Overview of Incision and Drainage
Incision and drainage (I&D) is a commonly used procedure in various healthcare environments like emergency rooms or outpatient clinics. In simple terms, this procedure is primarily done to treat abscesses, which are painful, pus-filled boils on the skin or the soft tissue underneath it. Sometimes, antibiotics are also given along with this procedure.
In this context, we will specifically talk about how this procedure is used to manage abscesses on the skin. According to data from 2013 by the Centers for Disease Control and Prevention (CDC), about 2% of all reasons people visited the emergency room were because of these skin abscesses. Out of all the people that came to the emergency room, around 0.9% of them had to undergo this procedure.
In children, the rate of skin and soft tissue infections (SSTIs), which includes conditions like abscesses, has gone up. The number of children being admitted to the hospital due to SSTIs has doubled in the last 20 years. This indicates that clinicians, who are the health professionals treating patients, need to be really well-prepared for carrying out I&D in both adult and kid patients.
Anatomy and Physiology of Incision and Drainage
A skin abscess is a pocket of pus that forms within the layers of your skin and beneath it. These pus-filled pockets can form anywhere on your body, but they are commonly found in areas like the groin, buttocks, armpits (axillae), and limbs.
It’s usually easy for a doctor to identify a skin abscess just by looking at it and feeling it. When you have an abscess, your skin might be red, hard, sore, and filled with fluid. However, it’s important that doctors don’t confuse a skin abscess with cellulitis, a skin infection that’s treated differently. While an abscess feels like it’s filled with fluid, cellulitis does not.
If the doctor isn’t sure if it’s an abscess or not, they may use an ultrasound. This is a medical device that uses sound waves to get pictures of the inside of your body. This would not only confirm if it’s an abscess, but also provide more details about its size and exact location.
Research has shown that ultrasounds can be more effective than just a physical examination in detecting an abscess, especially in children. Interestingly, the same research showed that if a doctor can already tell it’s an abscess just by examining it, an ultrasound won’t necessarily provide any more useful information.
However, it has been observed that when an ultrasound was used along with a physical exam for diagnosing an abscess, the chances of treatments failing was lower. This means ultrasounds could potentially enhance the outcomes of abscess treatment. But, of course, this is dependent on if there are experienced ultrasound technicians and radiologists available to perform and interpret the test.
Why do People Need Incision and Drainage
If you have an abscess, which is essentially a pocket of pus caused by an infection, your doctor will likely recommend a procedure called incision and drainage. This process involves making a small cut in the abscess to drain the pus, which helps speed up recovery. Simply taking antibiotics isn’t usually enough to treat an abscess completely.
However, if the abscess is small, you might not need this procedure. Instead, your doctor might suggest a more conservative treatment plan. This could involve taking antibiotics to fight the infection and manually pressing on the abscess to help push out the pus.
When a Person Should Avoid Incision and Drainage
There are certain conditions when it might not be safe for a doctor to make a small cut on your body and drain out the pus from an abscess (a swollen area filled with pus). These conditions can include:
If the abscess is very large or deep,
If there is a mass that throbs with your pulse near the infection (indicating it might be close to a major blood vessel),
If the abscess is near major blood vessels or nerves,
If there is a foreign body (like a splinter or piece of glass) within the abscess,
Or if the abscess is located in certain areas of the body.
Certain parts of the body are more difficult to treat with this simple procedure. This can be due to the area being very sensitive (like the palms of the hands, soles of the feet, or face), or because treating an abscess there might lead to complications. For example, abscesses near the rectum or nipple (perirectal and periareolar abscesses) may require a surgeon’s evaluation due to the high risk of developing a fistula (an abnormal connection between two body parts). Similarly, neck abscesses that might have started from pre-existing cystic lesions should be checked by an ear, nose, and throat specialist (otolaryngologist).
Also, if a patient has a fake or abnormal heart valve, they might need to take antibiotics before the procedure. It’s also important for the doctor to know if the patient has a bleeding disorder or if they are allergic to lidocaine (a local anesthetic), epinephrine (a drug used to minimize bleeding), or latex. These could potentially delay the procedure or require alternative methods or materials.
