What is the procedure for an incision and drainage (I&D) of an abscess?

Incision and Drainage (I&D) of Abscess Procedure Note

The standard procedure for incision and drainage of an abscess involves surgical drainage with appropriate anesthesia, thorough evacuation of purulent material, exploration for loculations, and proper post-operative care with or without packing based on abscess size and location. 1, 2

Pre-Procedure Assessment

• Confirm abscess diagnosis through physical examination (pain, swelling, fluctuance, erythema)
• Differentiate from other conditions (hematoma, cyst, tumor)
• Assess for systemic symptoms (fever, tachycardia) indicating more severe infection
• Consider ultrasound for uncertain cases to confirm fluid collection 2

Equipment Needed

• Sterile gloves, gown, mask
• Antiseptic solution (chlorhexidine or povidone-iodine)
• Local anesthetic (1% lidocaine with epinephrine)
• Syringes and needles for anesthetic administration
• Scalpel with #11 blade
• Hemostats or forceps for exploration
• Gauze for packing (if needed)
• Culture swabs
• Sterile dressings
• Basin for collection of purulent material

Procedure Steps

1. Patient Positioning and Preparation

   • Position patient for optimal access to abscess
   • Prepare the area with antiseptic solution
   • Drape to create sterile field

2. Anesthesia

   • Administer local anesthetic (1% lidocaine with epinephrine)
   • Consider field block around abscess rather than direct injection into cavity
   • Allow adequate time for anesthetic effect

3. Incision

   • Make incision along skin tension lines when possible
   • Ensure incision is large enough for adequate drainage (typically 1-2 cm)
   • For large abscesses, consider multiple counter incisions rather than a single long incision to prevent step-off deformity and delayed wound healing 1
   • Incise through skin and into abscess cavity

4. Drainage and Exploration

   • Allow spontaneous drainage of purulent material
   • Use hemostats or finger to break up loculations
   • Explore cavity thoroughly to ensure complete drainage
   • Avoid aggressive probing for fistulas to prevent iatrogenic complications 2
   • Consider culture collection for high-risk patients or those with risk factors for multidrug-resistant organisms 2

5. Irrigation

   • Irrigate cavity with sterile saline until clear
   • Ensure all purulent material is evacuated

6. Packing Decision

   • For abscesses >5 cm, consider packing to prevent premature closure and recurrence 3
   • For smaller abscesses (<5 cm), packing may be omitted as evidence shows equal efficacy without packing 4
   • If packing is used, place loosely to allow continued drainage

7. Dressing Application

   • Apply sterile absorbent dressing over wound
   • Secure with tape or bandage

Post-Procedure Care

1. Immediate Post-Procedure Instructions

   • Provide analgesia as needed
   • Instruct on wound care (warm soaks, dressing changes)
   • Schedule follow-up within 24-48 hours for wound check and possible packing removal 2

2. Antibiotic Considerations

   • Antibiotics are generally unnecessary for simple, adequately drained abscesses in immunocompetent patients 5, 3
   • Consider antibiotics for:
     • Severe or extensive disease
     • Rapid progression
     • Systemic illness
     • Immunocompromised patients
     • Incomplete drainage
     • Surrounding cellulitis 2

3. Follow-up Care

   • Monitor for signs of recurrence or complications
   • Ensure complete healing
   • Consider evaluation for underlying conditions in recurrent cases

Special Considerations

• Perianal/Perirectal Abscesses: Require prompt surgical drainage to prevent expansion into adjacent spaces. If sphincter involvement is suspected, consult colorectal surgery and consider placement of a loose draining seton 1, 2

• Complex/Deep Abscesses: May require imaging guidance (ultrasound or CT) for drainage, especially if inaccessible by standard approaches 6

• High-Risk Patients: Diabetic or immunocompromised patients require more aggressive management and closer follow-up 2

Documentation Elements

• Pre-procedure assessment
• Informed consent
• Procedure details (anesthesia, incision location and size, drainage characteristics)
• Estimated amount and appearance of drained material
• Culture collection (if performed)
• Packing details (if used)
• Post-procedure instructions provided
• Follow-up plan