NEJM Abscess Incision and Drainage

Introduction

This tutorial provides a step-by-step guide for performing incision and drainage (I&D) of cutaneous abscesses, a common procedure in clinical medicine. Understanding this process is essential for medical interns and new doctors, as it is a primary treatment for managing localized infections. This guide will help you navigate the procedure safely and effectively.

Step 1: Diagnosis of Abscess

Accurate diagnosis is crucial before performing incision and drainage. You can diagnose a skin abscess through the following methods:

• Physical Examination: Look for swelling, pain, redness, and fluctuation in the affected area.
• Needle Aspiration: If physical examination results are unclear, needle aspiration can help confirm the presence of an abscess.
• Bedside Ultrasound: This can assist in identifying localized fluid collections under the skin.

An abscess should be considered for I&D if it is larger than 5 millimeters and accessible. Complex or deep abscesses may need to be treated in a surgical setting.

Step 2: Preparation for Procedure

Before beginning the procedure, gather all necessary materials:

• Anesthesia Supplies:
  • 1% Lidocaine (or Lidocaine with Epinephrine, avoid in areas with single blood supply)
  • Bupivacaine for longer action if required
• Incision Supplies:
  • Scalpel blade and handle
  • Curved hemostat
  • Normal saline and sterile bowl
  • Large syringe with splash guard or needleless 18-gauge angiocath
  • Gauze, tape, scissors, and wound packing material
• Infection Control:
  • Skin cleansing agent (chlorhexidine or povidone-iodine)
  • Gloves and face shield for protection

Obtain informed consent by discussing the risks, benefits, and potential complications.

Step 3: Conducting the Procedure

Follow these steps to perform the incision and drainage:

1. Position the Patient: Ensure the area for drainage is fully accessible.

2. Cleanse the Skin: Apply the skin cleanser in a circular motion from the peak of the abscess outward.

3. Anesthetize the Area:

   • Insert a 25 or 30 gauge needle parallel to the skin, injecting into the dermis.
   • Ensure blanching occurs, indicating proper anesthetic spread.
   • Additional injections may be necessary for larger abscesses.

4. Make the Incision:

   • Hold the scalpel firmly and make an incision over the center of the abscess, aligned with its long axis.
   • Apply steady pressure to penetrate the subcutaneous tissue.
   • Aim for a cosmetic incision by following skin tension lines.
   • Extend the incision adequately to prevent recurrent abscess formation.

5. Drain the Abscess:

   • Allow purulent drainage to flow out.
   • Gently express any remaining contents using additional local anesthetic if needed.

6. Explore the Cavity:

   • Use a curved hemostat for blunt dissection to break up loculations within the abscess cavity.
   • Continue until the cavity is fully explored and any deep tracts are identified.

7. Irrigate the Wound:

   • Gently irrigate using sterile normal saline until the effluent is clear.

8. Pack the Wound:

   • Begin packing with quarter-inch or half-inch strips, ensuring to keep the walls separated.
   • Avoid overpacking to prevent ischemia and promote adequate drainage.

Step 4: Post-Procedure Care

• Dressing: Cover the abscess with a sterile non-adherent dressing.
• Monitoring: Schedule a follow-up visit in 2-3 days to remove packing and assess healing.
• Patient Instructions: Advise the patient to return if symptoms worsen, such as increased pain or fever.

Conclusion

Incision and drainage of abscesses is a straightforward procedure that allows the body to heal without the need for antibiotics in most cases. This guide has provided essential steps and considerations for performing this procedure safely. Always remain vigilant for complications and follow local guidelines for managing infections. As you gain experience, you will become more proficient in managing similar cases effectively.