Loop Incision & Drainage, Revisited

It’s been two years since I wrote my blog piece about loop incision & drainage, an alternative to the usual I&D procedure performed in the Emergency Department.

Abscesses. Yuck!

Abscesses. Yuck! …but what to do?!?

At that time, the literature was scant and was published in pediatric surgery journals.  I found that even after describing the technique to my colleagues and the residents rotating through our hospital and publishing this video, there remained quite a bit of reluctance to adopt this technique.

Specific impediments to utilizing loop incision and drainage that I’ve heard from peers include (1) a paucity of data validating its use in the ED and (2) difficulty in obtaining a suitable material to use for the loop.  Both of these concerns are addressed below in some newly published data which may sway some to consider changing their practice.

(1) A 2015 study suggests lower treatment failure rates with use of the loop incision & drainage technique compared with standard I&D.

The link to the original article is here, but the highlights of this study are outlined below.

Design:

  • Retrospective cohort, by physician chart review
  • Pediatric patients ages 0-17 yrs, single hospital, 80% ca-MRSA prevalence
  • ED incision & drainage only (OR excluded)
  • Face, scalp, hand & feet abscesses excluded
  • Outcomes assessed by follow up phone calls & medical record review
  • Primary outcome assessed: treatment failure, defined as:
    • need for repeat I&D
    • admission
    • antibiotics
    • surgical debridement

Results:

  • 142 children in final analysis (12 month period)
  • 91 standard I&D, 51 LOOP I&D
  • significant differences in baseline characteristics. LOOP group:
    • younger (mean 1.8 vs 6 yrs)
    • more likely to get sedation
    • more buttocks abscesses
  • treatment failure in 16.5% of standard I&D vs 3.9% in LOOP group (p=0.03)

Notable:

  • Retrospective design = many confounders
  • More sedation in LOOP group–>does this mean better I&D? or just younger patients? no way to understand provider thinking in this type of study
  • First ED study examining this technique

(2) Alternative “LOOP”

Another concern that comes up is the inability to readily locate a suitable material for use as a “loop” to place within the incisions in the cavity.  Although abscesses by definition are not clean, generally speaking most providers are reluctant to leave a foreign body in the tissue cavity that isn’t sterile and inert.

In the original description of the technique, the authors describe using a vessel loop, which is a sterile piece of colored silicone used in the OR to mark vessels and nerves intraoperatively.  Has anyone ever seen one of these in the ED? Not me.

In the video demonstration I published previously, I used a penrose drain; but honestly, these are pretty hard to come by even in my ED–I had to beg the OR to let me “borrow” one.

So here’s a solution to this problem that crafty emergency physician Dr. David Thompson engineered. Create a loop from something you already have: a sterile glove!

With this new data and this simple way to make a loop in mind, I’ve found myself using this technique more and more.  I invite other emergency physicians and urgent care providers to share their own experiences with loop incision & drainage here.

Advertisements