Professional Documents
Culture Documents
Bakal 1995
Bakal 1995
PmcmmEous drainage of abscesses and abnormal staged procedure during multiple sessions. Percuta-
fluid collections represents a dramatic advance in neous aspiration is defined as evacuation of a fluid
patient care. Primary and postoperative abscesses collection using either a catheter or needle, with re-
and fluid collections in nearly every organ system moval of the catheter or needle immediately after
have been successfully treated by percutaneous the aspiration.
means. This procedure has become the treatment of While practicing physicians should strive to
choice for a wide variety of fluid collections. The pro- achieve perfect outcomes (eg, 100%success, 0% com-
cedure has resulted in reduced morbidity and mor- plications), in practice all physicians will fall short of
tality and has helped to reduce length of hospital this ideal to a variable extent. Thus, indicator
stay and hospital costs (1-7). thresholds may be used to assess the efficacy of on-
These guidelines are written to be used in quality going quality improvement programs. For the pur-
improvement programs to assess percutaneous poses of these guidelines, a threshold is a specific
drainage procedures. The most important processes level of an indicator which should prompt a review.
of care are ( a )patient selection, ( b )procedure perfor- "Procedure thresholds" or "overall thresholds" refer-
mance, and (c)patient monitoring. The outcome ence a group of indicators for a procedure, for ex-
measures or indicators for these processes are indi- ample, major complications. Individual complica-
cations, success rates, and complication rates. Out- tions may also be associated with complication-spe-
come measures are assigned threshold levels. cific thresholds. When measures such as indications
or success rates fall below a (minimum) threshold, or
DEFINITIONS when complication rates exceed a (maximum)
Percutaneous drainage is defined as the place- threshold, a review should be performed to deter-
ment of a catheter using imaging guidance to provide mine causes and to implement changes, if necessary.
continuous drainage of a fluid collection. This in- For example, if the incidence of sepsis is one mea-
cludes localization of the collection, and placement sure of the quality of abscess drainage, then values
and maintenance of the drainage catheterb). This in excess of the defined threshold (in this case, 4%)
may be performed during a single session or as a should trigger a review of policies and procedures
within the department to determine the causes and
to implement changes to lower the incidence of the
Index terms: Abscess, percutaneous drainage Critical issues complication. Thresholds may vary from those listed
Quality assurance here; for example, patient referral patterns and se-
JVIR 1995; 6:6&70 lection factors may dictate a different threshold
value for a particular indicator a t a particular insti-
tution. Thus, setting universal thresholds is very dif-
'Address reprint requests to SCVIR, 10201 Lee Hwy, Suite 160, Fairfax, ficult and each department is urged to alter the
VA 22030. thresholds as needed to higher or lower values, to
o SCVIR, 1995 meet its own quality improvement program needs.
68
Bakal et a1 69
Volume 6 Number 1
Complications can be stratified on the basis of out- volved in the patient's care. Participation by the ra-
come. Major complications result in admission to a diologist in patient follow-up is an integral part of
hospital for therapy (for outpatient procedures), an drainage and will increase the success rate of the
unplanned increase in the level of care, prolonged procedure. Close follow-up, with monitoring and
hospitalization, permanent adverse sequelae, or management of the drainage catheter is appropriate
death. Minor complications result in no sequelae; for the radiologist.
they may require nominal therapy or a short hospital
stay for observation, generally overnight. (See Appen- Indications for diagnostic aspiration
dix). The com~licationrates and thresholds below re- and percutaneous drainage: Threshold
fer to major complications. Presence of an abnormal fluid collec-
tion with suspicion that the fluid is
Indications
infected, need for fluid characteriza-
Because of variability in the presentation of ab- tion, or suspicion that the collection
scesses and fluid collections, the indications for per- is producing symptoms sufficient to
cutaneous drainage and aspiration must be stated in warrant drainage 100%
general terms. The prerequisite for percutaneous
drainage is an abnormal fluid collection and one of
the following: suspicion that the fluid is infected, Success Rates
need for fluid characterization, or suspicion that the Diagnostic aspiration.-Successful diagnostic fluid
collection is producing symptoms sufficient to war- aspiration is defined as the aspiration of material
rant drainage. The collection may be detected by sufficient for diagnosis.
physical examination, but typically is discovered by
an imaging study, such as radiography, ultrasound, Threshold
or computed tomography. Additional studies may be Successful diagnostic fluid aspiration 95%
required to confirm the presence or nature of the
fluid collection and to evaluate the feasibility of Drainage of infected collections.-Curative drain-
drainage. age is defined as complete resolution of infection re-
~ i a k o s t i aspiration
c may be the only means of de- quiring no further operative intervention. Curative
termining that a fluid collection is infected. For in- drainage has been achieved in greater than 80% of
stance, while fever, leukocytosis, malaise, anorexia, patients. Partial success is defined as either ad-
or other systemic symptoms point to an infection, equate drainage of the abscess with surgery subse-
these signs and symptoms may be absent in elderly, quently performed to repair an underlying problem
very ill, or immunocompromised patients. If material or as temporizing drainage performed to stabilize the
that appears infected is obtained or if the operator patient prior to surgery. Partial success occurs in
cannot exclude the presence of infection, a drainage 5%-10% of patients. Failure occurs in 5%-10% and
catheter may then be placed. recurrence in 5%-10% (1-3). These results are simi-
Percutaneous drainage and aspiration may be per- lar for both abdominal and chest drainage proce-
formed in essentially every organ system. The contra- dures (4-7). These success rates will depend on the
indications are relative and depend on the suitability proportion of collections drained in patients with
of surgical alternatives. Common relative contraindi- relative contraindications, on the complexity of the
cations include coagulopathy and necrotic tissue re- collection, and on the severity of the underlying
quiring surgical debridement. There is a spectrum of medical problems.
disease complexity. Examples of more complex situa-
tions include multiple abscesses, abscess due to Threshold
Crohn disease, pancreatic abscesses, drainage route Successful drainage (curative
that traverses bowel or pleura, infected clot, and in- and partial success) 85%
fected tumor (8,9). Articles have documented curative
or partially successful percutaneous drainage in pa- Drainage of uninfected collections.-Due to the
tients with these complex situations (10-18). How- variability of the types of uninfected collections, the
ever, one should expect that percutaneous drainage success rate of drainage will be highly variable and it
in such cases will have a lower chance of success, be is not believed that a specific threshold for success
more technically difficult, require longer periods of can be set.
time for drainage, and have a higher rate of complica-
tions. In addition, abscesses in such cases may be Complications
more likely to recur. Decisions regarding percutane- Complications occur in approximately 10%of pa-
ous versus surgical drainage of complex collections tients (1-7). Published complication rates and sug-
should be made in concert with other physicians in- gested thresholds are given in the Table.
70 Journal of Vascular and Interventional Radiology
January-February 1995