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!
I’d recommend sticking to one unit of measurement – it sounds pedantic, but in medicine and especially US medicine, we don’t really know how to use the metric system for its full effect.
In short, stick to mm, avoid cm, never inches.
For the loop, I’m wondering how large is too large – I had a back abscess that was 60mmx40mm and I didn’t feel 100% comfortable with just a loop so we did packing. Wasn’t able to find anything useful in the literature.
Any ideas?
I was actually a part of the study in the emergency department when one abscess was horribly infected and another was about to be. I had the Severely progressed abscess done with the rubber loop and came back the next day to get a traditional one. I am 37 years old and in Canada so there was no cost involved. The rubber type loop was so much more comfortable, I could shower with it and it resolved in a very short time.
The traditional one however was a nightmare not to get wet in the shower, and I had to go to the emergency department every 2 days over the course of 2 weeks, to get it taken out clean the abscess, and resize the wick, so they could replace it, that was very painful, and this abscess was much smaller than the one I mentioned previously and to tell you the truth it didn’t properly heal for weeks after that. I will never have one done the traditional way ever in my life again, hopefully. The LOOP is the only way to go, it saves the patient a lot of time and pain, and money too, being Canadian, its just travel expenses to the hospital, but still, with the old way, it adds up.
The doctor explained that once the rubber loop is in you should have enough room to slide your finger under it, it shouldn’t be tight, the knot itself should be tight but that’s all. Also he instructed my to take it by the knot and move it from side to side so the two tiny incisions do not seal completely. I just did it in the shower. Anyway hope my experience helps out. Feel free to contact me if you have any other questions.
thanks so much for sharing your personal experience with the community! I am sure this will be of interest to the readers of this blog.
I’ve never understood the idea behind packing an abscess. I’m a veterinarian and have never packed an incision – don’t even remember it being discussed in school many years ago. I asked the other owner at my clinic, who graduated in 1980, and he was never taught to pack an abscess, either. Glad to see the MD’s are finally catching up to the DVM’s! (kidding!)
I do like the drain tying technique, and I’m going to do it on my next abscess (which won’t be long…). Normally we suture each end of the drain right to the opening through which it is passing with a couple loose interrupted sutures, as this prevents any sliding motion which stops inadvertently drawing a non-sterile section of the drain into the abscess and further contaminating it.
It hurts… A GREAT idea for my HS, BUT under a breast, the ‘zip tie’ is poking me to death and it seems like my skin is dying around it… I think it’s a great idea for draining, it just hurts like hell!!
Doesn’t ‘jiggling’ of the loop drain (which is essential) introduce bacteria from the exposed drain into the abscess? Correct me if I’m wrong…
Well, there’s nothing clean about an abscess to start with. It’s a good point though. I also recommend thrice daily sitz baths to clean the wound as clean as possible.