What is the recommended technique for incision and drainage of an abscess in the Emergency Room (ER)?

Recommended Technique for Abscess Incision and Drainage in the Emergency Room

The primary treatment for abscesses in the emergency room is surgical incision and drainage, which should be performed as close as possible to the site of maximal fluctuance to ensure complete drainage of all loculations while avoiding sphincter damage in perianal cases. 1, 2

Preparation and Anesthesia

• Patient positioning: Position based on abscess location (prone for perianal/sacrococcygeal, supine or lateral for others)
• Anesthesia options:
  • Simple, small abscesses (<5 cm): Local anesthesia (1% lidocaine with epinephrine)
  • Alternative technique for painful areas: Aspirate small amount of pus first, then inject anesthetic into abscess cavity through same needle 3
  • Complex or large abscesses: Consider procedural sedation or regional anesthesia
  • Severe or deep abscesses: May require general anesthesia

Incision and Drainage Procedure

1. Skin preparation: Clean with antiseptic solution (chlorhexidine or povidone-iodine)

2. Incision technique:

   • Make incision over point of maximal fluctuance
   • For perianal abscesses: Keep incision as close as possible to anal verge to minimize potential fistula length 1
   • Incision should be adequate to allow complete drainage (typically 1-2 cm)
   • Use scalpel (#11 blade preferred) to make a linear incision through skin and into abscess cavity

3. Drainage and exploration:

   • Express all purulent material with gentle pressure
   • Break up loculations with blunt finger dissection or hemostat
   • Explore cavity to ensure complete drainage and identify potential fistulas
   • Irrigate cavity with sterile saline until clear

4. Wound management:

   • Leave wound open to allow continued drainage
   • For perianal/perineal abscesses: No clear recommendation exists regarding packing 1
   • For other abscesses >5 cm: Consider packing to prevent premature closure 4
   • Alternative: Place drain if abscess is complex or has multiple loculations

Special Considerations

• Timing of drainage:

  • Emergent (immediate): Patients with sepsis/septic shock, immunocompromised patients, diabetics, or diffuse cellulitis 2
  • Urgent (within 24 hours): Cases without above factors 2

• Fistula management (perianal abscesses):

  • Low fistula not involving sphincter muscle: Consider fistulotomy during same procedure 1
  • Fistula involving sphincter muscle: Place loose draining seton 1
  • No obvious fistula: Avoid probing to prevent iatrogenic complications 1

• Antibiotic therapy:

  • Not routinely indicated for simple drained abscesses
  • Consider antibiotics for: sepsis, surrounding cellulitis, immunocompromised patients 1, 2
  • For perineal abscesses requiring antibiotics: Use broad-spectrum coverage including anaerobes 2

Follow-up Care

• Schedule follow-up within 48-72 hours to assess:
  • Response to treatment
  • Adequacy of drainage
  • Need for additional interventions
• Provide wound care instructions:
  • Regular cleaning with soap and water
  • Warm soaks or sitz baths (for perianal abscesses) 2-3 times daily
  • Signs of recurrence or complications requiring immediate attention

Common Pitfalls and Caveats

1. Inadequate drainage: Most common cause of recurrence (recurrence rates up to 44%) 1

   • Ensure complete breakup of all loculations
   • Make incision large enough for adequate drainage

2. Needle aspiration alone: Inadequate treatment with 41% recurrence vs. 15% with proper incision and drainage 2

3. Delayed treatment: Increases risk of recurrence and complications 1, 2

4. Failure to identify complex abscesses: Consider imaging (MRI, ultrasound, CT) for atypical presentations or suspected complex abscesses 1, 2

5. Pain management: Inadequate anesthesia leads to incomplete drainage; consider alternative techniques like aspiration-injection for painful areas 3