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Will be alive. Hi guys. My name is um Dacosta. I'm one of the train up here in Scotland. I'll be the modulator for today. I have my colleague here, Omi who would be presenting on access pathway. Um I see we have a few people up here already. I'm happy to have you guys here or first introduce our presenter for today and then we would have a quick pull before he start presenting if that's OK. So doctor Obey is a graduate of um Obafemi Au University in Nigeria where he studied, graduated in the top 3% of his class. So quite impressive fellow. And apart from being a very good clinician with vast clinical experience, he's also very new in medical education and this is obviously evidenced by his commitment to present him today. So we are very thankful for him. Yeah, he possesses um an un ving commitment to self as well and improvement of the quality of life for everyone. He currently works as a junior clinical fellow in general in Friendly Park Hospital in England and has very strong interest in surgical training. So without much I do, I would like him to take over and then tell us what he wants us to know for. Now, then I would release the polls afterwards. Thank you very much, Da Costa. Hello, everyone. My name is Mi. I'm a junior clinical fellow currently working in general Surgery at Park Hospital in England. Um, today I'll be taking us on the topic of the abscess pathway. Um, due to the vast and the, um, the vast nature of the topic of abscesses. Today, we'll be dealing with um superficial abscesses and how to effectively create and work towards creating a an abscess pathway to ensure that patients get the best of care as quickly as possible. So, um before starting the presentation, we just have um just four questions and would want us to read, pick the best answer as appeals to us or as we feel is most fit. Um We will discuss these answers at the end of the presentation and I'm hopeful that everyone would understand the concept better. So I'll read out the first pull. Um I just want to confirm, can everyone hear me? Yes, we can hear you. At least I can hear you. Ok. So a 50 year old man was coming to the hospital at 9 a.m. in the morning with perianal swelling, which has been present for the past five days with increasing pain. There is no associated fever or vomiting. He feels otherwise well in himself on examination, you find a four by four centimeter pilonidal abscess, which is pulse pointing, inflammation markers are within normal limits and vital signs are stable which of the following will be appropriate for this patient. So, um either discharge with antibiotics, analgesia anting, send the incision and drainage under general anesthesia. Since the incision and drainage under local anesthesia will allow for spontaneous drainage of the abscess. Ok. Um Do we have Suffian answers from the first one? I think we have people still answering those. Ok. But I'm sure they can have access to the previous question even. Yeah. Ok. So we just go on to the second question for five year old known diabetic man comes into the hospital with the swelling on her upper left back. The swelling has been in, in present for many years but has become increasingly painful over the last four days with a she history of fevers, chills, vomiting and anorexia. Uh Pain control has not been reached with oral analgesia on examination. You find an erma of tender flow trans differentially warm eight by six centimeters swelling and she has a temperature of 39 °C on presentation. However, other vital signs are stable your diagnosis. Sebaceous cyst abscess, blood investigations reviewed elevated inflammatory markers. What will be the appropriate management for her C an incision? A, an incision and drainage under local anesthesia. B admit for pain control IV antibiotics and aim for CD incision and drainage. Under general anesthesia allows continuous rupture of discharge with oral antibiotics and analgesia to follow up with GP. So just give a few seconds for people to read through and then all of a sudden we release the next po Yes, I agree. Yeah. So that, so for the third pool, for the third pool, we have this question, a 15 year old girl who was brought into the hospital by her mother with a painful swelling around her anus. After taking history and examining the patient, you suspect she had a pilonidal abscess, which of the following would strongly suggest that she needs admission for urgent incision and drainage, tenderness of swelling, high grade fever, anorexia and vomiting playing actively. None of the above and this will be the last pool for the day. You are the on call fy two doctor. You have just seen a 30 year old patient, a female patient with a diagnosis of an infected sebaceous cyst which needs drainage. You carry out the incision and drainage under local anesthesia to be side after smear review, the procedure is well tolerated by the patient. Full metals would be appropriate for wound skin closure. Um Simple inter which using two vi um sco using two monocryl leave wound close after packing with sterile gauze or skin staples. Ok. So we have our pre presentation polls done now and I think we have answers all, almost all of them. They would be available in messages. So when you are ready to discuss them in details, we can just look at them and see what the um the choice as well. OK. OK. All right. So, back to you, if you are happy to start your presentation, I think we are ready for you now. Brilliant. Thank you very much. Um I'll just like to share my presentation. Can everyone see this my presentation with the title Abscess Pathway? Yes, I can, I can see your presentation. OK. So, um like I said earlier, I'll be presenting on the Abscess Pathway. Um And using this outline. Um Now, the learning objectives include to understand the importance of an access pathway to the patient, the healthcare team and the hospital health system to understand the pathophysiology of um and presentation of abscesses, recognize and effectively manage patients with superficial abscesses, practical steps in incision and drainage of abscesses, raise awareness on the possibility of an outline abscess pathway and then review these scenarios um after this discussion. So OK, I'll