Difference between revisions of "Incision and drainage"

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==Background==
+
==Indications==
 +
*[[Abscess]] of skin or superficial soft tissue
  
==Diagnosis==
+
==Contraindications==
#[[Ultrasound: Soft tissue|Ultrasound can be helpful]]
+
*No absolute contraindications
#Needle aspiration
 
#Check: Blood Glucose, IV drug use (XR r/o needle), consider HIV counseling/testing
 
  
==Differential Diagnosis==
+
*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>:
{{Template:SSTI DDX}}
+
**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)
  
==Treatment==
+
==Equipment Needed==
#[[Antibiotics]]
+
*PPE
##Give if there is a large cellulitic component or [[fever]], multiple sites, young or advanced age, abscess in area difficult to drain, associated septic phlebitis, and failure with I&D alone
+
*Local anesthetic
##Need to cover [[staph]] and [[strep]]
+
*Incision and Drainage Tray:
##Preprocedure abx for pt with high risk cardiac lesions
+
**Scalpel
#Update [[Tetanus]]
+
**Hemostat
#MRSA decolonization for pts with recurrent skin infections
+
**Forceps
##Nasal mupirocin+chlorhexidine body wash+/-oral anti-MRSA abx for 5-10 days
+
**Gauze
 +
**Drape / towel
 +
**Iodine swabs
  
===Incision & Drainage===
+
{{Maximum doses of anesthetic agents}}
#Be sure to document if packing was placed in the wound
 
#Anesthesia should be [[lidocaine]] or Marcaine without epinephrine
 
#Most patients need some pain medicine prior to procedure
 
  
*Beware of toxic dose of [[lidocaine]]!
+
==Procedure<ref name="NEJM" />==
*Lido lasts 30-90 min, bupivicaine (.25%) max= 2mg/kg lasts 6-8 hr. Do NOT inject bupivicaine intravascularly b/c= refractory cardiac arrest!!!
+
===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.<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>
 +
 
 +
''Irrigation of [[abscess]] cavity has no benefit<ref>[[EBQ:Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success]]</ref>
 +
 
 +
===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. <ref>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.</ref>
 +
 
 +
==Complications==
 +
*Damage to surrounding structures
 +
*Progression of infection
 +
*Transient bacteremia
  
 
==Follow-up==
 
==Follow-up==
Wound check in 1-2 days and wound care sheet
+
*Wound check in 1-2 days.
 +
*Warm soaks to help facilitate ongoing drainage
 +
*7-day course of [[Trimethoprim–Sulfamethoxazole]] for all abscesses post incision and drainage (to prevent treatment failure)<ref>Talan DA, et al. Trimethoprim–Sulfamethoxazole versus placebo for uncomplicated skin abscess. NEJM. 2016; 374(9):823-832.</ref>
 +
**Previously [[antibiotics]] were indicated only for 1) overlying cellulitis; 2) evidence of systemic infection<ref>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.</ref>; for immunosuppressed patients; or [[abscess]] that does not respond to standard treatment <ref>Singer A, Talan D. Management of Skin Abscesses in the Era of Methicillin-Resistant Staphylococcus aureus. N Engl J Med 2014; 370:1039-1047</ref>
  
 
==See Also==
 
==See Also==
 +
*[[Abscess]]
 
*[[Lidocaine]]
 
*[[Lidocaine]]
 
*[[Bartholin Gland Abscess]]
 
*[[Bartholin Gland Abscess]]
 +
*[[EBQ:Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success]]
  
==Source==
+
==References==
*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
+
<references/>
*Singer A, Talan D. Management of Skin Abscesses in the Era of Methicillin-Resistant Staphylococcus aureus. N Engl J Med 2014; 370:1039-1047
 
 
 
  
[[Category:Derm]]
+
[[Category:Dermatology]]
 
[[Category:ID]]  
 
[[Category:ID]]  
 
[[Category:Procedures]]
 
[[Category:Procedures]]

Latest revision as of 20:34, 29 April 2020

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
  • 1% soln contains 10 mg/ml
  • 2% soln contains 20 mg/ml
Mepivicaine 7 mg/kg 8 mg/kg
Bupivicaine 2.5 mg/kg (max 175mg) 3 mg/kg (max 225mg) 6-8 hr
  • 0.5% soln contains 5 mg/ml
  • May cause cardiac arrest if injected intravascularly
  • Do not buffer with bicarbonate
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.
  • Warm soaks to help facilitate ongoing drainage
  • 7-day course of Trimethoprim–Sulfamethoxazole for all abscesses post incision and drainage (to prevent treatment failure)[6]
    • Previously antibiotics were indicated only for 1) overlying cellulitis; 2) evidence of systemic infection[7]; for immunosuppressed patients; or abscess that does not respond to standard treatment [8]

See Also

References

  1. 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.
  2. 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
  3. 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.
  4. EBQ:Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success
  5. 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.
  6. Talan DA, et al. Trimethoprim–Sulfamethoxazole versus placebo for uncomplicated skin abscess. NEJM. 2016; 374(9):823-832.
  7. 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.
  8. Singer A, Talan D. Management of Skin Abscesses in the Era of Methicillin-Resistant Staphylococcus aureus. N Engl J Med 2014; 370:1039-1047