Background:
Cutaneous abscess is an infectious condition that affects millions of people each year, and the incidence is on the rise. Between 1993 and 2005, the annual number of emergency department (ED) visits for skin and soft tissue infections increased from 1.2 to 3.4 million, and this largely attributed to a rise in the prevalence of Methicillin Resistant Staphylococcus Aureus (MRSA) in the community.
The standard treatment for cutaneous abscess is incision and drainage at bedside in the ED. Following this procedure, many clinicians insert a strip of gauze, known as packing, to maintain the open surgical incision, enhance drainage, and prevent re-accumulation of the abscess. If the abscess is packed, patients typically have to return in 2-3 days for a repeat visit to have the packing removed. The present standard of care, gauze packing, is difficult for patients to remove alone, as the packing itself becomes impregnated with pus and blood. Additionally, the packing procedure can be painful, despite the use of local anesthetics.
A newer approach advocates for the use of a silicon string, known as a PDS loop for purposes of packing and drainage. While this approach can reduce pain, and is equally effective in terms of healing time, and treatment failure, the PDS, or Vessiloop is not readily available in emergency departments and outpatient clinics, as it is a specialized sterile surgical device used in vascular procedures. Furthermore, this procedure does not facilitate irrigation of the abscess cavity, since a much smaller incision is made. Finally, the PDS loop requires a surgical knot which may come loose.
Objective:
To investigate the use of a novel silicon packing device, the Derma-Stent™. The novel device will facilitate self removal by patients, as it has a narrower profile, and, as a nonabsorbent material, will not become saturated with bodily fluids. Although it will not absorb body fluids, it is believed that the Derma-stent will achieve the objective of wound healing by maintaining the opening of the surgical incision.
Hypothesis:
The acceptability of self removal will be significantly higher for the novel device.
Study Protocol:
ED Visit
1. Abscess measured by ultrasound. Study will be performed by a trained research assistant, and will be verified by a physician certified to interpret soft tissue sonographic images.
2. Abscess photographed, with measurement tape, to allow for objective measurement of skin induration and erythema.
3. Abscess will be incised and drained, utilizing standard of care technique, with local anesthetic
4. Packing performed according to randomization group.
5. Sterile dressing applied.
6. Subject completes assessment form - pain scale.
7. Practitioner fills out assessment form - ease of use.
Follow up visit 1 - 3-5 days
1. Removal of packing. Subjects will be asked to remove packing on their own under supervision of the physician. Physician will remove the packing if they not able to.
2. Measurement of abscess diameter and volume, utilizing measuring tape, photograph, and point of care ultrasound.
3. Practitioner and subject assessment form as above, but adding ease of procedure, and likelihood that subject would have removed packing at home.
Follow up visit 2 - 24-32 days
1. Assessment of residual erythema and fluid collection by measurement, photograph, and US
2. Practitioner and subject assessment including global satisfaction, and satisfaction with cosmetic result.
Adverse Effects:
If physician is impressed that the wound is not appropriately at either f/u visit, antibiotics may be prescribed, and repacking may be performed, utilizing gauze packing strip. Use of antibiotics for abscess is controversial and most physicians prescribe these on a case by case basis. Antibiotics will be prescribed at the discretion of the physician and not related to the study protocol.
Population:
Convenience sample of adult patients presenting with uncomplicated cutaneous abscess amenable to bedside drainage to either DRH or SGH ED.
Sample size calculation:
As this is a hypothesis generating study, and the effect size is unknown, formal sample size calculation was not performed. 60 patients was chosen as the sample size.