just move through these ones as they've been discussed. So it is um important to know that um in creating or working with an abscess pathway. Uh It is key to, first of all understand how abscesses come about the pathogenesis. Uh uh the clinical presentation and their management. Um It is with the on this background that you can effectively use an abscess pathway. Um So, an abscess pathway is basically a tool or an algorithm which is used by healthcare um institutions or hospitals to um increase or to fast track the management of patients with superficial abscesses. This is because there's quite a high burden of patients presenting with superficial abscesses. I'm sure that everyone of us listening at one point of the time must have met a patient who's come to the hospital with a superficial abscess um due to the burden of these patients coming in. Uh these are cases that can be effectively managed quickly and have them on their way home instead of keeping them in the hospital except under certain circumstances. As we know, an abscess is a painful condition which is readily treated using simple incision and drainage procedures. Um depending on the preference of the patient, the preference of the surgeon also considering the overall clinical state of the patient. Now um unless complicated most times, suture, abscesses are seem to be low priority and as a result, they are, they can be um they may be managed late and as such lead to uh complications which we discuss um later on. So, having an ambulatory ab abscess pathway helps to conserve scarce hospital resources and provide a safe and effective care pathway for patients. Um and this in turn improves their outcomes as er makes it better than would be expected if you keep them in the hospital um for prolonged periods, um reduction of inpatient uh duration of inpatient stay um increases the amount of patients that can be treated um within the NHS this NHS is just, I'm just using this as a framework as to also um imply that other health systems uh would also benefit from reduction in inpatient stay uh especially among patients that are coming in with abscesses. Um gains. It all reported in 2020 that 60% of total bed occupation time was spent awaiting discharge uh demo and this demonstrates the importance of having an ambulatory care pathway for uh patients with abscesses. So as to get them into the hospital, have their abscesses drained, ensure that they are clinically safe and stable to go home. Um In 2002 at all, carried out a study in West Suffolk Hospital here in England. And they noted that the likelihood of a super sha abscess been drained on the same day of admission was reduced significantly um after if a patient presents to the hospital after 4 p.m. and this is due to a couple of factors could be due to theater pressures, reduced staff strength, uh amongst others. Um by way of epidemiology, um there's not much recorded as to with regards to abscess pathways in Africa. Uh but we just have bits and pieces of what um research is done in Africa and um all over the world on abscesses um in developing countries. They are mostly due to um non-sterile injections using contaminated needles and are most common in gluteal abscesses and most common the glutar region. Uh As many of us would have seen at one point or the other in our clinical practice. Um and I at all, in a series of um 391 Children with soft tissue infection showed that only 38% of them had clearly defined predisposing factors which mostly could be attributed to trauma or adjacent skin sepsis. And this will show that in most cases, the risk factors for developing abscess in patients may not be exactly known. However, some documented risk factors include um malnutrition, obesity, uh diabetes, uremia, uh generally conditions that weaken or reduce the immune system, either the um innate or the acquired immune um response. So, um in abscesses which are infectious etiology, staphylococcosis is the most commonly identified uh organism and it is mostly found in these areas of the body, the axilla, the groin. Um this is to clarify that um there are also abscesses which can occur as a result of um immune conditions like Crohn's diseases, which are not exactly infectious um in their own way. Um Pilonidal sinus disease is quite common in men and it, it's important that we talk about this because it's, it's a very common background on which abscesses develop. Uh pilonidal disease basically involves um cause when um a hair strand of hair which has grown out cause and grow back into the skin, thereby in, in um initiating or enacting a foreign body response by the skin. And this over time develops a sinus which can be filled with debris, become infected and become an abscess. It's important to know that pilonidal sinuses are common in the midline of the body and they are common in the natal cleft because of the soft and moist uh conditions that present within the natal cleft which predisposes to um uh which allows bacterial proliferation. And it's also common in the N Cleve because of the presence of hair strands within the N cleft. It's also been documented that it can be found in the interdigital workspace of the hands of barbers and people who deal with hair and hair products. Um by way of pathophysiology, um abscesses, a localized collection of ent inflammatory tissue which is caused by suppurative process which is buried in a confined space. And um as has been an acute inflammatory process, it's usually um um marked by the cardinal signs of inflammation, redness, heat, uh pain, swelling, loss of function. Um usually an abscess will occur if there is a break can occur if there is a uh break in the mucosal integrity of the skin. Like I said this uh for this presentation, we'll be talking about superficial abscesses. Um when there's a breakage in the mucosal integrity of the skin integrity, allowing for seepage of pyrogenic bacteria. And it, this initiates a localized inflammatory response which is uh which leads to swelling and all the um cardinal signs of inflammation. By view of um microorganisms. Staphylococcus aosis found to be the co commonest cause. Although methicillin resistant staph aures has also been found in recurrent abscesses. Strep pyrogen is a common cause of