Clinical Radiology 69 (2014) e433ee433
Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Correspondence
Re: UK intussusception audit: A national survey of practice and audit of reduction rates. A reply Sir d I thank Moorthy et al. for their letter in response to our article1, in which they discuss their practice, our paper, and the subsequent commentary by Wilkinson. I agree with the first comment that strict adherence to BSPR guideline does not prevent perforation, the risk of which may be related to individual patient factors more than reduction technique. These factors were beyond the scope of our national audit making it difficult to comment on. As a surgeon, I read with interest the concerns of Moorthy et al. regarding radiologists being “under pressure” to increase reduction rates, preventing surgical morbidity, and also the safety concern regarding Wilkinson’s suggestion of increasing reduction pressure above 120 mmHg. Wilkinson also rightly describes some radiologists’ feelings that perforation is a cause for “shame” and to be avoided at all costs; hence, being less aggressive in reduction attempts and limiting maximum pressure to 120 mmHg. It appears radiologists may feel they are stuck between “a rock and a hard place”. Our authors (two surgeons, two radiologists), therefore, advocate a multidisciplinary team approach to reduction. As a result, we are more comfortable to try for longer, highpressure reductions (still within the limit of 120 mmHg), with the responsibility of reduction success and possible complications falling across the team, not on the individual radiologist. This system also gives the safety benefit of a surgeon being present, who should continually monitor and assess the patient, and be more skilled in resuscitation if any deterioration or perforation should occur. Although the safety kit mentioned is essential, we believe it is as important to have staff present with the experience and skill to
DOI of original article: http://dx.doi.org/10.1016/j.crad.2014.05.008.
manage all aspects of reduction and possible complications, i.e., a team including a radiologist, surgeon, and experienced paediatric nurse. The reduction rate of Moorthy et al. (76%) and that of the six centres in our study achieving rates above 80% using 120 mmHg suggest that this maximum pressure may not be limiting reduction rates nationally. Across centres that reported following the guidelines, there is great variation practically in how reduction is performed (including equipment, duration of attempts, etc.) and presumably variation in how “aggressive” centres are in reduction, even within the constraints of a maximum pressure of 120 mmHg. Before looking to increase maximum pressures above 120 mmHg, as suggested by Wilkinson, we need to standardize current practice, ensuring all centres utilize a team approach. Alongside this, a more detailed prospective national audit should be performed, including more individual patient/case detail to further clarify factors that affect the chances of successful reduction and risks of perforation. After this standardization of practice, we can then look to well-designed multicentre studies to see the effects of changing parameters, such as high maximum pressures. We are in the process of trying to establish new standardized, evidence-based guidelines through a crossspeciality working group and welcome involvement from any interested centres or clinicians. E. Hannon*, R. Williams, R. Allen, B. Okoye St George’s Hospital, Tooting, London, UK E-mail address: [email protected] (E. Hannon)
* Guarantor and correspondent: E. Hannon, St George’s Hospital, Tooting, London SW17 0QT, UK. Tel.: þ44 (0) 20 8672 1255; fax: þ44 (0) 2086727110.
0009-9260/$ e see front matter Ó 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.crad.2014.05.007
Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Correspondence
Re: UK intussusception audit: A national survey of practice and audit of reduction rates. A reply Sir d I thank Moorthy et al. for their letter in response to our article1, in which they discuss their practice, our paper, and the subsequent commentary by Wilkinson. I agree with the first comment that strict adherence to BSPR guideline does not prevent perforation, the risk of which may be related to individual patient factors more than reduction technique. These factors were beyond the scope of our national audit making it difficult to comment on. As a surgeon, I read with interest the concerns of Moorthy et al. regarding radiologists being “under pressure” to increase reduction rates, preventing surgical morbidity, and also the safety concern regarding Wilkinson’s suggestion of increasing reduction pressure above 120 mmHg. Wilkinson also rightly describes some radiologists’ feelings that perforation is a cause for “shame” and to be avoided at all costs; hence, being less aggressive in reduction attempts and limiting maximum pressure to 120 mmHg. It appears radiologists may feel they are stuck between “a rock and a hard place”. Our authors (two surgeons, two radiologists), therefore, advocate a multidisciplinary team approach to reduction. As a result, we are more comfortable to try for longer, highpressure reductions (still within the limit of 120 mmHg), with the responsibility of reduction success and possible complications falling across the team, not on the individual radiologist. This system also gives the safety benefit of a surgeon being present, who should continually monitor and assess the patient, and be more skilled in resuscitation if any deterioration or perforation should occur. Although the safety kit mentioned is essential, we believe it is as important to have staff present with the experience and skill to
DOI of original article: http://dx.doi.org/10.1016/j.crad.2014.05.008.
manage all aspects of reduction and possible complications, i.e., a team including a radiologist, surgeon, and experienced paediatric nurse. The reduction rate of Moorthy et al. (76%) and that of the six centres in our study achieving rates above 80% using 120 mmHg suggest that this maximum pressure may not be limiting reduction rates nationally. Across centres that reported following the guidelines, there is great variation practically in how reduction is performed (including equipment, duration of attempts, etc.) and presumably variation in how “aggressive” centres are in reduction, even within the constraints of a maximum pressure of 120 mmHg. Before looking to increase maximum pressures above 120 mmHg, as suggested by Wilkinson, we need to standardize current practice, ensuring all centres utilize a team approach. Alongside this, a more detailed prospective national audit should be performed, including more individual patient/case detail to further clarify factors that affect the chances of successful reduction and risks of perforation. After this standardization of practice, we can then look to well-designed multicentre studies to see the effects of changing parameters, such as high maximum pressures. We are in the process of trying to establish new standardized, evidence-based guidelines through a crossspeciality working group and welcome involvement from any interested centres or clinicians. E. Hannon*, R. Williams, R. Allen, B. Okoye St George’s Hospital, Tooting, London, UK E-mail address: [email protected] (E. Hannon)
* Guarantor and correspondent: E. Hannon, St George’s Hospital, Tooting, London SW17 0QT, UK. Tel.: þ44 (0) 20 8672 1255; fax: þ44 (0) 2086727110.
0009-9260/$ e see front matter Ó 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.crad.2014.05.007
