Cellulitis/Abscess — Incision and Drainage Procedure — Clinical Pathway: Emergency Department and Inpatient

Cellulitis/Abscess Clinical Pathway — Emergency Department and Inpatient

Incision and Drainage Procedure

Supplies

Provider Preparation Gown, mask/eye protection, gloves
Skin Preparation LMX, Tegaderm™
Lidocaine 1% (3-5 mL syringe, 27 gauge needle)
Povidone-iodine
Skin Incision 18 gauge needle, #10 or #11 blade scalpel
Irrigation Supplies 18 gauge IV catheter, 20-60 mL syringe, NS or sterile water
I&D of Large Abscess Laceration tray
To Obtain Specimen Red top culture
Packing for Large Abscesses Iodoform gauze

Procedure

Incision and Drainage Procedure
Indications
  • Large size (often ≥ 3 cm)
  • Currently draining
  • History of drainage with fluctuance
    • Obvious pustule with underlying fluctuance
  • Procedure Video  
Ultrasound Guidance
  • Consider when presence of abscess is not clinically evident
  • Can be used to localize ideal location of incision to access the largest cavity
  • Marin JR et al Bedside US had a much higher sensitivity and specificity than clinical examination for the 159 children in whom abscesses were not clinically evident (Sn: 78 vs. 44%, Sp 61 vs. 42%)
Incision
  • Prepare skin with povidone-iodine.
  • Make a simple linear incision trying to conform to the natural folds of the skin.
  • Hold scalpel vertically to skin to quickly get through the rind and into the abscess pocket.
Culture
  • Culture all abscesses that are drained
  • Send culture only on patients treated with antibiotics
Probing and Irrigation
  • Probe the abscess cavity with a hemostat to break up loculations and ensure proper drainage
  • Avoid probing with a finger, scalpel or scissors
  • Irrigate the cavity copiously with isotonic saline solution until all visible pus is removed
Closure
  • Do not close primarily
  • Allow to heal by secondary intention
Packing or Wick Placement
  • Abscess ≥ 5 cm in diameter and pilonidal abscesses:
    • Do not pack too tightly, excessive pressure can cause tissue necrosis
    • Use iodoform gauze to loosely fill the cavity
    • Leave a 1 cm tail to serve as a wick for drainage and facilitate subsequent removal of packing
    • Cover with absorbent dressing
  • Packing of drained abscess cavities is not supported in the literature for abscesses < 5 cm
Packing of drained abscess cavities is not supported in the literature for abscesses < 5 cm

References