INCISION AND DRAINAGE

DR.MATHISEKARAN.T

TMCH,Thanjavur

ABSCESS
Abscesses are localized infections of tissue marked by a collection of pus surrounded by inflamed tissue. Found in any area of the body,most abscesses presenting for urgent attention are found on the extremities, buttocks, breast, perianal area, or from a hair follicle.

ABSCESS
Abscesses begin when the normal skin barrier is breached, and microorganisms invade the underlying tissues.

Causative organisms commonly include Streptococcus, Staphylococcus, enteric

 It is an old axiom of medicine that pus collections must be drained for healing to occur. Carbuncles are aggregates of infected follicles. Cellulitis may precede or occur in conjunction with an abscess. An abscess is not a hollow sphere; it is a cavity formed by finger-like loculations of granulation tissue and pus that extends outward along planes of least resistance. A paronychia is a localized

 SMALL ABSCESS <5mm resolve by conservative measures (warm soaks) Larger abscesses will require incision to drain them, as the increased inflammation, pus collection, and walling off of the abscess cavity diminish the effectiveness of conservative measures.

 Abscesses may follow one of two courses. The abscess may remain deep and slowly reabsorb. Alternatively, the overlying epithelium may attenuate (i.e., pointing), allowing the abscess to spontaneously rupture to the surface and drain

Diagnosis
A localized area that is erythematous, tender, fluctuant and indurated likely represents a cutaneous abscess and may be a candidate for I&D.

If in doubt:
needle aspiration USG of the suspected lesion

Indications
An abscess that is not spontaneously resolving
Staphyloccal Disease Hidradenitis Suppurativa Breast Abscess Bartholin Gland Abscess Pilonidal Abscess Infected Sebaceous Cyst

Consider more aggressive therapy, closer observation, wound culture, and antibiotic therapy in patients with diabetes debilitating disease, compromised immunity facial abscesses located within the triangle formed by the bridge of the nose and the corners of the mouthrisk of septic

Caution and contraindications

 Size If an abscess is identified and thought to be too large, too deep or crosses/concerning vital structures. Location It can be difficult to estimate the size and depth of a peri-rectal or peri-anal abscess. Systemic risks-spillage into body cavitybacteremia Artificial valvesprophylactic antibiotics Cosmesistrained hands

Equipments
: Many commercially available suture kits will have the basic equipment to aid in the performance of an I&D. Here is what is essential. Universal precaution items Skin cleansing agent Needle and syringe for local anesthesia (small gauge needle 25g)

 Needle and 18g angiocath for irrigation with NSS

Culture swabs Curved hemostats Gauze for packing (1/4 or inch) medicated or plain Scissors

Preparation
Informed consent Patient Comfort: this procedure requires the use of a scalpel, blunt dissection and manipulation of an inflamed area.Analgesia is important. Local anesthesia:pitfall being LA wont act in acidic medium.

 Local field block Oral or parenteral pain medication (narcotic) or anxiolytics Wound cleansing: Be sure to prepare the wound with a commercially available skin preparation to limit the introduction of bacteria.

Procedure

 The abscess is ready for drainage when the skin has thinned and the underlying mass becomes soft and fluctuant (i.e., pointing).

Local anesthetic

Prep and drape the area in a sterile fashion. Administer a field block with local anesthetic .The skin overlying the top of the abscess also is anesthetized. Avoid injecting into the abscess cavity, because local anesthetics usually work poorly in the acidic milieu of an abscess

Incision
A no. 11 surgical blade is inserted and drawn parallel to the lines of lesser skin tension, creating an opening from which PITFALL: Abscesses can explode upward on pus may be expressed . entry. Wear protective eyewear if the abscess contents appear to be an under pressure Often, up-and-down incision with the no. 11 blade is adequate. Avoid extending the incision into non-effaced skin. Apply pressure around the abscess to expel pus from the

 Insert a probe, cotton-tipped applicator, hemostats, or curette through the opening, and draw it back and forth to break adhesions and dislodge necrotic tissue. If a culture is desired, obtain it from deep in the abscess cavity.

Cavity large enoughpack it with a ribbon of plain or iodoform gauze to promote drainage and prevent premature closure. Grasp the end of the ribbon with a pair of forceps, and place it through the incision to the base on the abscess . Fold additional ribbon into the cavity until it is filled. Leave approximately 1 to 2 cm of gauze on the surface of the skin.

Post opperative care

Simple abscesses usually require no antibiotics MRSA (Community Aquired) This has become a very prevalent microbe in many communities Culture all wounds Consider antibiotic coverage (Bactrim or CLindamycin) if MRSA infections are common in the community

 Pain Management With adequate drainage, patients will be dramatically improved at their 2 day follow-up visit. Consider narcotic pain management for 2 days At their 2 day wound check, if your patient still remains in significant pain, this may be an indication of inadequate drainage

Wound Check 2 days post procedure Remove packing If patient feels better and wound has minimal to no pus drainage, do not repack If still draining, change packing and revisit in 2 days Once packing is OK to stay out, let wound heal by secondary intention

Complications
Progression of abscess or to a cellulitis Bleeding and damage to adjacent structures Bacteremia Misdiagnosis (mycotic aneurysms) Pain and scar formation Consider additional drainage Consider antibiotics

THANKS FOR YOUR VALU