Abscess incision and drainage

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Incision and drainage (I&D) is a procedure used to drain pus from skin and soft tissue abscesses; it can be performed in both adults and children. This article describes bedside I&D, which should not be performed for abscesses that warrant surgical consultation such as those located near important structures (e.g., nerves, arteries) or in areas of cosmetic concern (e.g., face, breast). During the procedure, an incision is made into the overlying tissue to facilitate pus drainage. Abscess irrigation and packing may be performed after I&D, however, there is limited evidence to support their use. Complications include damage to surrounding structures and abscess recurrence.

For specific considerations regarding abscesses of the Bartholin glands, see “Bartholin gland abscess.”

• Fluctuant abscess > 5 mm in diameter that is accessible by percutaneous incision ^[2]

Do not perform I&D in the absence of fluctuance: Premature incision before abscess formation may cause extension of the infectious process. ^[3]

Most skin and soft tissue abscesses can be drained at the bedside, but the following findings may indicate the need for a surgical consult: ^[2][4]

• Abscess features
  • Large abscess (e.g., > 5 cm)
  • Complicated abscess (e.g., multiple abscesses, recurrent abscess, extension into deeper tissues)
• Abscess location
  • Close proximity to important structures (e.g., nerves, arteries, tendons)
  • Area of cosmetic concern (e.g., face, breast)
  • Perirectal or periurethral
• Patient factors
  • Coagulopathy
  • Inability to achieve adequate anesthesia

We list the most important contraindications. The selection is not exhaustive.

Incision and drainage

• PPE (mask, gloves, eye shield)
• Surgical drapes
• Antiseptic solution
• Local anesthetic (e.g., 1% lidocaine)
• Syringe with 25-gauge needle
• Scalpel with a No. 11 or No. 15 blade
• Clamp (e.g., hemostat)
• Gauze pads
• Culture swab (if indicated)
• Absorbent dressing

Abscess irrigation

• Sterile normal saline
• Syringe with needleless 18-gauge angiocatheter OR splash cap

Abscess packing

• Ribbon gauze (e.g., ¼ inch, ½ inch)
• Forceps
• Scissors

• Obtain informed consent.
• Identify the abscess by palpating for fluctuance.
• Consider using POCUS to identify and locate the abscess cavity. ^[5]
  • Technique: See “Soft tissue POCUS.”
  • Findings: Abscesses typically have a hypoechoic or heterogenous appearance and are characterized by posterior enhancement.
• Provide endocarditis prophylaxis, if indicated.
• Place the patient in a position that allows for easy access.
• Consider parenteral analgesia.
• Prep the skin and place drapes.
• Don PPE.

This procedure can be performed in both adults and children.

Anesthesia ^[3]

Multiple anesthetic options are available for I&D; the method used depends on abscess characteristics (e.g., size, location) and physician and patient preferences.

• Peripheral nerve block
• Field block
• Infiltration anesthesia of the abscess dome
• Topical anesthesia

Avoid injecting local anesthetic into the abscess cavity, as this can result in increased pain due to tissue distention or bacterial infiltration into healthy tissue.

Incision and drainage ^[2][3]

1. Provide local or regional anesthesia.
2. Make a linear incision across the length of the abscess with a scalpel.
3. Allow pus to drain.
4. Consider obtaining a sample for culture. ^[6][7][8]
5. Perform blunt dissection of the abscess cavity using a clamp to break up loculations.
6. Consider abscess irrigation.
7. Consider abscess packing.
8. Cover the incision with an absorbent dressing.

Irrigation and packing ^[2]

Both irrigation and packing are often described as part of the I&D procedure, however, evidence that these techniques improve outcomes is lacking. ^[9][10][11]

Abscess irrigation

1. Irrigate the wound with sterile normal saline.
2. Continue irrigation until the outflow runs clear.

Abscess packing

1. Insert the end of the ribbon gauze into the cavity using forceps.
2. Advance the ribbon gauze until the cavity is loosely packed.
3. Leave a short tail of ribbon gauze outside the cavity.

• Pain ^[3]
  • Avoid injecting into the abscess cavity, as this may further distend the cavity.
  • Provide additional local anesthesia prior to blunt dissection.
  • Consider a multimodal approach to pain management, e.g., parenteral analgesia, procedural sedation.
• Self-contamination: Use adequate PPE.
• Inadequate drainage
  • Ensure the incision spans the length of the abscess.
  • Verify that loculations have been fully broken up with blunt dissection.
  • Consider the presence of a foreign body.

• Antibiotics for purulent SSTIs prescribed, if indicated
• Wound care discussed
• Return precautions discussed
• Primary care physician follow-up 24–48 hours postprocedure arranged

• Damage to surrounding structures (e.g., nerves, arteries)
• Recurrence
• Progression of infection (e.g., osteomyelitis, necrotizing fasciitis)

We list the most important complications. The selection is not exhaustive.