You know you’re made for medicine when you see a bulging, fluctuant abscess and you just can’t wait to stick an #11 blade in to release it’s contents. In the early days of MidlevelU, I wrote about my I&D misadventure which sent a patient’s pus flying into my hair. Talk about a bad day. Fortunately, my technique has improved and working in the emergency department has pretty much made me an abscess-draining pro. But, there’s always room for a procedural refresher.
Here are a few things to remember when performing irrigation and drainage of a cutaneous abscess.
1. I&D is a clean but not sterile procedure
When performing an I&D, there’s no need to use sterile gloves, sterile drapes, and general sterile technique. An abscess is filled with pus which will immediately contaminate the surface once you start your procedure. Clean, but not sterile technique is in order for this procedure.
2. Wear a facemask
While wearing a facemask isn’t essential, it’s wise. You never know what sort of bodily fluids and smells will be released from an abscess so taking precautions is always your best bet. If you suspect an abscess may be particularly odorous, dab some peppermint oil on a cotton ball and place inside your facemask as a preventative measure.
3. Consider your anesthetic agent
Using an anesthetic containing epinephrine to numb the area where you will perform your incision is helpful. This prevents bleeding for better visualization while performing the procedure. Don’t forget that epinephrine cannot be used to anesthetize the most distal portions of the body such as digits, the nose, ears, and male genitalia. Use of bupivocaine rather than or mixed with lidocaine provides 4 to 8 hours of anesthesia rather than 2 hours with lidocaine alone offering the best post procedural pain control.
4. Be bold with your incision…but know your anatomy
Many providers make the mistake of creating too small of an incision. Your incision must be long enough to allow for adequate drainage and exploration of the abscess. In many cases, a proper incision may run much of the length of the abscess. Before you cut, consider the anatomy of the area. Are there major blood vessels? Nerves? If an abscess overlies important anatomical structures, you may need to make a smaller incision.
5. Culture complex cases
Simple abscesses most often do not need to be cultured. But, in patients who are immunocompromised, or who have large or complex abscesses, a culture of drainage should be obtained to guide antibiotic therapy.
6. Exploration and irrigation are key
Incising an abscess alone isn’t enough. Once you make an incising and drain the pus, explore the area with hemostats breaking up any inoculations. Some abscesses contain multiple chambers which will not be drained if you do not explore the cavity. Irrigate with normal saline to ensure as much debris as possible has been flushed from the area.
7. Consider cosmetics
Although your ultimate priority in an I&D is to treat the infection, consider cosmetics as you incise the abscess. If possible, make your incision in the same direction as skin folds to minimize scarring.
The following video offers a helpful tutorial for incision and drainage of cutaneous abscess.
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