Topic

• Introduction
• Indications
• Contraindications
• Procedure
• Coding Information

Figure(s)

• Incision and Pus Expulsion
• Promote Drainage and Prevent Premature Closure

• Pus collections must be drained for healing to occur.
• After incision and drainage (I&D), instruct the patient to watch for signs of cellulitis or recollection of pus.
• Train patients or family to change packing, or arrange for patient's packing to be changed as necessary.

Abscess that is not spontaneously resolving

Consider more aggressive therapy, closer observation, wound culture, and antibiotic therapy in patients with diabetes, debilitating disease, compromised immunity, or facial abscesses located within the triangle formed by the bridge of the nose and corners of the mouth (risk of septic phlebitis with intracranial extension).

• Abscess is ready for drainage when skin has thinned and underlying mass becomes soft and fluctuant (i.e., pointing). Prep and drape the area in a sterile fashion.
• Administer a field block with local anesthetic (see Chap. 23, Field Block Anesthesia). Also anesthetize the skin overlying the top of the abscess.
• Insert a no. 11 surgical blade inserted and draw it parallel to the lines of lesser skin tension, creating an opening from which pus may be expressed (Fig. 1-1A). Often, an up-and-down incision with the no. 11 blade is adequate.
• Avoid extending the incision into non-effaced skin.
• Apply pressure around the abscess to expel pus from the wound (Fig. 1-1B).
• Pitfall: Avoid injecting into the abscess cavity because local anesthetics usually work poorly in the acidic milieu of an abscess
• Pitfall: Abscesses can explode upward on entry. Wear protective eyewear if the abscess contents appear to be under pressure.
• Insert probe, cotton-tipped applicator, hemostats, or curette through opening, and draw it back and forth to break adhesions and dislodge necrotic tissue.
• If culture is desired, obtain it from deep in the abscess cavity.
• If the cavity is large enough, pack it with a ribbon of plain or iodoform gauze to promote drainage and prevent premature closure.
  • Grasp end of ribbon with pair of forceps and place it through incision to base on abscess (Fig. 1-2A). Fold additional ribbon into the cavity until it is filled.
  • Leave approximately 1–2 cm of gauze on the skin surface (Fig. 1-2B).
• Apply sterile dressing over area.
• Pitfall: Abscesses most often recur because of an incision that is not wide enough to prevent immediate closure.

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