What?

An abscess refers to a warm, fluctuant nodule with localized erythema caused by a bacterial infection (e.g., methicillin-resistant staphylococcus aureus) with induration and a collection of pus as a result of a break in the epithelium. Incision and drainage technique is an effective method to drain purulent accumulation for skin abscesses. Diagnosis of an abscess is made by physical examination in primary care settings. A bedside ultrasound can be used to delineate between an abscess that requires drainage and a simple cellulitis.

Why?

The proper incision and drainage method is essential for treating and managing a large, fluctuant abscess to promote healing and optimal outcomes.

How?

Pre-Procedure Steps

Prescribe prophylactic antibiotics for patients with high-risk comorbidities such as infective endocarditis, cardiac transplant, and those with prosthetic valves.

Supplies

• Anesthetic agents (lidocaine, lidocaine with epinephrine, bupivacaine)
• Antiseptic agent (Hibiclens®, chlorhexidine, betadine)
• Needle
• Syringes
• Personal protective equipment (mask, eye shield, and gloves)
• #11 scalpel blade
• 4 X 4 gauze pads
• Curved hemostat
• Scissors
• Tissue forceps
• Irrigation solution (normal saline)
• Packing ribbon
• Tape

Procedure Steps

• Wear personal protective equipment: mask and clean gloves.
• Cleanse the affected area with betadine or Hibiclens®.
• Anesthetize overlying skin with (Lidocaine and epinephrine) on the wound margins.
• Make an incision across the abscess with a number # 11 scalpel blade (Figure 3.15).
• Ensure the incision is deep and wide enough to prevent closure during the procedure.
• Probe the incision with hemostats at different directions to break the loculation.
• Drain the purulent discharge and obtain a culture.
• Irrigate with normal saline.
• Insert packing gauze loosely to avoid premature closure, and leave a 2cm tail.
• Apply dressing.

Post-Procedure Steps

• Educate the patient to change the dressing daily, apply a warm compress to encourage further drainage, and take over-the-counter analgesics.

• Prescribe antibiotics in combination with incision and drainage to improve patient outcomes. Evidence-based recommendations conclude that the use of a systemic antibiotic (such as trimethoprim/sulfamethoxazole [TMX-SMP], clindamycin, or doxycycline) with incision and drainage decreases the chances of reoccurrence and treatment failure.

• Follow up with patient in 1-3 days for reassessment to ensure procedure was successful.

Clinical Check point

• To prevent additional pressure and pain at the abscess site, do not inject anesthetic directly into the abscess. 
• Incision and drainage should not be performed on a deep-tissue infection, superficial infection (small abscesses), hidradenitis suppurativa, or on patients who are immunocompromised. 
• Be aware that incision and drainage are contraindicated for large or complex abscesses or sensitive areas such as the hand, breast, genitalia, and areas close to major blood vessels. Referral to general or specialty surgery is necessary for these patients. 
• For recurrent abscesses, suspect osteomyelitis, fungi, septic arthritis, retained foreign body, or undiagnosed diabetes and treat accordingly.