at academic centers, a difference that is likely also a function of the more frequent performance of percutaneous abscess drainage by subspecialists at these centers. In addition, this difference may be affected by the training environment during fellowship. The choice of large-bore drainage catheters at academic centers also likely reflects greater experience with catheters of larger size. It is interesting to note that within our own group of eight academic abdominal imaging specialists who routinely perform percutaneous abscess drainage, there is a wide variety of personal preferences with regard to technique, protective barrier, and catheter choices. We suspect that this range of preferences is, in fact, seen in most of the practices that responded to the questionnaire.
There appears to be a general consensus in postprocedural practices. Both respondent groups document the procedure similarly, admit the patient to the referring service, and write postprocedural orders. Just as prior surveys have noted, the number of respondents who make daily clinical rounds (74% in academic centers and 67% in private practice) seems low, particularly since prior studies have documented the importance of daily rounds, especially for the timely management of drainage complications such as catheter kinking and fistula formation (2,17,18). It is not surprising that the number of respondents who perform daily rounds is higher at academic centers, where residents, physician’s assistants, and nurse practitioners are available to perform this service.
There was a range of responses with regard to repeat imaging of the patient after drainage; however, the two groups were in general agreement that follow-up imaging may be helpful in deciding whether to remove a catheter. Both groups preferred that daily catheter output be less than 10 mL before the catheter is removed; in addition, a small subset of respondents in both groups identified apyrexia as a prerequisite for removal of the drainage catheter. These results are interesting, as they indicate that the respondents believe that the radiologist should have some influence on management of the catheter after placement.
There were several limitations to the structure of the survey and, ultimately, the results of the study. The questionnaires may not have reached their intended recipients in academic or private practice. The questionnaires were initially mailed to residency program directors, with instructions that they be forwarded to the section chief responsible for percutaneous abscess drainage; it is possible, however, that some questionnaires did not reach the appropriate person. The private practice recipients were recent attendees of CME courses at our institution, but they did not necessarily have an interest in percutaneous abscess drainage; in the ideal scenario, the questionnaire would have been forwarded to a partner responsible for percutaneous abscess drainage, but clearly that did not happen in all cases. We recognize that the use of our CME mailing list may have introduced a geographic bias, but we believe that any resultant geographic bias was less pronounced than it would have been if we had used professional association rosters and mailing lists. If there is a geographic difference in the practice of percutaneous abscess drainage, we were unable to identify it in this study.
Perhaps the greatest drawback is that the questionnaire did not evaluate the experience of the entire staff at each practice center but was completed by only one staff member. It is inappropriate to assume that one respondent’s opinion reflects the general consensus within his or her group. Indeed, even within our own group there is a wide range of opinions and practice patterns, a situation that makes the adoption of interventional guidelines and standards difficult. In addition, the study did not take into account the differences in attitudes of the referring clinicians, most notably the surgeons, or differences in the referral community or patient population. Despite the inherent drawbacks of this study, we believe that the results approximate the general trends in the two radiology communities.
In general, percutaneous abscess drainage is performed by radiologists with fellowship training, in patients with fluid collections of more than 3 cm in diameter and appropriate clinical indications, with use of conscious sedation and 8–12-F catheters.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Authors stated no financial relationship to disclose.
Author contributions: Guarantor of integrity of entire study, T.A.J.; study concepts and design, T.A.J., R.C.N.; literature research, T.A.J.; data acquisition, T.A.J.; data analysis/interpretation, T.A.J., R.C.N.; statistical analysis, D.M.D.; manuscript definition of intellectual content, T.A.J., R.C.N.; manuscript preparation, editing, revision/review, and final version approval, T.A.J., R.C.N., E.K.P.
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSIONREFERENCES |
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