This excellent article comes courtesy of Cincinnati Children’s Hospital Medical Center senior resident Landon Krantz, MD – who performed a thorough literature review and wrote a concise, informative review of the titular technique.

 

Subcutaneous abscesses are a common presenting problem in pediatric emergency rooms, and incision and drainage remains the gold standard of treatment. A new technique that is picking up steam and may be a very promising addition to your practice is the Loop Technique.

loop

The loop technique is a minimally invasive treatment of abscesses that allows for continuous drainage and eliminates the need for packing changes. Watch the video below for a more detailed explanation. In brief, the I&D is initiated in the typical manner with lidocaine injections and incision into the apex of fluctuance. While clearing loculations with a hemostat, the provider extends the hemostat to the other side of the abscess (opposite from the initial incision) and makes a second incision at that site. Then, a sterile rubber tube—or “loop”—is grabbed by the hemostat, looped through the wound, and tied off. The tube is then snipped with a scissors and removed once the cellulitis resolves, typically 7-14 days later. The loop itself can be a Penrose drain, a vessiloop, or even a sterile glove cuff(4).

Video from Closing the Gap, an excellent procedure resource

Historically, this procedure is more common in the surgical field, but it’s now being adapted to emergency rooms. Ladde et. al. evaluated its effectiveness with a retrospective cohort of 142 pediatric emergency room patients1. The results show a decrease in I&D failure rate from 16.5% to 3.9% with the loop procedure when compared to standard I&D therapy with packing. Failure was defined as any of the 3 following outcomes: admission, IV antibiotics, or needing repeat drainage. The odds ratio for the two techniques was 7.13 (favoring loop technique) but with a wide CI (1.17-43.5). Notably, the loop procedure patients were also more likely to have received sedation, which may have assisted with better drainage of the abscess independent of the drainage technique. Loop procedure patients also were significantly younger, which likely explains the increased need for sedation.

Other studies have also shown success with loop drainage. A 2009 retrospective study also involving 115 pediatric patients demonstrated a 5.5% rate of abscess recurrence (6/110 patients)(2). Average time until drain removal was 10.4 days. This study had no control group and all patients were surgical patients who received general anesthesia. Procedures only lasted an average of 10.8 minutes in the OR, which means it’s very doable in an ED setting. Another retrospective pediatric surgical study in 2010 showed average drain duration of 9 days and 0 recurrences out of 128 patients(3).

Overall, the loop technique is short, comparable to standard I&D in complexity, and requires no packing changes, making wound care much easier for the patient. Theoretically, the occasional movement of the loop itself also assists with ongoing drainage! Retrospective study results are promising that this technique is superior to traditional I&D’s, but a randomized controlled trial would be best. For now, it is definitely a viable option for ED physicians when draining subcutaneous abscesses.

References

1. Ladde, Baker, Rodgers, and Papa. The loop technique: a novel incision and drainage technique in the treatment of skin abscesses in a pediatric ED. American Journal of Emergency Medicine 33 (2015) 271-276

2. Tsoraides et al. Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children. Journal of Pediatric Surgery (2010). 45. 606-609.

3. Ladd, Levy, and Quilty. Minimally invasive technique in treatment of complex subcutaneous abscesses in children. Journal of Pediatric Surgery (2010) 45. 1562-1566.

4. Thompson, MD, MPH. Loop drainage of cutaneous abscesses using a modified sterile glove: a promising technique. The Journal of Emergency Medicine (2014). Vol. 47 No. 2 pp. 188-191.