From depts.washington.edu
Why are we still teaching the traditional incision and drainage approach to simple abscess drainage? They require frequent, painful packing changes to ensure persistent drainage of retained pus.
Loop Abscess Drainage from Rob from ercast on Vimeo.
Trick of the Trade:
Incision and loop drainage (I&LD) technique
As per usual, Dr. Rob Orman (ercast) beat me to this. He already reviewed the technique on his blog in 2010. This stems from a landmark article in the Journal of Pediatric Surgery, which involves creating a persistently draining fistula at two points by using a small vascular loop, tied into a non-tensile loop.
It makes sense to extrapolate and use this technique for both pediatric and adult patients with uncomplicated abscess, especially if the patients may not follow-up for packing changes as scheduled. The added benefit is that showering is encouraged to help encourage drainage without the risk of dislodging the secured loop.
Questions:
Does anyone have experience with this that they would like to share? Particularly, what if you don't have the skinny vascular loops in your Emergency Department?
What are the follow-up instructions?
Per the Tsoraides article:
- Take a bath/shower TWICE daily for the first 3 days.
- Remove the loop in 7-10 days (when the drainage stops and the overlying cellulitis resolves)
Reference
Tsoraides SS, Pearl RH, Stanfill AB, Wallace LJ, Vegunta RK. Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children. J Pediatr Surg. 2010 Mar;45(3):606-9. Pubmed .
Dr. Bonales and I trained together, and we both did these during our peds ED time, though I started to do them post residency in my adult patient population. Have had no complaints from patients, though few return to the ED for followup - which is sort of the point.
ReplyDeleteThanks for the insight. Wish I knew about this earlier in my career!
Deletehttp://www.epmonthly.com/the-literature/evidence-based-medicine/abscesses-to-pack-or-not-to-pack/
ReplyDeleteWe all do it but is it really necessary to pack a wound at all? Theoretically all pus wants to exit the body and will find the path of least resistance. I would imagine that a simple I and D of small abscess and then sitting in a bath tub for 20 minutes 2x a day with soap and water would function just as well as packing an abscess.
Interesting review by EP Monthly. Although the studies seem underpowered, it brings up an interesting point. I personally haven't been packing small abscesses, especially perianal/ perirectal abscess because patients indeed can do Sitz baths. If I'm really worried about premature closure of the incision site, I make an "L" shaped incision to help keep the flap open (not really a cosmetically important area).
DeleteSo in the end, I guess the choices are I+D (without packing), I+D (with packing), I+LD. Use at your discretion.
Maybe some of the US gurus can help me out.
ReplyDeleteThe video shows a "cluster of grapes" on the US which is said to represent an abscess. How is this different from the "cobblestone" we see for simple cellulitis w/o abscess.
Thanks,
AJ
AJ - great question - from the video it is tough to tell the difference since it is a still image you see there. Cellulitis will truly look like cobblestoning WITHOUT areas of pus. Abscess can have anywhere from none to many loculations which can obscure the image and prevent you from seeing a true hypoechoic area of pus as it will have different densities of pus/loculations that may appear like a cluster of grapes - BUT - it will have pus within it. So, in real-time video, you will see on the screen (with some pressure on the abscess) the flow of pus within those loculations in between those grapes. This will not occur with cellulitis. Hope that helps. There are some great examples of this on www.sonocloud.com
DeletePlease take this from the perspective of a junior doctor working in the south pacific on a years medical adventure. I'm going to be ED doc and have spent the last 10 months with a focus on how could it be done in a disaster and what can I gain from this experience?
ReplyDeleteThings get really tough with lots of customers and limited resources, so I have been taken on a "what works" approach. So if your ever stuck in that situation here are a few reflections from things I have seen and done with make shift drains.
Making a 1-2cm wide loop from the wrist of a sterile glove and then cutting it into a strip makes an excellent drain for amputated digits, testicles and abscesses, just use a small suture to hold it in place. Rather than placing it the way Dr Orman does we find the edge of the abscess and press the haemostat against the tissues from the inside of the abscess identifying the point on the skin and making a small incision for the tip to protrude through, the glove drain is then pulled into the abscess rather than pushing it through.
Second trick, was how to make a negative pressure drain when your container ship is delayed and you have run out of drains. We made one out of a nasogastric tube with extra drainage sites cut along the distal end. It was placed then connected to a 50cc syringe and the plunger withdrawn to create a negative pressure. The plunger of a 5cc syringe was then taped to the plunger of the 50cc between the finger grip on the barrel and the thumb grip on the plunger to maintain the negative pressure. Its cheap, effective and doesn't require a power source. It certainly got us out of trouble when there was nothing else available.
Thanks
Paul
Interesting and creative tips! Thanks for sharing your experiences of what works in potentially resource-limited environments. I love the idea of using the wrist portion of a sterile glove to create a loop. Keep up the great work.
Deleteim not so worried about premature closure in that pus seems to have a way of eating through tissue and eventually making its way to the surface. And given that if there is still an infection it seems unlikely that the wound would heal with an infection buried underneath.
ReplyDeleteYour reasoning makes sense. I just haven't had enough experience with NOT packing abscesses. Will have to start in select patients who will reliably follow-up. Thanks for commenting.
DeleteI started using the vessel loop in adult patients during my senior year in residency. Given that it was difficult to get follow-up and especially with the threat of another packing change, the vessel loop with the "come back in 10 days" made sense, and most of the patients never returned. A lot did, though with great results. Here I've trained the PA's and MD's and several are now doing them in the E.D. and in Urgent Care.
ReplyDeleteMy discharge instructions are: keep covered until the next day, change dressing only if excessively dirty. Then do hot compresses twice a day and "wiggle" loop at that time. Keep the loop covered at all times. Return in 2 days for a wound check if a significant cellulitis or in 10 days to have the loop removed, but some patients I just tell them to cut it off in 10 days.
Here's the link to the video I made which shows an actual placement. http://youtu.be/gw7tA1B9Aos
The edge is identified by ultrasound and infiltrated with lidocaine. The second site is infiltrated once it is identified from the abscess pocket. I sometimes use the "central comedone" as my entry point and then identify another exit point.
I also use the ultrasound and only loop abscesses measuring greater than 1 cm.
HI Veronica: Thanks so much again for sharing your slides above and your YouTube video link. It's a great example of how to do the I+LD. I'm really excited to share my first experience with this procedure. It really does have many advantages over the traditional I+D. Thanks again for sharing.
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