Hot off the press: Loop technique versus drainage and packing in emergency department abscess management

Management of cutaneous abscesses is bread and butter emergency medicine work, but studies show wide practice variations in the process of draining and treating abscesses.1, 2 In this study, the authors performed a randomized controlled trial of the LOOP technique versus standard incision and packing in ED patients undergoing management of cutaneous abscesses.3 This is an unblinded randomized controlled trial from Florida examining adults and children who had ED drainage of an uncomplicated skin abscess. A total of 109 were packed with ribbon gauze and 108 underwent the loop technique. In this procedure, two small incisions are made in the abscess cavity and a vessel loop is passed through the cavity and loosely tied. Patients were reviewed at 36 hours and treatment was deemed to have failed if the patient required a further procedure, IV antibiotics, or operative intervention. The researchers also used 10-point numeric rating scales to measure ease of procedure, pain at the time of procedure, and pain and ease of care over 36 hours. This is a randomized trial from a single emergency department (ED). Although the authors made efforts to recruit at all times of day and all days of the week, they were not able for practical reasons to be present and recruiting at all times. The concern for recruitment that is not truly consecutive is introduction of selection bias, where individuals enrolled in the trial are systematically different from those not enrolled. For example, those who attend with their abscess at 3 a.m. may be more ill than those who wait until daytime hours. Clinicians were allowed discretion in terms of use of local anesthesia, sedation, and antibiotics, risking introducing confounders (a clinician more comfortable with one technique might use more sedation for the other, making the procedure paradoxically easier). However, in the data provided in Table 1 in the paper this does not seem to have occurred,3 as sedation and antibiotics were used similarly between the groups. Lack of blinding of patient and clinician assessor is a significant limitation of this study, particularly given the subjective nature of the outcomes; a clinician less convinced of the merits of one technique might be more inclined to judge that treatment a failure at follow-up. Overall, 217 patients were enrolled and randomized—108 to the loop technique and 109 to incision and draining with ribbon gauze packing. At 36-h follow-up, 13% (13/99) in the loop group and 20% (20/97) in the packing group had treatment failure (needed a further procedure, IV antibiotics, or operative intervention). In an unplanned subgroup analysis of children, zero of 40 in the loop group and 21% (9/42) in the packing group had treatment failure. Clinician ratings of the ease of procedure and patients’ pain scores during the procedures were similar. On a 10-point scale, pain in the first 36 h was 2.7 (95% CI = 2.1 to 3.3) in the loop group and 3.7 (95% CI = 3.2 to 4.2) in the packing group (p = 0.004). The loop technique has a similar rate of treatment failure overall to conventional ribbon gauze packing but is more comfortable and has higher patient satisfaction. The apparent benefit in treatment outcomes in children is interesting but should be considered hypothesis-generating only. Vamsi Aribindi (@aribindi) What's novel about this? This has been standard practice in pediatric (and general) surgery for decades. You can use a penrose too, which is why many I&D kits come with them. If you have a lot of bleeding, pack once after putting vessel loops, remove the next day, don't repack. Lauren Westafer (@LWestafer) Big fan of the loop drainage technique (I use sterile glove cuff if I don't have a vessel loop). CADoctorJ (@CADoctorJ1) replies: Sterile gloves are a new one to me, thanks! I'm going to check if my ED's glove cuffs will work. We don't have vessel loops, usually I make do with the smallest infant NG tube I can find, a bit more flexible than penrose drains… Justin Morgenstern (@First10EM) Is it a knowledge gap, or is it just unnecessary? Is this technique any better than just doing nothing at all? (Just I + D and stop) They keep comparing it to packing, but I don't pack abscesses. Lauren Westafer (@LWestafer) replies: So I would argue a large incision may be unnecessary- thinking about what I would want, scarring outcomes have been better w/ loop vs I&d..so if it would be a decent sized incision…I loop. Justin Morgenstern (@First10EM) replies: That's fair. The management of abscesses is just so heterogeneous, that I was never sure of the scarring data. What kind of cut are people making? Never seemed to be a big issue in my practice (used to get patients to send me follow up images). Elisha Targonsky (@ETTube) replies: What do you mean heterogenous? 1) cruciate vs straight cut 2) reg I&D vs loop 3) ABX vs none 4) pack or not 5) irrigate or don't 6) swab for MRSA or assume MRSA. No controversies here. Consider loop drainage technique rather than incision and drainage the next time you encounter an uncomplicated abscess on shift.

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