So, I know I recently wrote an article about abscesses and here I am writing about them again. Truth of the matter is that I have a small obsession with them — but not in a weird way.
My obsession lies in the idea of continually finding ways to improve methods of incision and drainage as well as overall treatment of abscesses. So, that is why I decided to talk about the use of suction to aid in draining.
I’m not talking about attaching surgical suction drains to abscesses; I am talking about using wall mounted suctions during the actual incision and drainage. I thought of this idea randomly one day and I thought I was on to something genius. But after a discussion with my attending, it came to light that he had been doing it for 20 years. Then I began to think that maybe I was the only one that wasn’t doing this.
I started asking my colleagues about whether or not they use suction when they drain abscesses. Most stated they did not but it seemed like a good idea, one stated he had heard about it, and another mentioned he had seen it done it surgery so it makes sense to do it in the emergency department (ED). I decided I was going to try it and decide for myself whether suctioning abscesses was something I was going to implement in my practice.
The abscesses I was planning on using suction for were the big ones that come through the door. I think that the ones that are less than 1 centimeter can be easily drained without the use of suction. However, those that come in that are greater than 3 centimeter or very deep are prime candidates for suction. It actually took two patients before I was successfully able to make my decision about suctioning.
Patient number one was my first attempt; he presented with a large abscess on his buttock. As I prepared for the procedure, I went to put on a safety mask and ended up giving myself a corneal abrasion after somehow managing to poke myself in the eye with the safety shield. (Future blog post: beware the hidden dangers of safety shields). So I had to go home and the mission was aborted.
Patient number two turned out much better — a male patient with a large pilonidal cyst that he had for several days. Looking at it, I could tell it was going to have a lot of foul smelling purulence. So after setting everything up and sterilizing the area, I made my incision. The results are as follows:
It kept it clean: the large amounts of purulent fluid that was expressed did not flow all over the patient, down his buttocks or all over the bed. Instead, it was pleasantly suctioned into the unit on the wall. Even better, the patient’s wife was able to give a play-by-play to all of us as to how many cubic centimeters of fluid was being collected (20! 30! 40!). It also made cleanup a snap.
Breaks up loculations: I used a yankauer tip suction. It was relatively small, so I was able to use it instead of my finger to poke into the wound and break up the loculations, immediately suctioning the released purulent material.
Less smell: Oh, the dreaded smell of the pilonidal! It is a smell that you never forget and it stays in your nose for days. When you are draining an abscess, the whole ED has the pleasure of smelling the abscess too — but not with the suction. I had a brief whiff of pungency but that was it. No sooner had I smelled it than it was gone. It definitely minimized the smell and this is a reason in itself that I am a fan of the suction.
Helps with irrigation: Just like in surgery, the suction came in handy when it was time to irrigate. I found myself irrigating with way more saline than I normally do because it was easily suctioned away.
What I would do differently
I think I will make a different incision next time. My incision was strictly vertical, but after doing some research and talking with some colleagues, I think I will make a cruciate incision. This will allow me better penetration with the suction tip and probably allow for even better drainage. I will also try and have another set of hands to help me with the suction because it would have been much easier to have one person suction while the other person drained/irrigated.
So, in conclusion, I am a huge fan of using suction while draining abscesses. I am sure there are plenty of you out there that are already incorporating this into your practice, but as I mentioned, there were several colleagues I talked to that had never thought of this and I wanted to make sure that anyone who hadn’t thought about it was told about it because it is spectacular.
As for abscesses, has anyone found any other techniques they to be extremely helpful? My obsession with abscesses continues, and I would love to try them out!
Jillian Knowles, MMS, PA-C, is an emergency medicine physician assistant in the Philadelphia area.