I&D...sterile procedure?

Libby1987 · Aug 26, 2016

Good clean technique would be fine for my kid. Abscesses aren't sterile anymore than any other dirty wound.

Axgrinder · Aug 28, 2016

My BFF (also an RN) had a loop recorder implanted to try to capture a pesky arrhythmia that had been dogging her for years. The last one had scared the crap out of her because her vision telescoped down like she was about to have a LOC (or death). She had also been alone. Although severe while happening, the events occur very infrequently - maybe once or twice a year.

She was awake for the procedure which was performed via a local. She received no empyric Rx antibiotics pre or post-op, and a number of questionable occurred things before/during/afterward breaking the chain of asepsis that I won't go into.

When she became febrile on post-op day #2 she returned to her cardiologist's office for a wound check - more bungled things happened I again elect to skip over for brevity's sake. It was now at this point he finally Rx'd an antibiotic. He never got a culture of the drainage - he didn't feel it was necessary.

Less than 24 hrs later: the incision began to pop open, and she woke up with a huge hot, red patch surrounding the dressing on her chest. It felt like a lit cigarette had been stuffed in next to the device, then sewn back up. When she called her cardiologist's office to tell him how sick she felt and to share some of her concerns he dismissed and poo-pooed her. Already feeling like death warmed over, she began to cry because he continued blowing her off - instead of applying empathy to a frightened pt, he unkindly suggested she "do something about her anxiety".

He also snottily claimed the device would never work it's way out.

The following morning her PCP referred her to the ER - she was admitted.

The incision had dehisced, the device nearly extruded itself, and she started oozing yellow purulent drainage from the site. She had a pocket of foul smelling pus surrounding the device after less than a week S/P insertion that smelled like an exhumed coffin. She became septic - her blood cultures were positive for staph. Oh, did I mention the culture of the incision site came back positive for MRSA?

She just came home yesterday from a 5 day hospital stay with a PICC line and vanco infusions (which look pretty cool - like small balls).

Now her dance card for the next month or so is occupied with numerous MD appts (cardiology, infectious disease, wound care, et. al).

Could all this have been avoided had the MD just listened to my BFF's concerns and acted sooner? Or maybe if he had he done a whole lot of things differently before/during/after making that first incision? Dunno, but it certainly couldn't have hurt though.

This is a slightly different scenario than your average, garden variety I&D, however it makes me believe one can never to "too sterile" while performing any invasive procedures.

And just for the record: If it were me or my son, I'd prefer sterile gloves - please and thank you.

*

The good news? After reading the device an "event" had been captured and recorded in less than a week after insertion!

Libby1987 · Aug 28, 2016

My BFF (also an RN) had a loop recorder implanted to try to capture a pesky arrhythmia that had been dogging her for years. The last one had scared the crap out of her because her vision telescoped down like she was about to have a LOC (or death). She had also been alone. Although severe while happening, the events occur very infrequently - maybe once or twice a year.
She was awake for the procedure which was performed via a local. She received no empyric Rx antibiotics pre or post-op, and a number of questionable occurred things before/during/afterward breaking the chain of asepsis that I won't go into.
When she became febrile on post-op day #2 she returned to her cardiologist's office for a wound check - more bungled things happened I again elect to skip over for brevity's sake. It was now at this point he finally Rx'd an antibiotic. He never got a culture of the drainage - he didn't feel it was necessary.
Less than 24 hrs later: the incision began to pop open, and she woke up with a huge hot, red patch surrounding the dressing on her chest. It felt like a lit cigarette had been stuffed in next to the device, then sewn back up. When she called her cardiologist's office to tell him how sick she felt and to share some of her concerns he dismissed and poo-pooed her. Already feeling like death warmed over, she began to cry because he continued blowing her off - instead of applying empathy to a frightened pt, he unkindly suggested she "do something about her anxiety".
He also snottily claimed the device would never work it's way out.
The following morning her PCP referred her to the ER - she was admitted.
The incision had dehisced, the device nearly extruded itself, and she started oozing yellow purulent drainage from the site. She had a pocket of foul smelling pus surrounding the device after less than a week S/P insertion that smelled like an exhumed coffin. She became septic - her blood cultures were positive for staph. Oh, did I mention the culture of the incision site came back positive for MRSA?
She just came home yesterday from a 5 day hospital stay with a PICC line and vanco infusions (which look pretty cool - like small balls).
Now her dance card for the next month or so is occupied with numerous MD appts (cardiology, infectious disease, wound care, et. al).
Could all this have been avoided had the MD just listened to my BFF's concerns and acted sooner? Or maybe if he had he done a whole lot of things differently before/during/after making that first incision? Dunno, but it certainly couldn't have hurt though.
This is a slightly different scenario than your average, garden variety I&D, however it makes me believe one can never to "too sterile" while performing any invasive procedures.
And just for the record: If it were me or my son, I'd prefer sterile gloves - please and thank you.
*
*
*
*
*
The good news? After reading the device an "event" had been captured and recorded in less than a week after insertion!

