Abscess packing: is it necessary?

It is becoming apparent that our attempts to help abscesses heal faster may actually serve only to be agonizing and fruitless.

Abscess packing in the emergency department may not be necessary
Abscess packing in the emergency department may not be necessary

 I am going to be frank with you. When it comes to packing an abscess, I absolutely hate it. There is something so barbaric to the idea of shoving a foreign object into someone and telling them to come back in 48 to 72 hours to have it pulled out again.

Patients seem to think the same thing, as their eyes often widen when they are told they are being sent home with something left inside of them. To us in the medical field, this is a relatively normal idea. But to those with no medical background, this idea seems horrible.

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 In addition, no matter how hard I try, there appears to be no such thing as painless abscess packing in the emergency department (ED). Patients generally tend to hate it.

So is it really necessary? Why do we do it in the first place?

The purported purpose of packing is that it helps absorb any remaining exudate, prevents infection (if it is iodoform) and prevents the incision from prematurely closing, thus allowing the abscess to continue to drain. But in the world of so many medical advances, are we really still at this point?

Surprisingly, the answer is no. As more and more research is performed, it is becoming apparent that our attempts to help abscesses heal faster may actually serve only to be agonizing and fruitless.

In a study published by the Society for Academic Emergency Medicine, two groups were compared after they had their abscesses incised and drained. One group was discharged with packing in place; the other was discharged without packing. The groups were compared and it was found that those in the packing group used a statistically significant amount of more pain medicine including ibuprofen and oxycodone HCl, acetaminophen (Percocet).

In addition, they reported being in more pain at the time of discharge as well as 48 hours post-procedure. They also found that there were no real improvements to using packing, as both groups required the same amount of secondary intervention. 1

Interestingly, in a systematic review by the American Journal of Emergency Medicine, it was demonstrated that packed wounds do result in delayed wound closure, with closure times basically doubled. However, they found that the rate of wound reoccurrence was equal.2

So why do we think it is a good idea to delay wound closure? We've been telling ourselves that it is to prevent the wound from healing too soon, but in actuality this is an unnecessary practice.  Having patients return for packing removal can cost them both time and money as they will often have to take off from work to either follow-up in the ED or with their primary-care provider.  As the evidence against packing starts to stack up, I find myself using packing less and less in my practice.

I still pack abscesses, but not nearly as frequently as I did when I first started in the ED. Now, I will only pack under certain circumstances. If the abscess is particularly deep, I will pack, often using iodoform if I think the wound will need the assistance of an antiseptic agent. I will also pack if there is a lot of surrounding induration, because there is a good chance the wound will have more purulence in the days to come and need the wicking capabilities of packing. I will also pack if I want the patient to come back so that the wound can be looked at in the next couple of days.

f the patient gives strong indication that they will go home, keep the wound clean, apply a lot of heat and come back at any sign the infection is getting worse, I will not pack. If the patient appears as though they may not be particularly hygienic, not very dedicated to following their discharge instructions, and apt not to come in until they have a raging infection, then I will pack.

 If you tell a patient such as the aforementioned that you want to see them in two days for a recheck, there is a good chance they won't return. If you tell them you've left something inside of them and need to take it out again, following up becomes more of a priority. Funny how that works.

Jillian Knowles, MMS, PA-C, is an emergency medicine physician assistant in the Philadelphia area.

References

  1. O'Malley GF, Dominici P, Giraldo P, et al. Acad Emerg Med. 2009;16(5):470-3.
  2. Singer AJ, Thode HC, Chale S, Taira BR, Lee C. Am J Med. 2011;29(4):361-6.
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