cellulitis and eras eras basically affect more superficial areas where the of the skin, the epidermal layer where the cellulitis tends to involve the dermal layers. Also uh mycobacterial tuberculosis as is common in Africa is a recognized cause of abscesses. Anaerobes have also been found. Uh Kon basically involves a um a a purulent collection of um a poli collection within the skin or a body space as a result of fungal infection. This is common in individuals who have um tinea infection, tinea corpo tinea capitis as is common in Africa and in some other parts of the world. So, um this is supposed to show that abscesses are not only always bacteriological, they could also be caused by fungi and could also be caused by viral infections. As you will see in the case of herpes simplex, um the organisms can enter the tissue either by direct implantation th following penetrating trauma. Uh it could be spread from contiguous um site or could be disseminated by blood through blood or lymph uh tracts. And usually when an abscess occurs after a breakage in the mucosal integrity of the skin and seepage of pyogenic bacteria. This elicits a local inflammatory response which is a marked by the uh aggregation of uh polymorphonuclear leukocytes and the release of um cytokines like uh tumor necrosis factor interleukin. One interleukin cyst, all of which uh mediates and lead to the cardinal signs that we see the effect, the pain, the swelling, the redness and the um the loss of function and the war, the war that are seen in patients that have superficial abscesses. Um And as the due to these inflammatory responses, as the um leukocytes tend to or attempt to contain the infection, some of them die of releasing toxins which lead to tissue death and leads to increase inflammation of debris. Um all of which collects to form the abscess and as a way to wall off the abscess, there is further release of um inflammatory markers which could um increase the production of vascularized tissue, which surrounds this necrotic tissue, sort of walling it off in that particular area and helps to limit the spread. So these are just some of the risk factors which I mentioned at some point or the other in this uh presentation, the impaired um whose defense mechanism, presence of foreign bodies are seen in a Pilonidal disease or even in patients who have um implants or maybe suture materials within their skin. It could also eli elicit the same response, um obstruction to normal drainage tissue, ischemia, hematoma and trauma. On the basis of the understanding of the pa uh pathophysiology of these abscesses. Um The symptoms can be well worked out the cardinal signs of information as seen as seen in the first five points. Uh over time patient develops fever chills, night sweats, vomiting, anorexia and on examination, these are the signs which are elicited, which are seen, you see the erythematous swelling, uh pulse pointing. So, post pointing means that um due to the presence of debris, dead leukocytes, uh the dead tissue within the abscess within the abscess cavity, the overly skin tends to thin out after a while and then become slightly transparent, revealing the underlying pos. So that's what it means for an abscess to be p pointing. And usually it's an indication of imminent rupture of the abscess. So on palpating the abscess, it may be firm, soft or flow to differential warmth. There will be tenderness and in some cases, there may be unstable, vital signs like pyrexia, tachypnea, tachycardia, just the name a few. And this is just a picture of what an uh post pointing abscess can look like complications of abscesses. If not, well, if not um early managed, especially in patients who are immunosuppressed can lead to bacter spread. There could be spread to um adjacent tissues, widening of the abscess and it will worsen the patient's overall outcome. Um There could be bleeding from vessels into the abscess and then sort of leads to a hematoma which is infected. It could lead to impaired function of an or of a vital organ. This would be more um uh marked if it's an intra abdominal abscess where it leads to compression of adjacent structures or total loss of function and it increases metabolic needs and leads to um ation down here, the diagnosis of uh abscesses are clinical. So most times on see it physically with the history that the patient gives an examination findings. One can almost always accurately diagnose a superficial abscess. Um in working up a patient for management. It's it would be important to do some laboratory investigations which includes doing a full blood count, which could show um elevated inflammatory markers, elevated white cell counts, elevated CRP. All of these will be important in making a decision as to the best mode of management for this patient and how to go about it. Um It would also be important to check the patient's uh clotting profile as still if you are planning for them to have an incision and drainage, it's important to be sure they don't have any derangement in clotting. Um If the patient is overwhelmingly septic has tachycardia tachypnea, um Spiric has low BP and we won't send blood cultures just to rule out um widespread or spread of the infection. Now, um with, with regards to imaging, um some superficial abscesses when they are in parts of the body, in doubt, uh they may need an ultrasound just to properly identify them and be sure that they are well localized and they are not connected or spread to other parts um of the body or not deeper than anticipated. All of this is on the background of the history and the physical examination uh which is done for the patient um for deep abscesses. That's we are talking of intraabdominal abscesses and the legs, which is beyond the scope of this presentation. Um It may be important to do uh a CT scan which will help to properly delineate where the abscess is and can also help in guiding management. Usually, some patients may come in with, for instance, a perforated, maybe perforated appendicitis, which could have uh localized, which could have been complicated by localized uh pulse collection. Uh Such patients who would usually have pain, you will be feeling unwell, inflammatory markers markedly raised. Um They may have night sweats and chills