What are the steps for incision and drainage (I&D) of an abscess?

From the Guidelines

Incision and drainage (I&D) of an abscess involves several key steps, starting with obtaining informed consent and gathering necessary supplies, including sterile gloves, antiseptic solution, local anesthetic, scalpel, hemostats, gauze, and culture swabs, as recommended by recent guidelines 1. The process begins with cleaning the area with antiseptic solution such as chlorhexidine or povidone-iodine. Administering local anesthetic (typically 1% lidocaine with or without epinephrine) around the periphery of the abscess is crucial, avoiding direct injection into the abscess cavity which can spread infection. Once anesthesia takes effect, making a linear incision with a #11 blade scalpel along the area of maximal fluctuance or the skin tension lines is the next step. The incision should be large enough to allow adequate drainage but avoid excessive tissue damage. Expressing the purulent material by applying gentle pressure and collecting a sample for culture is essential for identifying the causative organism. Breaking up any loculations using a hemostat or finger to ensure complete drainage is also vital. Irrigating the cavity with sterile saline to remove remaining debris helps in reducing the bacterial load. For simple abscesses, packing with iodoform gauze may be necessary to prevent premature closure and allow continued drainage; this should be changed every 24-48 hours until the cavity begins to heal. Applying a sterile dressing over the wound and prescribing appropriate pain medication such as acetaminophen or NSAIDs are important for patient comfort and wound healing. Antibiotics should be considered only if there is surrounding cellulitis, systemic symptoms, or immunocompromise, as suggested by the guidelines 1. I&D is effective because it physically removes the collection of pus that contains bacteria, inflammatory cells, and debris, allowing the immune system to better manage any remaining infection and promoting healing from the inside out.

Some key considerations include:

• The timing of surgery, which should be based on the presence and severity of sepsis 1.
• The use of wound packing after drainage, which remains unproven and should be left to individual unit policy and patient discussion 1.
• The importance of complete and accurate drainage of the abscess to minimize the risk of recurrence 1.
• The need for a surgical approach with incision and drainage in patients with anorectal abscess, as recommended by strong evidence 1.

Overall, the goal of I&D is to provide adequate drainage, promote healing, and prevent complications, while also considering the individual patient's needs and circumstances.

From the Research

Steps for Incision and Drainage (I&D) of an Abscess

• The standard treatment for soft tissue abscesses is incision and drainage (I&D) 2, 3, 4, 5, 6
• I&D can be performed in an ambulatory office or emergency department setting 2, 5
• The procedure typically involves making a surgically appropriate incision to allow adequate drainage without injuring important structures 5
• Local anesthesia is generally used, with intraoperative and postoperative systemic analgesia as needed 5
• Postoperative care includes warm soaks, drains or wicks, analgesia, and close follow-up 5
• Antibiotics are usually unnecessary, but may be considered in certain cases, such as in immunocompromised patients or in the presence of high-risk features 2, 4, 5

Wound Packing and Post-Procedural Care

• Wound packing may not be necessary for all abscesses, and may actually increase pain and discomfort for patients 4, 6
• A high-vacuum wound drainage system may be a safe and efficient alternative to traditional I&D and wound packing 6
• This system has been shown to reduce pain and length of treatment for pediatric soft tissue abscesses 6
• Primary suturing of the wound and placement of a high-vacuum wound drainage system may also be an effective treatment option 6

Special Considerations

• Abscesses at specific locations may require special consideration for diagnosis and treatment, and may require specialty consultation 5
• The infectious agents responsible for abscess formation can vary depending on the anatomic location of the abscess 5
• Staphylococcus aureus and anaerobic bacteria are common etiologic agents of cutaneous abscesses 5