II. Indications

  1. Furuncle (Skin Abscess) at least 5 mm in size

III. Contraindications

  1. Furuncle of central face (risk of septic phlebitis)
    1. Infection below bridge of nose and above lip
    2. Treat with antibiotics and warm compresses

IV. Precautions

  1. Avoid incision deeper than floor of lesion
  2. Wear protective eyewear during Incision and Drainage
  3. Follow closely and wound culture higher risk patients
    1. Diabetes Mellitus
    2. Immunocompromised patient
    3. Serious underlying comorbid conditions
  4. Surgery Consultation in complicated abscess
    1. Extensive, large, deep abscesses
      1. Consider general surgery Consultation to perform in the operating room
    2. Cosmetically challenging areas (e.g. face, Breasts, genitalia, hands)
      1. Consider Consultation with general surgery or plastic surgery

V. Technique

  1. Clean overlying skin with betadine or hibiclens
  2. Inject Local Anesthesia in skin overlying Furuncle
    1. Use longer acting agents (e.g. Lidocaine with Epinephrine or Bupivacaine) to allow for adequate duration
    2. Consider systemic Opioid Analgesics prior to Incision and Drainage
    3. Regional blocks or performance in OR or under Procedural Sedation may be required for large deep abscesses
    4. Most providers use a Field Block over the surface of the abscess
      1. Inject adequate depth to anesthetize the deepest recesses
      2. Avoid infiltrating abscess (poor efficacy)
  3. Incise lesion with number 11 blade
    1. Make adequately wide incision to allow access, prevent reclosure, and insert packing
  4. Culture from within abscess (if indicated)
    1. Typical Bacterial cause is MRSA (in 2014)
    2. Primary management is drainage of the abscess (not antibiotics)
      1. Cultures are unlikely to drive further management if antibiotics are not used
      2. Consider culture if antibiotics are administered (see Skin Abscess for antibiotic indications)
  5. Break up loculations with hemostat (if needed)
  6. Irrigate wound (questionable efficacy)
    1. Typically performed with sterile saline via syringe with splash guard
    2. Recommended in most guidelines but does not appear to alter course
      1. Chinnock (2015) Ann Emerg Med [PubMed]
        1. http://www.annemergmed.com/article/S0196-0644(15)01188-9/abstract
  7. Wound packing options
    1. Packing is not required in most wounds (see below)
    2. Avoid tight packing (painful, Skin Tenting)
    3. Insert sterile gauze packing loosely
      1. Non-iodiform 1/4 inch sterile gauze packing
      2. One end of gauze protrudes as wick from incision site
    4. Alternative: Penrose drain insertion (Loop drainage)
      1. Two small, 5mm incisions made into abscess (each within 4 cm of the other)
        1. First incision at the most fluctuant area of the lesion
      2. Penrose drain inserted into one incision and looped out through the other
      3. Penrose tied loosely on skin surface with 5 to 6 knots
        1. Consider tying penrose over the top of a 30 cc syringe layed flat to allow adrequate slack
      4. Patient regularly pulls the loop in alternate directions to maintain open wound drainage
      5. Loop is removed in several days by a provider on wound recheck (or in some cases by the patient)
      6. Roberts (2013) Emerg Med News 5(2): 16-18
      7. Ladde (2015) Am J Emerg Med 33(2): 271-6 [PubMed]
      8. Tsoriades (2010) J Pediatr Surg 45(3): 606-9 [PubMed]
  8. Alternatives to wound packing
    1. Consider not packing small extremity abscesses (<5 cm) in immunocompetent patients
      1. Similar outcomes and less pain without packing
      2. O&#39;Malley (2009) Acad Emerg Med 16(5): 470-3 [PubMed]
      3. Kessler (2012) Pediatr Emerg Care 28(6): 514-7 [PubMed]
    2. Consider primary loose closure after Incision and Drainage of small abscesses (<5 cm)
      1. Requires careful drainage of all pockets and well irrigated (studies were done in OR)
      2. Loose closure was performed to allow for possible drainage
      3. Results in more rapid healing and return to work
      4. Same abscess recurrence rates (30%) for closure versus no closure
      5. Singer (2011) Am J Emerg Med 29(4): 361-6 [PubMed]
      6. Singer (2013) Acad Emerg Med 20(1): 27-32 [PubMed]
  9. Bandaging
    1. Apply sterile dressing over incision

VI. Disposition: Post-procedure instruction

  1. Wound re-packing is no longer recommended
    1. Previously repacking was recommended every 1-2 days
  2. Treat associated Cellulitis if present
    1. Antibiotics are usually not needed unless Cellulitis is also present

VII. References

  1. Chan (2014) Crit Dec Emerg Med 28(9): 2-7
  2. Derksen in Pfenninger (1994) Procedures, p. 50-3
  3. Anora and Menchine in Herbert (2014) EM:Rap 14(3): 1-2
  4. Stulberg (2002) Am Fam Physician 66(1):119-24 [PubMed]

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Ontology: Incision and drainage (C0152277)

Definition (NCI) A surgical procedure where a cut is made in a tissue or structure to allow the drainage of fluid.
Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 56783008
English Incision and drainage, i d, incision and drainage, d i, drainage incision, incision drainage, Incisional drainage, I and D, Incision and evacuation, Incision AND drainage (procedure), Incision AND drainage, Incision and Drainage, Incision & Drainage
Italian Drenaggio mediante incisione
Japanese 切開排膿, セッカイハイノウ
Czech Drenáž incizí
Hungarian Incisio et drainage
Spanish incisión Y drenaje (procedimiento), incisión Y drenaje, incisión y evacuación, Drenaje de la incisión
Portuguese Drenagem por incisão
Dutch drainage via de incisie
French Drainage d'une incision
German inzisionale Drainage