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Incision and drainage
From WikEM
(Redirected from I+D)
Contents
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]
Standard Technique
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
- Packing with iodoform gauze may be performed (goal is to prevent premature wound closure), however evidence indicates that packing is not necessary.[2][3]
Irrigation of abscess cavity has no benefit[4]
LOOP Technique
- Incise at most fluctuant area of abscess
- Incise second location <4cm from original incision
- For larger abscesses can repeat this step thus creating several LOOPs.
- Break-up loculations with hemostat
- Irrigate wound
- Pass hemostat through both incisions and pull penrose through
- Tie penrose drain loosely over 30cc syringe to form LOOP
- Patient can follow up with primary care provider or cut in 5-7 days
- Retrospective study showed decreased failure rate in LOOP technique vs standard I&D. [5]
Complications
- Damage to surrounding structures
- Progression of infection
- Transient bacteremia
Follow-up
- Wound check in 1-2 days.
- Antibiotics were indicated if overlying cellulitis or evidence of systemic infection[6], or for immunosuppressed patients or abscess that does not respond to standard treatment [7]
- New evidence suggest that a 7-day course of Trimethoprim–Sulfamethoxazole will prevent treatment failure[8]
See Also
- Lidocaine
- Bartholin Gland Abscess
- EBQ:Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success
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.
- ↑ EBQ:Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success
- ↑ Ladde JG, et al. The LOOP technique: a novel incision and drainage technique in the treatment of skin abscesses in a pediatric ED. Am J Emerg Med. 2015 Feb;33(2):271-6.
- ↑ 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
- ↑ Talan DA, et al. Trimethoprim–Sulfamethoxazole versus placebo for uncomplicated skin abscess. NEJM. 2016; 374(9):823-832.
