SGEM#311: Here We Go Loop De Loop to Treat Abscesses

Date: December 10th, 2020 Reference: Ladde et al. A Randomized Controlled Trial of Novel Loop Drainage Technique Versus Drainage and Packing in the Treatment of Skin Abscesses. AEM December 2020 Guest Skeptic: Dr. Kirsty Challen (@KirstyChallen) is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). She is Chair of the Royal College of Emergency Medicine Women in Emergency Medicine group and involved with the RCEM Public Health and Informatics groups. Kirsty is also the creator of the wonderful infographics called #PaperinaPic. Case: A 52-year-old previously healthy woman presents to your emergency department (ED) with an abscess on her left forearm. She is systemically well and there is no sign of tracking, so you decide to perform incision and drainage in the ED. When you ask your nursing colleague to set up the equipment, he wants to know if you will be using standard packing or a vessel loop drainage technique. Background: We have covered the issue of abscesses multiple times on the SGEM. Way back in 2012 we looked at packing after incision and drainage (I&D) on SGEM#13 and concluded routine packing might not be necessary. Another topic covered was whether irrigating after I&D was superior to not irrigating (SGEM#156). The bottom line from that critical appraisal was that irrigation is probably not necessary. Chip Lange (PA) The use of antibiotics after I&D is another treatment modality that has been debated over the years. Chip Lange and I interviewed Dr. David Talan about his very good NEJM randomized control trial on SGEM#164. The bottom line was that the addition of TMP/SMX to the treatment of uncomplicated cutaneous abscesses represents an opportunity for shared decision-making. One issue that has not been covered yet is the loop technique. This is when one or multiple vessel loops are put through the abscess cavity. This is done by making a couple of small incisions. An advantage to this technique over packing (which is not necessary) is that the Vessel loops do not need to be changed or replaced. Clinical Question: In uncomplicated abscesses drained in the ED, does the LOOP technique reduce treatment failure? Reference: Ladde et al. A Randomized Controlled Trial of Novel Loop Drainage Technique Versus Drainage and Packing in the Treatment of Skin Abscesses. AEM December 2020 Population: Patients of any age undergoing ED drainage of skin abscesses Exclusions: Patient with abscess located on hand, foot, or face or if they required admission and/or operative intervention. Intervention: LOOP technique where a vessel tie is left in situ Comparison: Standard packing with sterile ribbon gauze Outcome: Primary Outcome: Treatment failure (need for a further procedure, IV antibiotics or operative intervention), assessed at 36 hours. Secondary Outcomes: Ease of procedure, pain at the time of treatment, ease of care at 36 hours, pain at 36 hours. Dr. Ladde This is an SGEMHOP episode which means we have the lead author on the show. Dr. Ladde is in an active academic emergency physician working at Orlando Regional Medical Center serving as core faculty and Senior Associate Program Director. Jay also has the rank Professor of Emergency Medicine for University of Central Florida College of Medicine. Authors’ Conclusions: “The LOOP and packing techniques had similar failure rates for treatment of subcutaneous abscesses in adults, but the LOOP technique had significantly fewer failures in children. Overall, pain and patient satisfaction were significantly better in patients treated using the LOOP technique.” Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes