Learning Objectives: After reading this article, the physician should be able to:
1. Discuss the various issues involved in managing cutaneous abscesses.
2. Summarize the analgesic efficacy of various topical anesthetics for dermal instrumentation.
3. Define systemic inflammatory response syndrome, sepsis, severe sepsis, and septic shock.
Release Date: August 2009
Article from the 2009 Reading List
Abscess Incision and Drainage
Fitch MT, et al
N Engl J Med
Cutaneous abscess is frequently encountered in emergency departments. Antimicrobial therapy alone is often inadequate for cutaneous abscesses, and primary therapy involves proper and adequate incision and drainage. Needle aspiration or ultrasound may assist in the diagnosis when physical examination is unclear or equivocal. Incision and drainage for cutaneous abscesses can be appropriately performed when the abscess is large enough and is in an accessible location, but should not be performed in patients with only cutaneous cellulitis and no underlying abscess.
Preoperative antibiotics are unnecessary in most cases, but should be administered to patients at higher risk for endocarditis, such as those with artificial or abnormal heart valves. A majority of abscesses can be drained without surgical consultation, but may be required for abscesses involving the face, breast, palms, soles, and nasolabial folds.
Prior to the procedure, the article recommends obtaining informed consent from the patient, and the risks — pain, bleeding, and scar formation — should be discussed. Bupivacaine or lidocaine with epinephrine provides a longer duration of anesthesia when compared with lidocaine alone. For better cosmetic outcomes, it is best to make the incision along the existing skin tension lines, and pack the wound. Be careful not to overpack because this can result in wound ischemia and prevent drainage of the purulent material. Patients should be instructed to follow up within 48 hours for removal of the packing material and reassessment of the wound.
For most abscesses, antibiotics are not required after incision and drainage, but patients with extensive cellulitis or comorbidities may require antimicrobial therapy.
Article from the 2008 Reading List
Topical Anesthetics for Dermal Instrumentation: A Systematic Review of Randomized, Controlled Trials
Eidelman A, et al
Ann Emerg Med
Dermal instrumentation is often required during ED procedures such as lumbar puncture and intravenous line placement, with the eutectic mixture of local anesthetics (EMLA) the most common topical analgesic agent used in North America. This article is a systematic review of randomized, controlled trials comparing the analgesic efficacy of various topical anesthetics, including liposomal lidocaine and EMLA and conventional infiltration of local anesthesia for dermal instrumentation.
More than 200 potential articles were identified on initial search, but most were excluded; 25 randomized controlled trials using six different topical anesthetics on 2096 patients were used in the final analysis. Notably, studies involving children under 3 were excluded because they are unable to provide reliable pain ratings. Analgesic efficacy through patient self-report was chosen as the primary outcome in this investigation.
This systematic review found no consistent difference in analgesic effect between conventional infiltrated analgesics and EMLA, but pointed out that EMLA is significantly easier and less painful to apply. Three topical anesthetics (tetracaine, liposome-encapsulated tetracaine, and liposome-encapsulated lidocaine) had comparable analgesic efficacy with EMLA. Based on the reviewed studies, EMLA and liposomal-encapsulated tetracaine require 60 minutes to achieve full analgesic effect.
More rapid onset of action occurred with liposomal lidocaine, with full analgesic effect seen after only 30 minutes of application. No further pain reduction was noted with liposomal lidocaine if the time was extended to 60 minutes. Liposomal lidocaine was also less expensive than EMLA.
Article from the 2008 Reading List
Surviving Sepsis—Practice Guidelines, Marketing Campaigns, and Eli Lilly
Eichacker PQ, et al
N Engl J Med
This article comments on the relationship between pharmaceutical companies and sepsis practice guidelines. The intent of practice guidelines developed or approved by expert panels is to standardize care and improve health outcomes, and pharmaceutical and medical device companies have significant interest in them because they can be used for marketing and promotion.
The Food and Drug Administration (FDA) approved Eli Lilly's Xigris (recombinant human activated protein C) for sepsis in 2001 based on a single, phase III, randomized controlled trial (the Efficacy and Safety of Recombinant Activated Human Protein C for Severe Sepsis study by the PROWESS group; New Engl J Med 2001;344:699). The study demonstrated that Xigris was associated with a significant mortality benefit at 28 days, but due to various flaws in the study, the FDA acknowledged that the study required further confirmation. In the meantime, the FDA recommended restricting Xigris for patients with an APACHE II (Acute Physiology and Chronic Health Evaluation) score of 25 or greater. The agency also asked Eli Lilly to assess Xigris's efficacy in this specific population. All of the uncertainties about the PROWESS study and the FDA's hesitations led to a decline in sales of recombinant human activated protein C.
