LOOP, THERE IT IS!
Author: Dr. Ramsay, PGY-1 Emergency Medicine, Rush University Medical Center
Title of article: A randomized controlled trial of novel loop drainage technique versus standard incision and drainage in the treatment of skin abscesses
Citation: Ladde, J., Baker, S., Lilburn, N., Wan, M., & Papa, L. (2020). A randomized controlled trial of novel loop drainage technique versus standard incision and drainage in the treatment of skin abscesses. Academic Emergency Medicine.
Background:
- 1.4 million I&D’s each year in the United States (Baumann et al)
- Packing is controversial (O’Malley et al)
- Packing can be painful
- Antibiotic use is of limited benefit in uncomplicated abscess (List et al)
Study Question:
How does the failure rate of incision and drainage with LOOP technique compare to I&D with standard packing technique in adults and children presenting to the emergency department with subcutaneous abscess?
Design :
- Study type: prospective, randomized controlled trial
- Patient Allocation: convenience sample
- Location of Study: two level 1 trauma centers
- Inclusion criteria: any age, presenting with subQ abscess between March 14, 2009 and April 10, 2010
- Exclusion criteria: abscess of hand, foot, or face. Or if required admission or operative treatment
Study design:
- randomized, numbered, sealed envelopes taken in sequential order.
- contents of envelope not revealed until after patient consented.
Results:
- Similar failure rates in adults, but loop technique had 0% failure rate in children.
- Also, loop performed better when measuring ease of procedure, pain, ease of care and pain over 36 hours, patient satisfaction at 10 days, with the last 3 outcomes being significant
Discussion:
- Strengths: Similar characteristics in both groups
- Randomized, blinded
- ED setting
Weaknesses:
- Only 2 hospitals
- Convenience sample only when investigators available
- Not double blinded (but can’t really double blind this procedure)
- Packing may not be the standard at other institutions
- Pain/ease scores may be better without packing
- No comparison to I&D without any packing
- Abx and sedation was at the discretion of physician
- Techniques are user dependent
Application to my practice:
- Loop appears to be a safe alternative in adults
- Perhaps a better alternative in children
- Harder to remove a loop compared to packing?
- Perhaps kids play around with the packing?
Take Away:
Loop or no loop, both seem to be fairly good options and I’ll probably try the loop technique next time I have a pediatric patient with an abscess I need to drain
Loop technique (from Ladde et al)
- Anesthesia, incision, hemostat
- Tent skin, second incision
- Irrigate, hemostat through, pull
- Pull vessel loop through cavity
- Tie loop loosely
- Final product
References:
- Gaszynski, R., Punch, G., & Verschuer, K. (2018). Loop and drain technique for subcutaneous abscess: a safe minimally invasive procedure in an adult population. ANZ journal of surgery, 88(1-2), 87-90.
- Baumann, B. M., Russo, C. J., Pavlik, D., Cassidy-Smith, T., Brown, N., Sacchetti, A., … & Mistry, R. D. (2011). Management of pediatric skin abscesses in pediatric, general academic and community emergency departments. Western Journal of Emergency Medicine, 12(2), 159.
- O’Malley, G. F., Dominici, P., Giraldo, P., Aguilera, E., Verma, M., Lares, C., … & Williams, E. (2009). Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Academic Emergency Medicine, 16(5), 470-473.
- List, M., Headlee, D., & Kondratuk, K. (2016). Treatment of Skin Abscesses: A Review of Wound Packing and Post-Procedural Antibiotics. South Dakota Medicine, 69(3).
- Ladde, J. G., Baker, S., Rodgers, C. N., & Papa, L. (2015). The LOOP technique: a novel incision and drainage technique in the treatment of skin abscesses in a pediatric ED. The American Journal of Emergency Medicine, 33(2), 271-276.