Difference between revisions of "Incision and drainage"

(See Also)
 
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==Indications==
 
==Indications==
*Abscess of skin or superficial soft tissue
+
*[[Abscess]] of skin or superficial soft tissue
  
 
==Contraindications==
 
==Contraindications==
Line 24: Line 24:
  
 
==Procedure<ref name="NEJM" />==
 
==Procedure<ref name="NEJM" />==
 +
===Standard Technique===
 
''Sterile technique recommended, but not required''
 
''Sterile technique recommended, but not required''
  
*Cleanse skin overlying and surrounding abscess site with chlorhexidine or Iodine
+
*Cleanse skin overlying and surrounding [[abscess]] site with chlorhexidine or Iodine
 
*Anesthetize skin of planned incision site
 
*Anesthetize skin of planned incision site
 
**Local anesthesia
 
**Local anesthesia
Line 32: Line 33:
 
**Regional block
 
**Regional block
 
**In some cases, [[procedural sedation]] may be indicated
 
**In some cases, [[procedural sedation]] may be indicated
*Make a linear incision (along skin tension lines) over the center of the abscess cavity
+
*Make a linear incision (along skin tension lines) over the center of the [[abscess]] cavity
**Advance depth until abscess cavity entered
+
**Advance depth until [[abscess]] cavity entered
 
**Ensure incision is large enough to accommodate drainage and introduction of forceps/hemostat
 
**Ensure incision is large enough to accommodate drainage and introduction of forceps/hemostat
 
*Manually express contents
 
*Manually express contents
 
*Introduce hemostat and bluntly dissect to break up loculations
 
*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>
 
*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==
 
==Complications==
Line 47: Line 60:
 
==Follow-up==
 
==Follow-up==
 
*Wound check in 1-2 days.
 
*Wound check in 1-2 days.
*[[Antibiotics]] only indicated if overlying cellulitis or 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>, or 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>
+
*Warm soaks to help facilitate ongoing drainage
**Cover [[staph]] and [[strep]]
+
*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]]
  
 
==References==
 
==References==
 
<references/>
 
<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
 
  
[[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