One of the areas of wound care which has had the most significant advances and debate in the past few years is the management of cutaneous abscesses. I find this interesting because this is a field which has been essentially static for decades.
Traditional management of abscesses includes incision of the cavity; drainage including using a hemostat to explore the cavity and break up loculations; and finally packing with gauze strips to stent the cavity open and keep it draining until it heals by secondary intention. Some maxims of the optimal technique which were impressed upon me in my residency training included making sure the incision was “larger than I think it actually needs to be” and to “keep that wound open and draining as long as possible to prevent it from closing and reaccumualting.”
Turns out a lot of the things we thought we knew about abscesses may be wrong.
For example, in 2012, a study was published showing that in a pediatric population, packing vs. no packing did not seem to make a difference in treatment failure nor recurrence rates: http://www.ncbi.nlm.nih.gov/pubmed/22653459.
Just this year, Adam Singer and his co-researchers published a study showing that even when you primarily close an abscess cavity, the rates of wound healing and treatment failure were similar to when you treated it traditionally: http://www.ncbi.nlm.nih.gov/pubmed/23570475. That said, there was also no difference in patient satisfaction between the two groups, which begs the question, why bother to close the abscess if the patient doesn’t care?
Most emergency practioners I’ve spoken to about this topic tend to agree, packing is probably an unnecessary step for many of the abscesses we see. However, everyone across the board seems to shudder at the idea of primary closure of an abscess. It’s essentially a reversal of the dogma of abscess management, which I think is too contrary to our indoctrinated beliefs to be accepted.
Thus, on this page I am highlighting a technique which I think is an excellent compromise. It foregoes packing, safely allows for smaller incisions, and thus allows better cosmesis–with similar treatment failure and healing rates. This is the technique of abscess incision and loop drainage. A video link illustrating this technique follows:
It involves placement of a sterile drain–typically a 1/4 inch penrose drain or a vessel loop (used by surgeons to mark vessels intraoperatively) to stent the cavity open between two incisions spaced 4-5 cm apart within the abscess cavity. The drain is tied together to form a loop, preventing it from falling out prematurely. The beauty of this technique is that the patient can manage the drain themselves by jiggling it (to facilitate drainage and prevent adhesion) and then cut the drain and remove it at home when it stops draining and surrounding cellulitis resolves (two criteria used in the studies to determine when the drain is ready for removal, usually ~7 days). It’s been reported by patients to be less painful than traditonal packing, especially if that packing is replaced on a daily basis.
The technique was originally developed and used in a pediatric population undergoing abscess I & D in the OR setting, and adapted for use in the emergency department. Some of the first studies of this technique in the ED were published in 2010 by Ladd et al. (ttp://www.ncbi.nlm.nih.gov/pubmed/20223328) and 2011 by Mcnamara et al.(http://www.ncbi.nlm.nih.gov/pubmed/21376200). Though I have yet to see a study published showing efficacy in a generalized, adult ED population, I know that many practitioners I’ve spoken to have already taken to and adapted use of this technique for all types of patients.
I think the technique is great personally and I foresee it will start to be used more widely in our field in years to come. However, some I have spoken to about the technique think it is more of a fad that will be forgotten. I guess we’ll have to wait and see!