Surgery - Abscesses Incision & Drainage Flashcards
Abscesses: Incision & Drainage
What is an abscess?
- Localized area of induration or fluctuance
- caused by a collection of pus within the dermis or deeper skin tissues secondary to infection and inflammation.
Abscesses: Incision & Drainage
What causes an abscess?
- There is usually a breakdown in the integrity of the skin allowing normal flora to invade.
- Ex: insect bites, abrasions, shaving, IVDA
- Increased likelihood of abscess formation with:
- Increased temperature
- Increased humidity
- Poor hygiene
- Sitting often
- DIABETICS
- Common affected areas include gluteal, superior gluteal fold and axilla but often found on back and extremities
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Abscesses: Incision & Drainage
What organisms coommonly cause abscesses?
- Causative organisms depend on area of abscess but most commonly caused by Staph. Aureus and Streptococcus.
- Increase in incidence of CA-MRSA (community associated methicillin-resistant Staphylococcus Aureus )
Abscesses: Incision & Drainage
What are common risk factors for MRSA?
- Resident of long term care facility
- Sharing needles, razors or other sharps
- Sharing sports equipment
- Military service
- Incarceration
- IVDA
- Men who have sex with men
- HIV infection
- Recent hospitalization
Abscesses: Incision & Drainage
How will an abscess present?
- Painful, tender, erythematous
- Indurated in early, fluctuant later
Abscesses: Incision & Drainage
What are some common types of abscesses?
Cutaneous
- Perirectal
- Pilonidal
- Infected Sebaceous Cyst
Hidradenitis Suppurativa
- Axilla, groin, perineal
- Blocked apocrine glands
- Chronic
Bartholin’s gland abscess, Paronychia, Felon
What is the treatment of choice for abscesses?
- INCISION AND DRAINAGE!
How do I know?
Early abscess: indurated
- Warm compresses, antibiotics
- Warn most likely need I&D
- F/U in 3-4 days
Fluctuant
- If unsure, can aspirate (18 guage needle and 10 cc syringe)
How to drain an abscess?
Equipment
- Gloves
- Drape
- Local anesthetic (1% or 2% lidocaine)
- Syringe with 25 to 30 guage needle
- Alcohol or betadine wipe
- 4 x 4 inch guaze
- No. 11 blade
- Curved hemostat
- Irrigation tray with irrigating fluid
- Iodoform gauze
- Culture swab
- Scissors
- Dressing of choice
How to drain an abscess?
Technique
- Explain procedure
- Glove and clean with betadine
- Drape
- Anesthetic: 1% or 2% lidocaine
- Incise with 11 blade scalpel
- Culture wound
- Probe: with curved clamp or hemostat
- Irrigate
- Packing: iodoform
- Apply dressing
Healing & Repair
Wound Assessment
- Date and time
- Size and depth (wound bed)
- Site
- Wound edges
- Necrotic tissue and slough
- How to document?
When should I culture a wound?
Since the increase in incidence of MRSA, ALWAYS. Why?
Adjust antibiotics accordingly
Investigate prevalence of MRSA in particular communities
Impaired healing?
Local Factors:
- Poor blood supply
- Wound stress- surgical technique
- Infection
- Position- over joint
Systemic factors:
- Malnutrition
- Obesity
- Smoking
- Medication (steroids)
- Co-morbidites
- Immunosupression
Chronic wounds >6weeks:
- Sinus and fistula formation
- Malignant transformation
- Osteomyelitis- common agent?
- Heterotrophic calcification
- Anaemia
- Sepsis
- Abx resistance
When should I consider senior advice or referring a patient?
- Extensive involvement- progressive streaking/cellulitis
- Patient appears ill (systemic), immuno-compromised or not responding to treatment
- Concern about anatomical area, proximity to nerve, major vessel or organ, Perirectal, facial, hand, foot, breast (may require biopsy)
- Secondary to IV drug misuse
Lymphangitis:
- Lymphangitis is an inflammation or an infection of the lymphatic channels that occurs as a result of infection at a site distal to the channel.
- The most common cause of lymphangitis in humans is Streptococcus pyogenes (Group A strep), although it can also be caused by the fungus Sporothrix schenckii.
What about antibiotics?
- I&D remains the TOC
- Controversial topic since recent rise in incidence of MRSA
- Many believe that I&D should be the only treatment for simple, small abscesses without significant surrounding cellulitis in otherwise healthy patients
- Antibiotic use should be strongly considered if:
- Underlying comorbities such as DM, immunocompromised state
- If significant surrounding cellulitis
- Abscess is large (>5cm)
- S/S of systemic disease
- Risk factors for MRSA
Antibiotics and MRSA
Length of prescription for antibiotics?
- 5-7 days
- Severity?
- Co-morbidities?
Bactrim:
- BEST for MRSA (rapidly bactericidal against MRSA).
- Covers staph, strep, MRSA, E-coli and other gram negs.
- NOT good for anaerobic coverage
Tetracyclines:
- Good for all (old school)
Clindamycin:
- Staph, strep, MRSA, anaerobes.
- NOT good for E-coli and other gram negs
Inpatient::
- vancomycin, rifampin, linezolid,
- **Quinilones and macrolides are NOT recommended for MRSA
What complications are associated with abscesses?
Depends on location
- Perianal = fistula
- Hand = tenosynovitis
Septicaemia
Cellulitis
What other management should I provide for my patient?
- Patient Education
- Explain to patient abscesses often reoccur
- Return to ER or call office for fever, red streaks coming from wound, increased redness, increased swelling, reaccumulation or if packing falls out
- Keep dressing clean, dry and intact
- If dressing falls off, can reapply clean dressing
- Return in 24-48 hours for wound check, packing change/removal
