Incision and drainage of an abscess

Indications

• Fluid-filled abscess large enough to warrant I&D

Contraindications

• Extremely large abscesses which require extensive incision, debridement, or irrigation (best done in OR)
• Deep abscesses in very sensitive areas (supralevator, ischiorectal, perirectal) which require a general anesthetic to obtain proper exposure
• Palmar space abscesses, or abscesses in the deep plantar spaces
• Abscesses in the nasolabial folds (may drain to sphenoid sinus, causing a septic phlebitis)

Materials

• Chlorhexadine or iodine for cleaning
• 25G needle on 5cc syringe for local anaesthetic
• 18-21G needle on 5-10cc syringe for aspiration
• 2% lidocaine (or 1% if necessary)
• Culture swab, if necessary
• Small scalpel (No. 11)
• Curved forceps
• Packing material and diluted iodine, if packing is required

Technique

• Position patient for comfort during procedure
• Landmarking using linear ultrasound probe to:
  • Confirm presence of fluid in an apparent abscess
• Identify largest pocket for drainage
• Clean area and drape appropriately to contain expelled pus
• Inject 2% lidocaine to raise a bleb
• Use larger-bore needle to aspirate abscess contents; these may be sent for C&S if useful
• Inject 2% lidocaine in field block around entire abscess
• Create small incision using tip of blade
• Expel as much pus as possible
• Use curved forceps to break up any pockets within the abscess
• Pack with packing material soaked in saline or iodine diluted 1:1 with saline, when:
  • 5 cm in diameter
  • Pilonidal abscess
  • Abscess in an immunocompromised or diabetic patient

Post-Procedure Instructions

• Cover with bandage, leave wound unclosed, and keep clean
• Remove packing material in 3 days, if used
• Antibiotics not routinely indicated
  • If MRSA positive, extra coverage required