and high grade temperature. So insert patient, it would be good to do a CT scan just to properly delineate the abscess and to possibly plan for laparotomy or uh IR drainage. That's interventional radiology, drainage if appropriate MRI is also a very good sensitive um imaging modality for such abscesses. Now to the management of abscesses. Um some authors have stated that there may be a place for conservative management and this would all depend on the history taken from the patient, the clinical presentation, the examination, the observations, that's the vital signs of patient, uh the blood results, the level of the inflammatory markers. Some of the opinion that for small abscesses, they may be conservatively managed with uh pain control antibiotics, uh compression, keeping, uh en en ensuring hygiene. Um but others have also argued that even in place of this, even when this conservative managements are put in place uh that the place for an incision and drainage cannot be uh left out in any um abscess collection. And that brings us to the definitive management for abscess in most cases, which is to incise and drain it. Um incisional drainage being a surgical procedure has to be done under an anesthetic. And there are two options, could either be done under local anesthetic or general anesthetic. A brief pharmacology of how local anesthetics work. Um Local anesthetics are em I or esters and they work better in alkaline environments. So the way they work is they are they block the sodium voltage gated channels at the nerve endings and thereby prevent action potential from being generated. When action potential is not generated, the patient will have no sensation of pain in patients who have abscesses. We know that due to um the acidotic nature of the abscess cavity, um it's always um said that local anesthetics may not work well and they, they may not be as effective. And um this is because normally for a local um for a local anesthetic like loca prilocaine, bupivacaine just to name a few for any of them to work. Um they need to be in the non ionized and the ionized phase at different points in their mechanism of action on when they get to the extracellular um part of the cell membrane of the nerve cells, they need to be in their own ionized form to be able to cross the lipid bar the lipid membrane to enter into the nerve cell. Um when they enter the nerve cell, they then become ionized. It is only then that they can block the sodium, the voltage, sodium voltage gated channels and then inhibit the sensation of pain. But because an abscess, the environment of an abscess is you almost always acidic. Um due to the abundance of hydrogen ions, the hydrogen ions. Once an abscess is once a local anesthetic is injected around an abscess, the hydrogen ions tend to bind to the um local anesthetic, thereby making it ionized. And in this ionized state, it is difficult for the um local anesthetic to cross the um cell membrane and block the sodium channels. This is the reason why um local anesthetics tend to have very reduced effectiveness when inject injected into abscesses. However, we see that most times um abscesses are still successfully drained by um using local anesthetic by doing what we call a field block. I would show you pictures in the next slide field block which involves injecting just one centimeter around the abscess around the area of intact skin and where the acidotic where the Ph is not as low. And uh this will give the local anesthetic more chance to work and um which which would increase the effectiveness of local anesthetic. Um general anesthesia as we all know is uh a good choice and it's a relatively straightforward choice to for um anesthetizing patients with inci for incision and drainage. Uh The patient is put to sleep appropriately positioned and the abscess is drained. And um after the patient is um the anesthesia is re reversed and the patient goes home, incision and drainage serves to drain the pus and bacteria and all the debris from the cavity and helps to improve the pain, irrigate the cavity. Also a good way to get post sample for microscopic culture and sensitivity inci. The incision is usually advised to be made on the most flow trans part of the swelling and it should be made parallel to the lungs lines. Uh the lungs lines are the lines that demonstrate the direction in which the collagen fibers are lean on the skin. So as to allow um the wound to be kept open wide enough for complete drainage of the abscess and to allow for good healing by secondary intention and minimal scarring. There is a debate regarding the use of linear incisions versus cruciate incisions. Uh those who prefer cruciate incision are of the opinion that it helps keep the cavity the post cavity open for long. So as to allow all the exudative fluid and pus to be drained out completely before it seals up. However, the cruciate incision is best advised for abscesses on parts of the body that are not um visible because of the poor cosmesis with uh these incisions and as with any other surgical procedure, these are complications of uh abscesses of, of the incision and drainage in this case. OK. So here's a pictorial representation. Uh six simple steps on how to drain an abscess. You find the flow track point to do the field block, which is just in a diamond shape around the abscess. And then you make the incision using an 11 blade or just make a stab incision and make the incision as wide as possible to ensure that the entire um cavity is emptied of the post. After this, um you could use uh forceps to sort of pro gently prude in the cavity to um break up any locals of po or you could also use your um little finger to just stick it into the cavity just as an easy way to break out any locals. So as to prevent recurrence of the abscess. Um Also another step would be to after getting out the locals to irrigate the wound, the wound cavity, um you could clean it with an iodine soap gauze or not. And then you could pack the cavity with some um sterile dressing material or some medicated gauze. Like to start just the name that uh you could just put that into um keep the and the aim of this is to keep the abscess cavity open for as long as possible to allow the fluids or the uh the pus and the