Incision and drainage: Difference between revisions
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*No absolute contraindications | *No absolute contraindications | ||
*Abscesses that may require OR management or specialist consultation include<ref>Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M. Abscess incision and drainage. N Engl J Med. 2007 Nov 8;357(19):e20.</ref>: | *Abscesses that may require OR management or specialist consultation include<ref name="NEJM">Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M. Abscess incision and drainage. N Engl J Med. 2007 Nov 8;357(19):e20.</ref>: | ||
**Large or deep abscesses that are difficult to access or anesthetize | **Large or deep abscesses that are difficult to access or anesthetize | ||
**Abscesses of the palms, soles, or nasolabial folds | **Abscesses of the palms, soles, or nasolabial folds | ||
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{{Maximum doses of anesthetic agents}} | {{Maximum doses of anesthetic agents}} | ||
==Procedure== | ==Procedure<ref name="NEJM" />== | ||
''Sterile technique recommended, but not required'' | |||
*Cleanse skin overlying and surrounding abscess site with chlorhexidine or Iodine | |||
*Anesthetize skin of planned incision site | |||
**Local anesthesia | |||
**Field block | |||
**Regional block | |||
**In some cases, [[procedural sedation]] may be indicated | |||
*Make a linear incision (along skin tension lines) over the center of the abscess cavity | |||
**Advance depth until abscess cavity entered | |||
**Ensure incision is large enough to accommodate drainage and introduction of forceps/hemostat | |||
*Manually express contents | |||
*Introduce hemostat and bluntly dissect to break up loculations | |||
*Irrigate abscess cavity with saline | |||
*Packing with iodoform gauze may be performed (goal is to prevent premature wound closure), however evidence indicates that packing is not necessary.<ref>Kessler DO, Krantz A, Mojica M. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department. Pediatr Emerg Care. 2012 Jun;28(6):514-7</ref><ref>O'Malley GF, Dominici P, Giraldo P, Aguilera E, Verma M, Lares C, Burger P, Williams E. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med. 2009 May;16(5):470-3.</ref> | |||
==Complications== | ==Complications== | ||
*Damage to surrounding structures | |||
*Progression of infection | |||
*Transient bacteremia | |||
==Follow-up== | ==Follow-up== | ||
Revision as of 04:15, 23 June 2015
Indications
- Abscess of skin or superficial soft tissue
Contraindications
- No absolute contraindications
- Abscesses that may require OR management or specialist consultation include[1]:
- Large or deep abscesses that are difficult to access or anesthetize
- Abscesses of the palms, soles, or nasolabial folds
- Areas in which cosmesis is important (face, breast)
Equipment Needed
- PPE
- Local anesthetic
- Incision and Drainage Tray:
- Scalpel
- Hemostat
- Forceps
- Gauze
- Drape / towel
- Iodine swabs
Maximum Doses of Anesthetic Agents
| Agent | Without Epinephrine | With Epinephrine | Duration | Notes |
| Lidocaine | 5 mg/kg (max 300mg) | 7 mg/kg (max 500mg) | 30-90 min |
|
| Mepivicaine | 7 mg/kg | 8 mg/kg | ||
| Bupivicaine | 2.5 mg/kg (max 175mg) | 3 mg/kg (max 225mg) | 6-8 hr |
|
| Ropivacaine | 3 mg/kg | |||
| Prilocaine | 6 mg/kg | |||
| Tetracaine | 1 mg/kg | 1.5 mg/kg | 3hrs (10hrs with epi) | |
| Procaine | 7 mg/kg | 10 mg/kg | 30min (90min with epi) |
Procedure[1]
Sterile technique recommended, but not required
- Cleanse skin overlying and surrounding abscess site with chlorhexidine or Iodine
- Anesthetize skin of planned incision site
- Local anesthesia
- Field block
- Regional block
- In some cases, procedural sedation may be indicated
- Make a linear incision (along skin tension lines) over the center of the abscess cavity
- Advance depth until abscess cavity entered
- Ensure incision is large enough to accommodate drainage and introduction of forceps/hemostat
- Manually express contents
- Introduce hemostat and bluntly dissect to break up loculations
- Irrigate abscess cavity with saline
- Packing with iodoform gauze may be performed (goal is to prevent premature wound closure), however evidence indicates that packing is not necessary.[2][3]
Complications
- Damage to surrounding structures
- Progression of infection
- Transient bacteremia
Follow-up
- Wound check in 1-2 days.
- Antibiotics only indicated if overlying cellulitis or evidence of systemic infection[4], or for immunosuppressed patients or abscess that does not respond to standard treatment [5]
See Also
References
- ↑ 1.0 1.1 Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M. Abscess incision and drainage. N Engl J Med. 2007 Nov 8;357(19):e20.
- ↑ Kessler DO, Krantz A, Mojica M. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department. Pediatr Emerg Care. 2012 Jun;28(6):514-7
- ↑ O'Malley GF, Dominici P, Giraldo P, Aguilera E, Verma M, Lares C, Burger P, Williams E. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med. 2009 May;16(5):470-3.
- ↑ Fahimi J, Singh A, Frazee BW. The role of adjunctive antibiotics in the treatment of skin and soft tissue abscesses: a systematic review and meta-analysis. CJEM. 2015 Feb 20:1-13.
- ↑ Singer A, Talan D. Management of Skin Abscesses in the Era of Methicillin-Resistant Staphylococcus aureus. N Engl J Med 2014; 370:1039-1047
- Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011;52:e18-e55