Comparison of Loop Drainage Versus Incision and Drainage for Abscesses in Children

BACKGROUND INFORMATION:

Infections of skin and soft tissue remain one of the more common chief complaints in the
pediatric emergency department. With methicillin-resistant Staphylococcus aureus being a
prevalent pathogen, abscess development is not uncommon. The emergency department remains
the common setting for required therapeutic intervention. However, active investigation
exists in regard to the ideal intervention for children and adults.

Incision and drainage of cutaneous abscess has remained the standard of care for years.
However this standard has been adopted without robust supportive evidence. Recently, various
studies have questioned the benefit of various aspects of treatment, including antibiotics,
incision size, and necessity for packing. Other studies have even suggested a less-invasive
approach. Some of these have utilized a vessel loop and have demonstrated a reduced need for
home-health visits, reduced inpatient length of stay, good patient tolerance, and no
increase in failure rates. These studies are, however, retrospective in design with
execution primarily by the surgical team.

STUDY DESCRIPTION:

Upon obtaining written informed consent/assent by the study team member, subjects will be
randomized using a computerized randomization procedure and opaque envelopes. Initially,
thorough history and physical exam will be performed. A data sheet will be completed
detailing patient characteristics (eg. age, gender, ethnicity, prior treatment) and wound
characteristics (eg. greatest diameter of both erythema and induration, presence of
spontaneous drainage, location). Pain control/procedural sedation will be selected at the
discretion of the treating physician, consistent with current local practice (eg. topical
lidocaine, intranasal fentanyl and/or midazolam, oral acetaminophen/hydrocodone or
ibuprofen, intravenous ketamine, morphine, or fentanyl). Pain will be assessed prior to
physical exam and again shortly after the procedure via the validated FACES-Revised Pain
Scale. The patient will provide this assessment if 5 years or older. Otherwise, the parent
will provide the degree of pain perceived for their child. The difference between these two
pain assessments will be evaluated as an endpoint. Physicians will report on their
satisfaction with the procedure using a 5-point Likert scale.

The control arm of incision and drainage will require a single linear incision over the most
fluctuant portion of the abscess at a length deemed necessary by the treating physician.
Expressed contents will be sent for wound culture. Loculations will be disrupted with a
hemostat followed by copious irrigation with sterile saline. At the discretion of the
treating physician, the wound may be packed with ¼-inch iodoform gauze and dressed with dry
gauze.

The intervention arm of vessel loop-drainage will require placement of a small incision of
4-5 mm at the periphery of induration. Expressed contents will be sent for wound culture.
Using a hemostat, the loculations will be disrupted and expressed. Using the hemostat
through the abscess cavity, the opposite aspect will be probed and a second 4-5 mm incision
will be placed. The cavity will then be copiously irrigated with saline. A vessel loop
(DeRoyal Industries; Powell, TN) will then be pulled through the cavity via the two
incisions and loosely tied to itself above the skin using a surgeons knot. The wound will be
dressed with dry gauze.

A prescription for antibiotics and pain medication will be provided at the discretion of the
treating physician. The parent will be given standardized wound-care instructions
(twice-daily soaks for 5 days with dry dressing re-application), contact information (phone
and email) will be confirmed, selection of 24-48 hour follow-up will be made, and necessity
of the 14- and 90-day follow-up will be emphasized. The parents will be encouraged to keep a
pain medication diary (charted upon their care instructions) and bring the diary to their 2
initial follow-up appointments.

Upon completion of the initial ED encounter, data will be collected regarding type of pain
control/procedural sedation during the ED course, selection of prescribed antibiotics and
pain medication, and eventually results of wound culture.

24-48 hours after the incision and drainage procedure, subjects will return to the ED for a
repeat evaluation. Packing will be removed from patients in the standard incision and
drainage arm. The wound will be evaluated for five inflammatory components (i.e. presence of
induration, fluctuance, drainage, tenderness, and warmth). If the evaluating physician
decides that an abscess is still present and requires re-instrumentation, or if the
infection requires admission for IV antibiotics, treatment failure will be declared.
Following the assessment, the control arm may be repacked only if determined to be
necessary. Parents will report on their satisfaction with the procedure, and simplicity of
and anxiety with wound care utilizing a Likert scale of 1-5. Pain medication use will be
quantified using their diary and then documented. Their contact information will be
reconfirmed and the second follow-up appointment will be scheduled.

Subjects in the loop-drainage arm will receive emphasized instruction about technique and
timing of loop removal. This will be performed at home only after drainage has ceased. Local
practice by the general surgeon group suggests this is typically around post-operative day
5. Previous loop studies have performed this removal near day 8 to 10. We will encourage the
parent to remove the loop on day 7 (if drainage has ceased) by simply cutting one side of
the loop and pulling it from the cavity. A phone call will be performed on day 7 to assess
readiness and provide support for removal. The day of loop removal will be documented.

Follow-up at post-procedure day 14 will be performed in the ED by a physician member of the
study team. Prior to this visit, the parent will be reminded via telephone and email 2-3
days prior to the appointment. The wound will be evaluated for the same signs of
inflammation as the previous visit. The wound will again be evaluated for indications of
re-instrumentation or hospital admission (treatment failure). If the patient demonstrates
systemic illness, parenteral antibiotics will be initiated with admission to the hospital. A
second assessment will be performed at this follow-up visit; the Hollander scale will be
applied to determine cosmetic outcome. The same Likert scales will be given to the parent
regarding both the simplicity of, and anxiety with wound care. Pain medication use will
again be quantified using their diary and then documented. The parent will be asked if any
other physician encounters (here or elsewhere) were pursued and if re-instrumentation or
hospital admission occurred. Follow-up will be encouraged with a $25 gift card (utilizing
funding received from Scientific, Education and Research Foundation of UTSW Austin
Research/Fellow Grant, and from research funds of the PEM fellowship department) to
compensate families for their time and travel.

If the subject is unable to make the second follow-up appointment, a phone call will be
performed to inquire if the patient presented to a hospital for intervention secondary to
treatment failure of the initial abscess. If phone follow-up is unsuccessful, computerized
chart review of the Seton network will be performed to obtain the same end-point.

At 3 months, parents will be called to inquire of their satisfaction with the wound scar
using a 5-point Likert scale. They will also be reminded to return to the hospital to obtain
photographic documentation of the scar. Another $25 gift card will be issued to those able
to do so.

All patient records will be maintained in a locked, secure location, accessible by research
personnel only.

Inclusion Criteria:

- Physical findings suggestive of skin abscess warranting incision and drainage
(determined by treating physician)

Exclusion Criteria:

- Abscess not suitable for drainage in the ED (eg. <1 cm induration, >15 cm induration)

- Immunocompromised status (eg. diabetic patient or taking immunosuppressive
medication)

- Need for hospitalization following drainage

- Abscess located above the clavicles or significantly involving genitals/pilonidal
region

- Previous instrumentation to the abscess

- Primary language not English or Spanish

- High probability of loss to follow up (parent does not commit to both mandatory
follow up appointments)