egg, the exudates to be drained out and um to also allow the wound to heal by secondary intention. Ok. So here is a um relatively easy and just another picture of the um the simple process of an incision and drainage. Of course, all of this is done after the initial skin preparation and it is best done with strict asepsis um applied. Yeah, Pectineus needle drainage is advocated by some for superficial skin abscesses. Uh But the disadvantage of that is uh the inability to properly clear the cavity by percutaneous needle drainage. Um So, it's recommended that incision and drainage is still the best way to leave a big enough opening for the abscess to be drained and um for all the exodus to be cleared. Pectin needle drainage may be of benefit for deeper abscesses or intra-abdominal abscesses where indicated by way of uh antibiotics. Uh The choice of oral versus parenteral depends on the general um state of the patient. The um depends on the clinical presentation, the general state of the patient. Uh the local guidelines, the guidelines for antibio antibiotic use um in for uh that's after drainage of abscesses in your local hospital or in the um health system work with. Um so, but most commonly we uh the several active antibiotics like penicillins have been known to be a very good um choice for antibiotic coverage after incision and drainage. Uh There are some who are of the opinion that the patient who has had an incision and drainage done does not need antibiotics. But then uh this is best left to clinical the decision of the clinician analgesia, of course, is very important because the patient needs pain control uh as per wound care after the incision and drainage is done and the cavity has been packed with sterile gauze and covered with some sterile dressing. It is recommended that the wound is reviewed daily. So as to allow for proper monitoring and uh to ensure that the cavity is being properly drained, um, as the wound dressing is done daily, the the gauze in the cavities removed daily and the new one is put in that way, it sort of serves as a weak drain and it's it, um, getting up the post, whatever pus may be left within the cavity or any um, fluids and allows the wound to heal by secondary intention. Um It should be noted that of course, abscess wounds are not closed, using sutures, abscess wounds are not closed. Primarily, we leave them to close to be, to heal by secondary intention and then follow up can be done uh by um local nurses depending on where the patient is or um, yeah, can be done by local nurses or if the wound is not healing, satisfactorily, medical opinion can be see, can be sought after on the basis of all I've discussed so far. Um We now understand some uh we now understand how an abscess comes about the different ways of management. And it's on this understanding that one can work towards creating an abscess pathway or work with an abscess pathway where available. So this uh on my, this table on my screen was created by me at all. Um with are when they did a research in West Suk Hospital here in England. And this, they created a sort of super ab abscess ambulatory care pathway where they had these four criteria with which they used to determine if a patient needed inpatient care or outpatient care for abscesses. So the patient had to be apyrexia with the low white cell count, lo crp or no significant um comorbidities. And on the basis of that, they created this sort of pathway where if a patient met the criteria, um they would offer the patient, um they will consider offering the patient the same the operative care. Um if it is possible if they have the staff strength, the theater space and um there's an anesthetic for review or um if all the conditions are met and the there's enough staff strength for this. Uh They could aim to drain the abscess on that day and send the patient home either by local or general anesthetic depending on preference of the patient and for the surgeon. Um if they can't offer the patient same day, um they would maybe the patient comes in towards the end of normal working hours where there's reduced staff strength or maybe on, on during, on four hours. Um They could ask the patient to go home and with analgesia and plan for an inpatient drainage. The following day. Of course, this decision will be made in a patient who is relatively stable with uh unremarkable inflammatory markers and has the pain controlled. But if the criteria for this patient for the uh which was created by this group was not met, they would offer the patient inpatient care where the patient will be admitted for antibiotics, um analgesia, parenteral analgesia and to be planned for the same day or an urgent incision and drainage of the abscess. Here, just another picture representation of another framework created by another trust on manage the management of abscesses. Um So it's just, it's just a framework basically just to um ensure that patients who have abscesses get managed as early as possible. So as to reduce the burden to uh on the hospital, to improve patient experience and to ensure that they can go back home as soon as possible to live their um normal lives. Now, this is just a list of potential factors which I recon could um affect compliance with an abscess pathway. Um First of all, there has to be uh if there's paucity of data regarding management of abscesses. Um if a hospital has not been keeping enough data to sort of track how they manage these abs this superficial abscesses, it may be difficult to know what they need to work on and how they need to go about it. The time of patient presentation, if the patient comes early in the morning, it's likely that other things being equal. And if they are no pressures and uh if this, there's enough staff strength and the patient is willing, they could have it done that same day in compliance with the abscess part of the hospital and they can be sent home. Um staff strength stata pressures. I mentioned the patient's preference also, um we also have to consider the patients. In this case. There are some patients who despite having small abscesses that can be drained uh local, using the local anesthetic at the bedside may prefer to have it drained under general anesthetic. And if um after assessing them, if