Ver el código de «Incision and drainage»

==Indications==
{{Skin anatomy background images}}
*[[Abscess]] of skin or superficial soft tissue

==Contraindications==
*No absolute contraindications

*Abscesses that may require OR management or specialist consultation include<ref name="NEJM">Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M. Abscess incision and drainage. N Engl J Med. 2007 Nov 8;357(19):e20.</ref>:
**Large or deep abscesses that are difficult to access or anesthetize
**Abscesses of the palms, soles, or nasolabial folds
**Areas in which cosmesis is important (face, breast)

==Equipment Needed==
*PPE
*[[Local anesthetics|Local anesthetic]]
*Incision and Drainage Tray:
**Scalpel
**Hemostat
**Forceps
**Gauze
**Drape / towel
**Iodine swabs

{{Maximum doses of anesthetic agents}}

==Procedure<ref name="NEJM" />==
[[File:PMC2453116 1472-6920-8-38-3.png|thumb|Standard technique: A) A scalpel is used to incise the abscess; B) Hemostat and culture swab are used to break up loculations within the interior of the abscess cavity; C) Wound packing material is inserted into the abscess cavity.]]
===Standard Technique===
''Sterile technique recommended, but not required''

*Cleanse skin overlying and surrounding [[abscess]] site with chlorhexidine or Iodine
*Anesthetize skin of planned incision site
**Local anesthesia
**Field block
**Regional block
**In some cases, [[procedural sedation]] may be indicated
*Make a linear incision (along skin tension lines) over the center of the [[abscess]] cavity
**Advance depth until [[abscess]] cavity entered
**Ensure incision is large enough to accommodate drainage and introduction of forceps/hemostat
*Manually express contents
*Introduce hemostat and bluntly dissect to break up loculations
*Packing with iodoform gauze may be performed (goal is to prevent premature wound closure), however evidence indicates that packing is not necessary.<ref>Kessler DO, Krantz A, Mojica M. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department. Pediatr Emerg Care. 2012 Jun;28(6):514-7</ref><ref>O'Malley GF, Dominici P, Giraldo P, Aguilera E, Verma M, Lares C, Burger P, Williams E. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med. 2009 May;16(5):470-3.</ref>

''Irrigation of [[abscess]] cavity has no benefit<ref>[[EBQ:Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success]]</ref>

===LOOP Technique===
*Incise at most fluctuant area of abscess
*Incise second location <4cm from original incision
**For larger abscesses can repeat this step thus creating several LOOPs.
*Break-up loculations with hemostat
*Irrigate wound
*Pass hemostat through both incisions and pull penrose through
*Tie penrose drain loosely over 30cc syringe to form LOOP
*Patient can follow up with primary care provider or cut in 5-7 days
**Retrospective study showed decreased failure rate in LOOP technique vs standard I&D. <ref>Ladde JG, et al. The LOOP technique: a novel incision and drainage technique in the treatment of skin abscesses in a pediatric ED. Am J Emerg Med. 2015 Feb;33(2):271-6.</ref>

==Complications==
*Damage to surrounding structures
*Progression of infection
*Transient bacteremia

==Follow-up==
*Wound check in 1-2 days.
*Warm soaks to help facilitate ongoing drainage
*7-day course of [[Trimethoprim–Sulfamethoxazole]] has been shown to decrease treatment failure<ref>Talan DA, et al. Trimethoprim–Sulfamethoxazole versus placebo for uncomplicated skin abscess. NEJM. 2016; 374(9):823-832.</ref>
**Previously [[antibiotics]] were indicated only for 1) overlying cellulitis; 2) evidence of systemic infection<ref>Fahimi J, Singh A, Frazee BW. The role of adjunctive antibiotics in the treatment of skin and soft tissue abscesses: a systematic review and meta-analysis. CJEM. 2015 Feb 20:1-13.</ref>; for immunosuppressed patients; or [[abscess]] that does not respond to standard treatment <ref>Singer A, Talan D. Management of Skin Abscesses in the Era of Methicillin-Resistant Staphylococcus aureus. N Engl J Med 2014; 370:1039-1047</ref>
**[[Clindamycin]] shown to be as effective as TMP/SMX, but with higher adverse events<ref>Daum RS, Miller LG, Immergluck L, et al. A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. N Engl J Med. 2017;376(26):2545-2555. doi:10.1056/NEJMoa1607033</ref>

==See Also==
*[[Abscess]]
*[[Lidocaine]]
*[[Bartholin Gland Abscess]]
*[[EBQ:Irrigation of Cutaneous Abscesses Does Not Improve Treatment Success]]
*[[Procedure sample documentation]]

==External Links==

===Videos===
*ERCast Loop Abscess Drainage (6:58) https://vimeo.com/19580472 
*NEJM (10:12) https://www.youtube.com/watch?v=MwgNdrA18fM&feature=emb_logo

==References==
<references/>

[[Category:Dermatology]]
[[Category:ID]] 
[[Category:Procedures]]