# Abscess Incision and Drainage

## Overview

This module describes how to identify and manage an abscess where incision and drainage is indicated.

## Indications

1. Fluctuant superficial abscesses > 5 mm in diameter

## Contraindications

1. Abscesses < 5 mm; treat with antibiotics

2. Very large or deep abscesses; refer to surgery

3. Perianal or periareolar abscesses; refer to surgery

4. Abscesses in an inaccessible area; refer to surgery

5. Neck and facial abscesses; refer to surgery

6. Palm or sole abscesses; refer to surgery

7. Cellulitis with no abscess; treat with antibiotics

8. Patients with abnormal or artificial heart valves; give prophylactic antibiotics before proceeding

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“This skin infection is called an abscess or boil, which must be cut open to allow the pus inside to run out, before the area can heal.”

### What can my patient expect?

“I will give you an injection for pain, first. Then I will make a small cut and clean out the pus.”

### What is my patient’s role?

“Let me know if you have any allergies, a heart condition, or a bleeding tendency, or use blood thinners. Fearing blood or needles is normal, but tell me if you have fainted from it. Keep as still as possible. If you feel strange sensations like tingling or severe pain, tell me immediately.”

## Preparation

###

### Documentation

1. Patient notes

### Equipment

1. Sterile gloves
   Sterile gloves

   Although it is considered best practice to use sterile gloves to perform minor procedures, there is mounting evidence that infection rates are similar for sterile and non-sterile glove use.

2. Alcohol-based hand rub

3. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

4. Sterile drapes

5. Skin disinfectant
   Skin disinfectant

   Commonly used preparations include 0.5-2% chlorhexidine in 70% alcohol (Steriprep), or 10% povidone iodine. There is no consensus on the superiority of one agent above another. Caution: chlorhexidine solutions may be associated with burns and skin breakdown in infants < 2 months old.

6. Supplies for anaesthesia:

   1. Lignocaine (1-2% with adrenaline). For small abscesses not on the face, consider ethyl chloride spray. Consider procedural sedation for larger abscesses.
   2. Alcohol swab
   3. 5-10 ml syringe
   4. Blunt fill needle & a small gauge injection needle

7. Suture pack

8. No. 11 scalpel blade

9. Bottle of normal saline for irrigation

10. 20 ml syringe

11. IV cannula

12. Gauze pad and a dressing (transparent film or crêpe bandage as required)

## Site and Positioning

Position the patient supine or reclining with the abscess within easy reach. When making the incision, incise along

Langer's lines

Langer's lines

of skin tension.

## Procedure

Follow medical asepsis with sterile gloves; however, due to the nature of abscesses, complete sterility may not always be achievable.

1. Perform hand hygiene.

2. Draw up approximately 5-7 ml lignocaine and

   anaesthetise
   anaesthetise

   A popular choice is to perform a field block by injecting in a diamond pattern around the abscess. Do not inject into the abscess cavity. Do not underestimate the value of adequate anaesthesia.

   the area, use ethyl chloride spray for small abscesses, or consider procedural sedation for large abscesses.

3. Open the suture pack to create a sterile field. Pour cleaning solution into the well. Open the scalpel blade, 20 ml syringe, dressing and IV cannula onto the field. Open the bottle of normal saline.

4. Don sterile gloves.

5. Clean
   Clean

   Clean in a circular fashion from the abscess in the centre outwards.

   and drape the area.

6. Make a stab incision in the centre of the abscess over the point of fluctuance.

7. Extend the incision if necessary.

8. Apply pressure to the area around the abscess to expel pus.

9. Insert a haemostat or curved forceps. Use

   blunt dissection
   blunt dissection

   Insert the haemostat closed, then open it. Work in a circular fashion until the entire interior of the abscess has been covered.

   to break down loculations inside the abscess.

10. Apply pressure to expel remaining pus.

11. Use the 20 ml syringe and cannula (needle removed) to irrigate the abscess cavity thoroughly.

12. Dress the wound. Routine wound packing of small (<5cm) cutaneous abscesses is

    no longer recommended
    no longer recommended

    Traditionally, a cutaneous abscess was packed with gauze and a 1 cm wick to promote epithelial lining, and prevent entrapment of bacteria /build-up of pus with premature closure of wound edges. However, several randomised control studies found no evidence that packing effects outcomes or reduces risk of abscess recurrence. Conversely, packing was associated with increased pain post-procedure and at 48-h follow-up.

    .

13. Dispose of medical waste safely.

14. Record the completion of the procedure in patient notes.

15. Advise the patient to have a wound check in 24-48 h. If packing was done for a large abscess, remove gauze within 2 days.

## Troubleshooting

I’m not sure whether this is an abscess or not.

To distinguish between cellulitis and abscess, use ultrasound to check for a dark collection of fluid contents under the point of maximum fluctuance/erythema and swelling.

My patient gets recurring abscesses.

After incision and drainage, take a deep swab and send for microbial culture and targeted antibiotics. For repeated axillary abscesses, refer to dermatologist to exclude hidradenitis suppurativa.

## Risks

1. Pain

2. Injury to nerves, vessels, and other local structures

3. Local cellulitis

4. Bacteraemia and sepsis

5. Sharps injury to healthcare personnel

6. Vasovagal response (fainting)

## References

1. Pastorino A, Tavarez MM. Incision and Drainage. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556072/

2. Streitz MJ. How To Incise and Drain an Abscess. In: MSD Manual. 2020. Available from: https://www.msdmanuals.com/professional/injuries-poisoning/how-to-do-skin,-soft-tissue,-and-minor-surgical-procedures/how-to-incise-and-drain-an-abscess

3. Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M. Abscess Incision and Drainage. N Engl J Med. 2007;357:e20