you feel they are safe to have a general anesthetic and there's no contraindication, uh sometimes just to ensure the patient has the best clinical experience, it may be uh considered to uh the patient may be considered to have a general anesthetic for a small abscess. Um Also, if the patient uh may be found not to be able to tolerate the procedure under local anesthetic. Despite irrespective of the size of the suture abscess, we need to be changed to um the general uh anesthetic pathway. All of this could lead to increased hospital stay. And um yeah, the increase hospital stay social factors may also include um if the patient doesn't have, the patient is elderly, probably doesn't have carers or someone to stay with them at home, they may need to be kept in the hospital overnight just to um have the procedure at once and for all and they can be sent home. So to conclude abscess pathways, as we have seen, they are useful tools for hospitals in the management of superficial abscesses. And it's very important that they are used to improve patients in hospital experience, to improve clinical outcomes and to save costs for hospitals and organizations um knowledge of this abscess pathway. Um I'm hoping would uh help all listeners to be aware of this possibility. Uh It's a good idea for to look into your hospitals um guidelines to see if they have an abscess pathway. And it, it's a good uh opportunity to run an audit to see if your department or your trust is keeping in line with this um with this set guidelines and this would also help in um improving patient outcomes and patient experience. Um Thank you very much for listening. Um We would take uh questions now. Yeah. Um I think that was a very good presentation, quite detailed, very academic and thank you very much for spending so much time to prepare this. It looks like obviously you spent a lot of effort, get this done. We have the pulls from before. Do you want to deal with that first before we delve into the questions that have been asked or do you want to answer the questions before you talk about the polls? Yes. Uh I think I'll go with the pos first. Me. Just see. OK. So, and uh oh, the first question, um you had 14% of the respondents saying that discharge with antibiotics and analgesia and sein and it was a split between same day incision and drainage and the general anesthesia and then same day incision and drainage and the local anesthesia. Um Yeah, I again, the answers to these questions are would be, would vary depending on our clinical experiences. Uh The resource setting in which we are working in. So I'm not surprised that we have equal distribution between um the second and the third one. But from um the presentation so far, um if this patient comes in in the morning with uh otherwise systemically, well, observation, stable inflammation markers, normal, we find a four by four centimeter abscess. Uh If the patient can't tolerate an incision and drainage under local anesthetic, I am of the opinion that the patient should be offered this um option because of course, the recovery uh from local anesthetic is way quicker than with the general anesthetic. Uh The patient gets to go home the same day and the outcomes are basically the same as with uh if it's done under a general anesthetic. So, yeah. OK. Yeah. And with the second pool, you had about 80% of the respondents saying that you admit for pain control IV antibiotics and aim for seeing the discharge, the incision and drainage. Yeah. Yes. Uh Well, um, for this question, we seen as she is diabetic and um, she's had a sebaceous cyst which has recently become infected and is complicated by an abscess and she is systemically unwell uh with a temperature of 39 degrees um with elevated inflammatory markers. Um I do agree that it may be of the options listed. It may be um sensible to keep her in for uh pain control. Um because the pain is also not controlled um under uh local analgesia, start her on some antibiotics and aim to drain it as soon as possible. Great on the PE D pole. You had most participants in that um high grade fever and RAA and vomiting just start with a b just a few 16% just tenderness of the swelling. Yes. Yes, I agree with the uh uh the answer that the choice that the patient having high grade fever, anorexia, vomiting uh mean she's a kid systemically appears systemically unwell. Um She may need to be admitted to um have an urgent drainage of the abscess. Uh She may need IV fluids if she's been pyrexic, uh she's been vomiting. She may have some elements of dehydration which would be well replaced by intravenous fluid therapy in this, in this case. Yeah. And the last question about the choice of closure for the um, a full incision and drainage. You had close to 70% saying they would need the wound and closed after packing cavity with sterile gauze. Yes. Um Like I mentioned during the presentation, generally abscess cavities, it's advised that they are not closed, primarily using sutures. And this is because we want to keep the wound open for as long as possible um to allow for the drainage of any remaining pores or exudative fluid that may be in the cavity. So generally, wounds created fulling incisions and drainage are not closed, using suture materials or staples, they are left open and allowed to heal by secondary intention. Ok. There are a few questions here. Two from me actually and then one from Stanley. So my first question was uh what, what is your stance on administering antibiotics? Post incision and drainage compared to against the I you? So patients who've had incision and drainage done, do you routinely give antibiotics to every one of them? And if you don't, why? Oh, ok. Um The definitive management for incision and drainage for, for an abscess is to get the po out which is achieved by an incision and drainage. Um The giving of antibiotics after is, as I have seen from my experience, it varies from um surgeon to surgeon. Sum of the opinion that uh they would rather just give a five days cover of antibiotics. Um because uh after draining the abscess and clearing the cavity, this would improve the blood flow to the area. And with improvement of the blood flow to the area, there is improved um availability of these antibiotics to the local