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Incision and Drainage of Abscesses

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Written by Archana Fernando   
Tuesday, 14 April 2009 22:57

Introduction to Incision and Drainage

  • I+D is the primary therapy for the management of cutaneous abcesses
  • Most localized skin abscesses can be managed with simple I+D and do not require antibiotics
  • General anaesthetic (GA) is required for large abscesses requiring extensive incision, debridemenet or irrigation. Also deep abscesses in sensitive areas (supralevator, ischiorectal, perirectal) require GA for proper exposure
Tip: Patients with anal or perianal abscesses should also have an examination under anaesthesia (EUA) - digital as well as with a rigid sigmoidoscope- looking for fistula or any evidence of inflammatory bowel disease.

Preparation

An appropriately consented and anaesthetized patient should be draped in order to expose the abscess.
If EUA is required then the patient should be placed in the lithotomy position.

Procedure

  • Incision - can be elliptical or cruciate and should be made over the most fluctuant point of the abscess.
  • Deroof abscess - remove skin (and any necrotic tissue) in order to leave a hole overlying the abscess.
  • Pus swab - take a swab from deep within the abscess and send off for microscopy, sensitivity and culture.
  • Explore the abscess cavity - use your finger or a curette to break down all loculi and evacuate as much of the pus as possible.
  • Irrigation - now you can wash out the abscess cavity using a large amount of normal saline. There is no evidence to support the use of one form of irrigation solution over another. The important thing is to use lots of irrigation.
  • Haemostasis - pressure alone should stop any bleeding. If you can see an obvious point of bleeding you can use diathermy.
  • Pack - loosely pack the abscess cavity from the bottom up using kaltostat or gauze making sure the opening in the skin remains wider than the base which should allow it to granulate from the bottom up. There are not any studies that compare different packing materials but loose packing is important to avoid significant discomfort and difficulty in changing dressings.

Post-op

  • Routine observation of heart rate, blood pressure and temperature
  • The patient can go home the same evening or the next day 1
  • Daily dressing change (by district nurse if necessary) until the packs become dry
  • Antibiotics are not usually required. Treatment with I+D alone leads to resolution without complications at the same rate (>90%) as patients treated with I+D and antibiotics 1,2
  • Takes approximately 4 - 6 weeks to heal
Tip: The principles for performing I+D with local anaesthesia are the same. The anaesthetic is most effective if infiltrated in the skin overlying and surrounding the abscess rather than directly into or under it.

 

  1. 1) A Hankin, L Everett et al. Are antibiotics Necessary after Incision and Drainage of A Cutaneous Abscess? Annals of Emergency Medicine. 2007; 6: 232-4
  2. 2) M Paydar, K J Hansen, F Charlebois et al. Inappropriate Antibiotic Use In Soft Tissue Infections. Arch Surgery. 2007; 141: 850-56
 

Comments  

 
-1 # Abdellatif El Alwany 2009-04-17 16:13
thanks for antibiotics advice and your effort.
I hope to include difficult situations as deep communicating abcess and how to deal with.
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-1 # kyaw kyawsoe 2009-04-26 17:28
thanks for your discription.
i prefer to aspirate before i & d for-
1. to confirm
2. to know the depth from skin
3.to send pus for c&s
i prefer to use antibiotics is case of sepsis , an d if there is surrounding cellulitis is present.
i use the linear or elliptical incisions for superficial one and cruciate + deroofing for deep abscess.
Hilton\'s method should also be used in cases of cosmetically important sites as well as if important structres are present near by.
thanks , with respect
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+1 # Dr.Gigi Joseph 2009-07-01 16:21
Good article.
Teach me how to extirpate a pre auricular sinus.
Dr.Gigi Joseph.S
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0 # Ahmed Adam 2010-05-28 17:28
thx
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0 # osama al shammari 2010-08-01 09:30
thans
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0 # Ramadan Shaker 2010-08-11 23:41
c&s mandatory for perianal abscess if abscess producing organism is of skin commensal no liability to fistulae
but if of gut it has liability to fistulae
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