Quality improvement methodology can reduce hospitalisation for abscess management

BackgroundAbscesses are a common reason for ED visits. While many are drained in the ED, some require drainage in the operating room (OR). We observed that a higher percentage of patients at our institution in Columbus, Ohio, were admitted to the hospital with abscesses for incision and drainage (I&D) in the OR than other institutions, including paediatric institutions. Our aim was to decrease hospitalisations for abscess management.MethodsA multidisciplinary team convened to decrease hospitalisation for patients with abscesses and completed multiple ‘Plan-Do-Study-Act’ cycles, including increasing I&Ds performed in the ED. Other interventions included implementation of a clinical pathway, training of procedure technicians (PT), updating the electronic medical record (EMR), credentialing advanced practice nurses in sedation and individual follow-up with providers for admitted patients. Data were analysed using statistical process control charts. Gross average charges were assessed.ResultsAdmissions for I&D decreased from 26.3% to 13.7%. Abscess drainage in the ED improved from 79.3% to 96.5%. Mean length of stay decreased from 19.5 to 11.5 hours for all patients. Patients sedated increased from 3.3% to 18.2%. The number of repeat I&Ds within 30 days decreased from 4.3% to 1.7%.ConclusionWe decreased hospitalisations for abscess I&D by using quality improvement methodology. The most influential intervention was an initiative to increase I&Ds performed in the ED. Additional interventions included expanded training of PTs, implementation of a clinical pathway, updating the EMR, improving interdepartmental communication and increasing sedation providers.

Compartment syndrome as a donor-site complication of anterolateral thigh free flap: a case report

Compartment syndrome (CS), a complication at the donor site of anterolateral thigh free flap (ALT-FF), has a low incidence. Our patient was a 26-year-old male, a professional soldier with large thigh muscles. His defect on the right ankle was reconstructed with a 30×10 cm2-sized ALT-FF. By the pinch test, the flap width was designed to be sufficient for primary closure of the donor. However, on the postoperative day 8, severe pain, tense and purulent discharge were found at the donor site. We diagnosed CS clinically, and immediately performed incision and drainage. There are various extrinsic or intrinsic factors that can influence the development of CS. Therefore, in patients with these contributing factors, such as a young man with high muscle mass, a higher level of suspicion for CS is needed. Moreover, it would be safer to design the flap width smaller than the pinch test or to cover the donor site with a skin graft.

Conservative Management of Submandibular Space Infection in a 5-Year-Old Child: A Case Report

Submandibular space infection is a potentially fatal infection that could arise as a result of odontogenic or non-odontogenic infections. The management should be prompt as the infection can spread rapidly leading to airway obstruction. A 5-year-old child reported with a complaint of swelling on the left side of the face for four days. On examination, patient had a diffuse swelling involving the left submandibular region with decreased mouth opening secondary to carious 75. The patient was administered intravenous (i.v) fluids, antibiotics and analgesics. Incision and drainage of the abscess was done extraorally under i.v sedation using midazolam with local anaesthesia followed by rubber drain placement. Patient responded to the treatment with progressive decrease in the swelling. Pulpectomy of 75 was performed followed by stainless-steel crown placement. This case highlights the importance of prompt appropriate treatment supplemented by salvage treatment to overcome the associated morbidity at this very young age.

Omphalitis with Umbilical Abscess in an Adult with a Urachal Remnant

Omphalitis is an inflammation of the umbilicus and is seldom diagnosed in adults. It is even rarer when it results from an infection of the urachus, an embryological remnant that connects the umbilicus to the dome of the bladder. Patients with omphalitis present with erythema, edema, tenderness, and purulent discharge form the umbilical stump. Workup includes ultrasonography and CT scan of the abdomen and pelvis. Management consists of antibiotics and incision and drainage of the umbilical abscess, followed by surgical resection of the urachal remnant. In this article, we report a case of omphalitis complicated by umbilical abscess in a 20-year-old female with a urachal remnant.

Peritonsillar Abscess Treatment under Local Anaesthesia: Incision and Drainage versus Needle Aspiration

Background: Peritonsillar abscess is usually complication of acute tonsillitis which itself is prevalent in society. As a general surgical principle, abscess any were, has to be drained so same applies for quinsy but methodology for this drainage is not being agreed. Aim: To find best modality for drainage of this abscess and see its incidence in which age group and sex. Study design: Prospective study Place and duration of the study: Department of ENT, Rai Medical College, Sargodha from 1st Feb. 2017 to 31st Jan. 2019. Methodology: One hundred and thirty five patients above 15 years of age and those in need of hospital admission due to severity of symptoms were included. Paediatric, immunocompromised, requiring general anesthesia and acute tonsillitis patients were excluded. Results: There were 65.2% males and 34.8% females. Commonly affected age group was 21-40 years. Needle aspiration was found more effective for management of peritonsillar abscess. Conclusion: No consensus for single modality and both needle aspiration and incision/drainage is advocated and needle aspiration proved fruitful in management. Keywords: Quinsy, Peritonsillar abscess, needle aspiration

The efficacy of primary closure following incision and drainage of lactational breast abscess over traditional open method

Background: The incidence of breast abscess ranges from 0.4 to 11% of all lactating mothers. Although breast abscess is a serious common complication of mastitis with high morbidity rate, there is a lack of high-quality randomized trial to demonstrate the best treatments.Methods: The Study was conducted in the Department of Surgery of Universal medical college and hospital, Dhaka, Bangladesh and MH Samorita hospital and medical college. It was a randomized controlled trial to see the efficacy of primary closure following incision and drainage of lactational breast abscess over traditional open method. Total 120 population were randomly selected in group A (60 patients) and group B (60 patients) and data was collected with their signed ethical consent. The study was conducted from January 2014 to December 2019. Collected data were classified, edited, coded and entered into the computer for statistical analysis by using Statistical package for social sciences (SPSS) version 22.Results: In patients of group A, most breast abscesses healed successfully with a nicer circumareolar scar, earlier healing, lesser number of hospital visits and lower total cost as compared to patients in group B. There was early resumption of breastfeeding and better patient satisfaction seen in group A.Conclusions: Primary closure of lactational breast abscess following incision and drainage is an effective modality of treatment of lactational breast abscess and it should be the first line of treatment, especially for larger and multilocular breast abscesses while traditional incision and drainage should be reserved for abscesses with gangrenous skin changes, where primary closure is not justified.