site. This would also help to um this would also help to uh sort of clear out any other microbiological organisms that could have caused the inflammation at this site. So, uh again, it varies from surgeon to surgeon, some of the opinion that the patient does not need it. Some of the know that the patient needs it. So it's a, it's a balance. It also depends on the clinical presentation of the patient. How unwell the patient was when they presented, uh the patient is otherwise fit unwell and uh the patient had normal bloods, normal inflammatory markers, normal observations. The patient may do well without having antibiotics after an incision and drainage as opposed to a patient who came in very unwell. That's what I was saying. Yeah, I think I would tend to agree with you with this because um there have been a recent um national audit in the UK called the magic um study. And it will probably be what reading for people who might be interested in finding out the variation and practice when it comes to management of abscesses because they address the questions like this as well. So do also to look for it if you have the time and you are interested that. It's called a Magic study. I'll, I'll try and find the, the link to the, the project and then paste it in the charts just for those who are interested. Thank you very much for that. And, um, the next question was from Stanley and Stanley wants to find out what determines the follow up plan for those treated with antibiotics on outpatient basis. I'm sorry, I didn't get that. What determines to follow up plan for those treated with antibiotics on outpatient basis. Mm. Well, if I understand that question correctly, um follow up plan for patients treated uh with antibiotics. Follow up the follow up for patients who have had the incision and drainage is basically to ensure that the wound is healing well and the cavity has not uh closed up early, thereby collecting the abscess again. Um The follow up may not necessarily be due to um antibiotic use. Usually the follow up is routine just to check just to ensure that the wound is healing. Well, the abscess is not recurred and the patient has otherwise improved. Usually after incision and drainage of a superficial abscess, most patients don't need follow up. However, for high risk patients, patients who are diabetic, who are immunosuppressed, um It may be worthwhile to arrange a clinic like sort of clinic, uh medical follow up with them just to assess how they've improved um with the use of antibiotics and post the procedure. So I'll say uh patients who have, who are at high risk of complications such as the diabetics, the immunocompromised Children. Uh Yeah, would benefit from the follow up following an incision and drainage. I hope that was clear enough. Yeah. And I think um Lilian wants to see if he could show the slide for abscess management again. So she would appreciate it if you could show that slide briefly and probably talk about it again. Oh OK. Do you the slide on management or the abscess pathway? Um Can you show us a slide again for a assess management? I think management? OK. Me a second. Let me, can you see the slide now, please, uh we can see your slides, we can see you going through it. Thank you. OK. Is it the management? Yeah. Yeah. My Yeah, I li uh is this, is this a slide you wanted? Not sure if she said it, but probably I I'll just, I'll just run by it again um within the next few minutes. So um for management of abscesses, uh the main stay or definite management remains to incise during the cavity and to drain the pus out. Um I did mention that there are some proponents of con for conservative management for small abscesses in patients who are well with normal inflammatory markers who have no significant comorbidities uh which involves use of antibiotics. Um So sorry to you, but Lillian said it's the last one in color. That's what she's looking for. Sorry, Lian wants the last one in color. I'm not sure which one should be the one. OK. This one. Yeah. OK. So um this is uh this is just a schema or a framework that was created by a hospital for management of their patients with abscesses. There is no single, at least from my search. I did not find a single uh sort of universal abscess pathway, but this is just to illustrate what an abscess pathway can look like so that each of us can sort of uh work towards developing access pathways for uh different workplaces if they are not, if we don't have one in place. So from here, this, this just basically shows for this hospital if the patient is referred from the ED or GP um indications for admission, if the patient has requires IV pain relief or s uh signs of systemic infection. Yes. Then you admit, if the patient has none of these, then you could send through an ambulatory care pathway and history is taking observations, bloods are done. Then the clinical diagnosis is made if the patient needs a drainage. Yes. Um It now depends if it can be done under a local anesthetic. If it can be done, then we aim to do it that day uh with patient's consent and uh care for the wound and send the patient home with advice on how to care for the wound. If it cannot be done on that day. Um According to this schema, it says patients fasted and is unable to be done in theater within the next three hours. If it can be done, then we hope to get it done under general anesthesia in theater. If it cannot be done that day and the patient cannot have it under local anesthetic, you can uh book the patient to return the following day to have it under a general anesthetic. OK. Thank you very much. Yeah, I think I think it would also be helpful to review the slide Lily and once it's uploaded, so you can actually take your time and go through it once the slides uploaded up. So that will be helpful for you. So then you can have some reference to follow back up and we have some insight from um a Mala Chuk who quite um nice insight. So he said for a four centimeter abscess, it's quite unlikely that it can be done under local anesthesia because of pain and inadequate anesthesia will prevent proper washout. And then he did mention that um however, if the patient refuses general anesthesia, then you can educate the patient on the risks of recurrence and inability to