Comparing imbedded hardware closed with sutures to an I&D of an encapsulated abscess that is left open to drain is apples and oranges.

allnurses Guide · Aug 28, 2016

It is a clean procedure where I work. Instruments are sterile but sterile gloves are not used. I don't routinely culture unless the patient has recurrent abscesses. Antibiotics are not necessary unless this is a recurrent problem or the patient has systemic symptoms. This is per our health system's protocol.

Same. Alcohol prep, local anesthesia, povidone-iodine prep, drape, disposable scalpel, and clean gloves. Once the abscess is opened its non-sterile anyways.

He does know more than you do, and I&D is not a sterile procedure.

Wound care nurse here. Absolutely this is a clean procedure.

Don't turn the doc in or you might have a bit of egg on your face. That's why it was good to come here to get advice.

There is no reason you can't ask for sterile gloves as a parent but the truth is, we don't use them routinely on I&D procedures.

AceOfHearts<3 · Aug 28, 2016

My BFF (also an RN) had a loop recorder implanted to try to capture a pesky arrhythmia that had been dogging her for years. The last one had scared the crap out of her because her vision telescoped down like she was about to have a LOC (or death). She had also been alone. Although severe while happening, the events occur very infrequently - maybe once or twice a year.
She was awake for the procedure which was performed via a local. She received no empyric Rx antibiotics pre or post-op, and a number of questionable occurred things before/during/afterward breaking the chain of asepsis that I won't go into.
When she became febrile on post-op day #2 she returned to her cardiologist's office for a wound check - more bungled things happened I again elect to skip over for brevity's sake. It was now at this point he finally Rx'd an antibiotic. He never got a culture of the drainage - he didn't feel it was necessary.
Less than 24 hrs later: the incision began to pop open, and she woke up with a huge hot, red patch surrounding the dressing on her chest. It felt like a lit cigarette had been stuffed in next to the device, then sewn back up. When she called her cardiologist's office to tell him how sick she felt and to share some of her concerns he dismissed and poo-pooed her. Already feeling like death warmed over, she began to cry because he continued blowing her off - instead of applying empathy to a frightened pt, he unkindly suggested she "do something about her anxiety".
He also snottily claimed the device would never work it's way out.
The following morning her PCP referred her to the ER - she was admitted.
The incision had dehisced, the device nearly extruded itself, and she started oozing yellow purulent drainage from the site. She had a pocket of foul smelling pus surrounding the device after less than a week S/P insertion that smelled like an exhumed coffin. She became septic - her blood cultures were positive for staph. Oh, did I mention the culture of the incision site came back positive for MRSA?
She just came home yesterday from a 5 day hospital stay with a PICC line and vanco infusions (which look pretty cool - like small balls).
Now her dance card for the next month or so is occupied with numerous MD appts (cardiology, infectious disease, wound care, et. al).
Could all this have been avoided had the MD just listened to my BFF's concerns and acted sooner? Or maybe if he had he done a whole lot of things differently before/during/after making that first incision? Dunno, but it certainly couldn't have hurt though.
This is a slightly different scenario than your average, garden variety I&D, however it makes me believe one can never to "too sterile" while performing any invasive procedures.
And just for the record: If it were me or my son, I'd prefer sterile gloves - please and thank you.
*
*
*
*
*
The good news? After reading the device an "event" had been captured and recorded in less than a week after insertion!

I had a patient who came in for something unrelated (forget what) and upon doing a skin check we found a wound where the ICD (that the patient was 100% dependent on) had migrated and eroded through the skin and was exposed. So it certainly can happen, even long after the device is implanted.

psu_213, BSN, RN · Aug 28, 2016

This is a slightly different scenario than your average, garden variety I&D, however it makes me believe one can never to "too sterile" while performing any invasive procedures.

First, I sincerely hope your BFF recovers fully and has her arrhythmia issues resolved.

However, there is more than just a slight difference between her situation and a routine I&D. With implanting a sterile device into a sterile space, of course it needs to be done with strict sterile technique. When draining a collection of pus, the area over the abscess should be cleaned and sterile instruments (i.e, scalpel) should be used, but any sterility is lost the moment the abscess is opened.

Dianna11 · Aug 28, 2016

Hi OP. I'm not an RN yet, just graduated, but I've had experience with I&D in fast track part of ED (in my clinicals). I've assisted the physicians with the culture, and it is indeed a sterile procedure. Otherwise they wouldn't have special kits for it.

Dianna11 · Aug 28, 2016

...Once the abscess is opened its non-sterile anyways.

At least we don't introduce other bacteria. Especially if you need to culture it. I don't know, like I said, I was taught that it is a sterile procedure.

Axgrinder · Aug 28, 2016

Comparing imbedded hardware closed with sutures to an I&D of an encapsulated abscess that is left open to drain is apples and oranges.

I'd still prefer the sterile gloves.

Libby1987 · Aug 28, 2016

What kind of bacteria do you suppose is introduced into the open abscess with a clean pair of gloves?

Do you all not properly store and don your clean gloves?

Dianna11 · Aug 28, 2016

What kind of bacteria do you suppose is introduced into the open abscess with a clean pair of gloves?
Do you all not properly store and don your clean gloves?

I do, but ive seen many not do it properly, as you probably have witnessed as well.

YoutubeTheNP · Aug 28, 2016

This should be an incident report. Don't let doc get away with it. He is supposed to know more than you do.

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