Equipment used for Incision and Drainage
For a procedure to be carried out safely and successfully, it’s necessary to have certain sterile equipment on hand. This includes a cleaning agent (usually povidone-iodine or chlorhexidine), a local anesthetic that can be injected (like 1% or 2% lidocaine, lidocaine mixed with epinephrine, or bupivacaine), a small syringe with a fine needle, gauze, a scalpel with a handle, a curved tool called a hemostat, a saltwater solution with a large syringe, or a bowl for washing the wound, materials for packing the wound (like iodoform or plain gauze), wound culture swabs if needed, and scissors and tape for dressing the wound.
Incision and drainage is a procedure that can be quite painful. Because of this, additional to the local anesthetic, pain relievers taken orally or injected into a vein might be needed.
Who is needed to perform Incision and Drainage?
The process is quite straightforward and is usually carried out by one doctor. However, there might be times when extra help is needed. This is particularly true when dealing with children. Here, child life services can really make a difference in helping the procedure go smoothly.
Child life specialists are professionals who are trained to provide emotional support to kids and families in hospitals or clinics. A recent research study in children’s emergency medicine examined how child life can influence how kids react to having a cut sutured in the emergency room.
The study compared children who had the procedure by themselves to those kids who were helped by a child life specialist. It was discovered that the kids who had the extra support experienced less fear and stress during the procedure.
Preparing for Incision and Drainage
Before a medical procedure can begin, it’s important for the doctor to get a clear and informed consent from the patient or their legal guardian if necessary. In simpler terms, the patient should have a clear understanding and agreement on what the procedure involves and the possible risks that might come with it, such as bleeding, pain, and potential scarring. Additionally, doctors need to check if their patients’ tetanus shots are up to date. Tetanus is a serious bacterial infection that can be prevented by a routine vaccination.
For the safety of both the doctor and the patient, the doctor needs to wear safety gear like a gown, gloves, and a mask or goggles. This is to prevent the spread of any potential infection. Despite the area they’re treating might already have an infection (meaning it’s not sterile), it’s wise for the doctor to still follow these sterile-like precautions. This helps to ensure the best possible outcome for the patient and reduce the risk of other complications.
How is Incision and Drainage performed
When a doctor treats an abscess, or a pocket of pus, they usually make a small cut into it to drain the pus. They hold a small, sharp tool called a scalpel, and they cut carefully to avoid leaving a scar. They then use a little tool called a curved hemostat to gently break up any pockets of pus within the abscess. Sometimes, they might apply some pressure to help get more pus out. After that, they clean the wound with a saltwater solution. If the abscess is smaller than 5 cm, or about the size of a lime, then your doctor may not add gauze inside the wound. That’s because the gauze doesn’t change how well you heal, and it might even cause more pain. It doesn’t help prevent more abscesses either.
Following this, the doctor will cover the wound with a bandage. It’s important to make another appointment for about 2-3 days after your procedure so the doctor can check up on your wound. The wound should be allowed to heal naturally, from the inside out.
A less commonly used method is to drain the abscess using a needle, guided by an ultrasound. However, research has shown this method isn’t as successful. In a study, only 26% of the patients got better with needle draining, compared to 80% who had the cut and drain method described above.
Another option is loop drainage. This technique might cause less pain and scarring. Some studies suggest it fails less often than the other methods. But, not too many doctors use it right now.
Possible Complications of Incision and Drainage
Usually, the process of draining an abscess (known as I&D) is well-handled by patients, with the most normal complication being pain. If the abscess isn’t properly drained, things might get worse. The infection could spread to nearby tissues, and the patient’s overall health could decline.
What Else Should I Know About Incision and Drainage?
Incision and drainage is a procedure often carried out in various healthcare settings. This treatment is the go-to method for dealing with abscesses (pockets of pus) that are under the skin. It can be done with or without the addition of antibiotics.