do a proper job under local. So basically, all he's trying to say is if the abscess is more than four centimeters, it might be difficult to properly incise and then wash it out and the local anesthesia. And then you, I think you spoke about the reason why local anesthesia will probably not work properly if you administer it to patients with abscesses. Right. And so then he went on to see if the patient still wants it done under local or not under general, then you have to let them know that there's a chance that it won't be done as well if it were under general compared to local. Ok. So, um, that, that, that is it. I think I had one more question. Er, we, we have a minute to talk about that. And so what is your viewpoint on packing versus not packing abscesses fully in Dr? Um. Ok. Thank you for that. Um Routinely, it's recommended that the cavity is uh packed. Um and the packing is to be done lightly. I'm not sure if I mentioned that it's not, we are not, the aim is not to stop the cavity with uh or to over pack the cavity with gauze. So it doesn't cause some pressure effect and increase pain for the patient packing the cavity and leaving a small part of the, of the um material with which you've packed either a sterile gauze or a medicated gauze would serve as a weak drain to help take out the exudative fluid and better improve uh the healing process of the wound. I would recommend that not packing the cavity um may not allow for this to be possible early also. And the second reason for packing the wound is to ensure that the wound is kept open as long as possible for the exudative process to be completed and for the wound to heal by itself by, by secondary intention. So, if you don't pack the wound, there's a possibility that the abscess cavity, the skin which has been incised could close up back here leaving the cavity empty, which may still contain some uh pore. And this could lead to a recurrence of the abscess. So I would say I'm a proponent of packing the cavity to allow for it to be as open for as long as possible and to allow the proper healing process to occur. Ok. Thank you for your insights. Um I, I would like to mention though that there have been a few studies comparing the the the two packing versus non packing and, and um it might be worth taking a look just for, you know, extra, extra information and then just expanding your knowledge as well. But I do agree that um there've been a bit of controversy regarding packing versus not packing because of the obvious issues. You've mentioned some of the pain and whatnot. Um I think we have. Sau Davis wants you to clarify the rule of local anesthesia and abscess drainage. So the rule of local anesthesia in abscess drainage, um I think Sam Old Davis wants you to clarify that and I think that would be the last um thing for, for today. OK. Um So for local anesthetics, um the way they work is that they are um ers or a mines which em I which work better in alkaline environments for a local anesthetic to work. Um It has to be in the ionized form and the ionized form at different points in its mechanism of action when it is injected into a healthy tissue, um in its ionized form, it is able to cross the lipid membrane of the neurons that subserve that sort of register the pain response. So when it the ionized form of the anesthetic crosses the lipid membrane within the cell, it becomes ionized and it is only in this ionized state within the cell that it can block the sodium voltage-gated channels, which play a very key role in the development of action potential in the nerves that subserve the response to pain or the sensation of pain. In an abscess, the environment is generally acidotic with a low ph and with a low ph, there's a lot of hydrogen ions when a local anesthetic is injected into an abscess cavity, um the hydrogen ions tend to ionize the local anesthetic, thereby making it impossible for it to cross the lipid membrane and act out its function. So that is why um local anesthetics are not as effective as they should be around acidotic infected or inflamed tissues. So for abscesses, it is recommended that a field block is done which involves a four quadrant in um infiltration of the skin, healthy skin just around the ha abscess where we still expect the PH to be near normal or normal. So this way, the patient uh that area it provides some degree of anesthesia, thereby allowing for the abscess to be drained. It is recommended that you don't inject the local anesthetic into the abscess cavity because number one, it will be ineffective. Number two, it would only increase the pressure within the cavity and increase the pain that the patient experiences. I hope that's um yeah, I think someone will be happy with the clarification desk. Now, um I have shared um the link to the document I mentioned earlier about the study comparing management of abscesses across the UK. So for those, the link is out there, but thank you very much um for the presentation I think was very great. I think you took your time and research it and your knowledge is obviously um high, high knowledge, you, you really know what you're talking about. But thank you very much and we hope we see you again on our channel with fe teaching sessions. Uh We'll be, we'll be happy to see you again. OK. And I there are no additional questions. So um if you have any questions and remarks you want to deliver, you are welcome to do it. If not, we would just say goodbye for now and then catch up again another time. Um Yeah, I would just say that um this is just a brief overview of um abscess management. And I am hopeful that with this uh uh knowledge are refreshed on the management of abscesses. We are aware of the uh feasibility of creating a pathway by which uh these patients, patients who come in with superficial abscesses can have uh quick care given to them so that we can improve patient outcomes, improve our own experience and skill set. It's also a good way to sort of carry out quality improvement projects for our hospitals and um build our portfolios and become better professionals. Thank you very much. Thank you again. Um Thank you all for joining us today. We hope to see you on our future sessions. Please do enjoy the rest of the weekend and see you later. Bye.