Is a small horizontal incision at the area of maximal fluctuance for Incision and Drainage (I&D) gross negligence?

From the Guidelines

No, making a small horizontal incision at the area of maximal fluctuance for Incision and Drainage (I&D) is not gross negligence, but rather a standard approach for treating abscesses. When performing an I&D, the area of maximal fluctuance represents the point where the abscess is closest to the skin surface and contains the most fluid, making it the optimal location for drainage 1. The procedure should include adequate local anesthesia, proper sterile technique, complete drainage of the abscess cavity, breaking up of loculations if present, and consideration of specimen collection for culture. Following the procedure, the wound may be packed lightly or left to heal by secondary intention, and patients should receive appropriate pain management and follow-up care. This approach is consistent with standard medical practice for treating abscesses and aims to resolve infection while minimizing scarring and preserving tissue function. According to the Infectious Diseases Society of America guidelines, incision and drainage is the primary treatment for cutaneous abscesses, and antibiotics may be recommended in certain cases, such as severe or extensive disease, or when there are signs of systemic illness 1. However, the use of antibiotics should be individualized based on the patient's clinical response and the results of culture and sensitivity testing. In general, a small horizontal incision at the area of maximal fluctuance is a reasonable and standard approach for I&D, and is not considered gross negligence.

Some key points to consider when performing an I&D include:

• The use of adequate local anesthesia to minimize pain and discomfort
• Proper sterile technique to reduce the risk of infection
• Complete drainage of the abscess cavity to prevent recurrence
• Breaking up of loculations if present to ensure complete drainage
• Consideration of specimen collection for culture to guide antibiotic therapy
• Appropriate pain management and follow-up care to ensure optimal outcomes. It's also important to note that the management of abscesses may vary depending on the location, size, and severity of the abscess, as well as the patient's overall health status. Therefore, it's essential to individualize treatment and consider the latest guidelines and evidence-based practices when managing patients with abscesses 1.

From the Research

Incision and Drainage (I&D) Procedure

• The standard of care for skin abscesses is Incision and Drainage (I&D) 2
• A small horizontal incision at the area of maximal fluctuance is a common approach for I&D
• However, there is no direct evidence in the provided studies to suggest that this approach is considered gross negligence

Management of Skin and Soft Tissue Infections

• The Infectious Diseases Society of America (IDSA) has published guidelines for the management of Skin and Soft Tissue Infections (SSTI) 3
• The guidelines recommend I&D for abscesses, but the decision to hospitalize and choice of antibiotics may vary depending on the severity of the infection
• A study found that treatment fully complied with guidelines in only 20.1% of cases, highlighting the need for ongoing education and review of published guidelines 3

Role of Antibiotics in I&D

• Current evidence does not support prescribing oral antibiotic agents after surgical debridement of cutaneous abscesses 4
• A prospective study found that antibiotic agents are not necessary for uncomplicated subcutaneous abscesses after I&D, and these cases can be managed safely on an outpatient basis without any increase in morbidity 4

Incision Choices in Surgical Procedures

• Incision planning is a critical factor in nipple-sparing mastectomy outcomes, and different incision types may have varying rates of major ischemic complications 5
• A study found that inframammary and inverted-T incisions are associated with a higher risk of major ischemic skin envelope complications after nipple-sparing mastectomy and immediate microvascular breast reconstruction 5

Diagnosis of Abscess using Point-of-Care Ultrasound

• Point-of-care ultrasound (POCUS) can be useful in identifying abscesses in ED patients with Skin and Soft Tissue Infections (SSTI) 6
• A systematic review found that POCUS has a high sensitivity and specificity for diagnosing abscesses, and can assist physicians in distinguishing abscess from cellulitis 6