In 2002, Eli Lilly hired a public relations firm to implement its marketing strategy, and created the Values, Ethics, and Rationing in Critical Care (VERICC) Task Force and the Surviving Sepsis Campaign. In June 2003, international critical care and infectious diseases experts gathered to create guidelines for sepsis management and their recommendations were published five years ago. (Crit Care Med 2004;32 :858.) Eli Lilly provided a significant portion of the funding for this meeting.
Because randomized, controlled trials provide the best available evidence, there is often an overreliance on these studies in practice guidelines. This preference also can lead toward favoring new drugs and devices (Xigris was given a highly favorable rating: Grade B). In comparison with older established therapies (e.g., antibiotics, fluids, and vasopressors), newer agents and devices are more likely to have undergone randomized, controlled trials and therefore receive higher grades while older (yet established) therapies receive lower grades (e.g., grade D or E). One side effect associated with Xigris is bleeding, which is not often mentioned, or its magnitude is not fully disclosed within sepsis guidelines.
Sponsors of the Surviving Sepsis Campaign Guidelines included 11 professional societies, but the Infectious Diseases Society of America (IDSA) declined to endorse them, citing various faults such as an inadequate rating system and the pharmaceutical sponsorship. Professional societies need to create a consistent development process, a reliable rating system applicable and agreeable to all specialties, and a policy that inhibits pharmaceutical and medical device companies from influencing and intervening.
Article from the 2008 Reading List
Severe Sepsis and Septic Shock: Review of the Literature and Emergency Department Management Guidelines
Nguyen HB, et al
Ann Emerg Med
This literature review outlines the pathogenesis, diagnosis, and therapeutic advances in severe sepsis and septic shock in adults. A patient meets criteria for the systemic inflammatory response syndrome (SIRS) when two or more findings are present: temperature higher than 38°C or lower than 36°C, pulse greater than 90 beats per minute, respiratory rate greater than 20 breaths minute (or PaCO2 less than 32 torr), and white blood cell count more than 12,000/mm3 or less than 4,000/mm3 or more than 10% immature band forms. The presence or presumed presence of an infection accompanied by SIRS defines sepsis.
Severe sepsis is present when sepsis is accompanied by one or more organ dysfunctions such as coagulation abnormalities, thrombocytopenia, altered mental status, and renal, liver, or cardiac failure. Septic shock is defined as the presence of sepsis and refractory hypotension such as systolic blood pressure less than 90 mm Hg, mean arterial pressure less than 65 mm Hg, or a decrease of 40 mm Hg in systolic blood pressure compared with baseline and when unresponsive to a crystalloid fluid challenge of 20 to 40 mL/kg.
Bacteremia is defined as the presence of viable bacteria in the blood, but it is only found in about 50 percent of the cases. An elevated or increasing lactate level is associated with a poor prognosis, and it is recommended that the serum lactate level be measured when severe sepsis is suspected. A low bicarbonate level or increased anion gap is not always associated with an elevated lactate level. Peripheral venous lactate levels should be interpreted with caution because they may not correlate with more reliable central venous or arterial lactate levels.
Once severe sepsis or septic shock is recognized, early goal-directed therapy should be instituted as soon as possible, with placement of a subclavian or internal jugular central venous catheter for monitoring central venous pressure and central venous oxygen saturation (ScvO2). Target hemodynamic goals are the central venous pressure of 8 to 12 mm Hg, mean arterial pressure of 65 to 90 mm Hg, hematocrit level greater than 30%, and ScvO2 greater than 70%. In addition to aggressive hemodynamic stabilization, timely and appropriate administration of antibiotics, and infection source control are integral in managing severe sepsis and septic shock. For those patients who require mechanical ventilation, the goal should be to maintain an end-inspiratory plateau pressure of less than 30 cm H20 with the use of low-tidal volumes.
Luis M. Lovato, MD, an Associate Clinical Professor at the David Geffen School of Medicine at UCLA, the Director of Critical Care in the Department of Emergency Medicine at Olive View-UCLA Medical Center, and the Medical Editor of www.emcme.com, serves as the medical editor of this column.
About the LLSA
As part of its continuous certification program, the American Board of Emergency Medicine has developed the Lifelong Learning and Self-Assessment (LLSA) program to promote continuous education of diplomates. Each year, beginning in 2004, 16 to 20 articles are chosen based on the Emergency Medicine Model. A list of these articles can be found on the ABEM web site, www.abem.org.
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