Overview of Incision and Drainage
Incision and drainage (I&D) is a common procedure done in various healthcare settings like the ER and outpatient clinics. This procedure is most commonly used to treat skin and soft tissue abscesses. Abscesses are swollen areas within body tissue that contain an accumulation of pus. Whether or not a patient is also given antibiotics, incision and drainage is the main treatment method.
This explanation will specifically address using incision and drainage for treating skin abscesses. According to 2013 stats from the CDC, skin abscesses were the reason for about 2% of all visits to the ER. The same data revealed that almost 1% of all ER patients went through incision and drainage.
In kids, the number of skin and soft tissue infections (SSTI) has been growing, and the need for hospital stays because of SSTI has doubled over the last 20 years. For this reason, it’s really important for medical professionals who work in both adult and pediatric care to be knowledgeable about incision and drainage procedures.
Anatomy and Physiology of Incision and Drainage
A cutaneous abscess is a pocket of pus that forms within the skin and the layer just below it. These abscesses can occur almost anywhere on the body, but they are commonly found in areas like the groin, buttocks, armpits, and limbs.
Studying the physical signs can often help a doctor diagnose a cutaneous abscess. The usual signs of an abscess are redness, hardening of the skin area, sensitivity to touch, and a fluid-filled bump, which is a sign that there’s an abscess. It’s crucial not to mix up an abscess with cellulitis, a skin condition that’s usually treated with antibiotics without drainage. The presence of a fluid-filled bump, which isn’t present in cellulitis, can confirm the presence of an abscess.
When the presence of an abscess isn’t apparent, an ultrasound (a type of imaging technology that uses sound waves) can be used. It can help identify the presence of an abscess and provide details about its size and location.
Research shows that using an ultrasound to detect an abscess can be more accurate than just a physical exam, especially when the signs of an abscess are not clearly noticeable. One study showed that children who had hard-to-diagnose abscesses were more accurately diagnosed using an ultrasound combined with a physical exam than with just the physical exam. The same study found no difference in accuracy when the abscess could be easily diagnosed. However, another study showed that patients who received an ultrasound diagnosis had better treatment success than those who had a physical exam alone.
Using an ultrasound to check for abscess can lead to better treatment results. However, it’s essential to consider the availability of trained ultrasound technicians and radiologists for a successful ultrasound diagnosis.
Why do People Need Incision and Drainage
If someone has an abscess, which is a pocket of pus in tissue, they usually need a small medical procedure called an incision and drainage. This is where a health professional makes a small cut in the abscess to let the pus out, which helps it to heal. Just taking antibiotics is usually not enough to clear the infection. A different approach can be taken for small abscesses that are not too serious. In these cases, the doctor might suggest a more conservative approach, where the patient takes antibiotics and the doctor manually presses on the abscess to help the pus come out.
When a Person Should Avoid Incision and Drainage
In some situations, a doctor might not be able to conduct a simple, bedside incision and drainage procedure. Some factors that could prevent this include abscesses (infected pockets of pus) that are too big or too deep, abscesses that are near blood vessels or nerves, abscesses that contain something foreign, when there is a pulsating lump at the site of infection and abscesses that are located in particular areas of the body.
Certain body areas can make drainage more difficult to perform. This could be due to the sensitivity of the area like the palms, soles and face, or because of complex issues that might arise. For instance, the area around the rectum (perirectal) and nipples (periareolar) could lead to fistula formation (an abnormal connection between two body parts) and would require a surgical expert’s intervention.
Neck abscesses, especially those that could have developed from preexisting cysts (sacs filled with fluid or other substances), should be evaluated by a head and neck specialist (otolaryngologist).
People with artificial or abnormal heart valves might need preventive antibiotics before the procedure which could delay it. Finally, if you have pre-existing blood clotting disorders or known allergies to anesthetics like lidocaine or epinephrine, or to latex (which could be found in gloves used during the procedure), it’s important to tell your doctor in advance.
Equipment used for Incision and Drainage
To conduct a safe and successful medical procedure, the following clean equipment is usually needed: a disinfectant (usually povidone-iodine or chlorhexidine), a local drug for numbing (1% or 2% lidocaine, lidocaine mixed with epinephrine, or bupivacaine), a small syringe with a slim needle, sterile cotton pads, a scalpel with a handle, a curved instrument for stopping blood flow (hemostat), saline solution (a sterile mixture of salt and water) with a large syringe/splash guard/bowl for cleaning the area, packing material (iodoform or plain gauze) to fill the wound after cleaning, swabs to collect samples from the wound for testing (if needed), and scissors and adhesive tape for dressing the wound.
Incision and drainage procedures, which involve cutting the skin and draining out fluid or pus, can sometimes be painful. In addition to the numbing medicine applied locally, you may also need some pain-relieving medicine taken orally or injected into your body.
Who is needed to perform Incision and Drainage?
The process is fairly straightforward and is usually carried out by only one doctor. However, additional staff might be needed in certain situations.
For example, in children’s healthcare, child life services can greatly aid in carrying out a successful treatment. Child life specialists are professionals who provide emotional support to children and their families in hospitals or clinics. A recent research study in children’s emergency medicine examined the effect of these specialists on the emotional well-being of children who needed stitch-up for cuts in the emergency room.
The study compared children who got stitches without these specialists to those who had a child life specialist present. The children who had these specialists with them were found to be less scared or upset during the procedure.
Preparing for Incision and Drainage
Before starting a medical procedure, the patient or their legal guardian needs to give their clear, informed consent. This means they must understand and agree to the risks involved. These risks might include bleeding, pain, and the possibility of a scar forming afterwards.
Also, it’s important to make sure the patient has been vaccinated against tetanus. This vaccine protects against a serious bacterial infection that can occur when a wound isn’t properly cleaned.
During the procedure, it’s crucial for the doctor to follow safety procedures. This includes wearing protective clothing such as a gown, gloves, and a mask or safety goggles. Even though the procedure is not considered to be sterile (because the area being treated is already infected), it’s still wise for the doctor to use clean tools and hands to prevent the spread of other infections.
How is Incision and Drainage performed
If you have an abscess, a kind of skin infection that is filled with pus, your doctor may decide to do a small operation to drain it. This treatment is often called incision and drainage, or I&D. Here’s how it works:
The doctor starts by using a sharp knife, called a scalpel, to make a tiny cut over the middle of the abscess. They make the cut in line with the natural lines of tension in your skin, which helps to avoid scarring. Once the cut is made, pus will start to come out.
Next, the doctor uses a special curved tool to move apart the skin and tissue inside the abscess. This helps to break up any clumps of pus or tissue, which can help the pus drain out more effectively. The doctor might also squeeze the abscess gently to help get the pus out.
Once the pus is drained, the doctor rinses out the wound with a sterile salt water solution. If the abscess is 5 cm or smaller, the doctor may decide not to pack the wound (fill it with a special bandage) because this doesn’t always help it heal and it might cause more pain. Packing the wound also doesn’t necessarily prevent the abscess coming back.
After the abscess has been cleaned, the doctor covers it with a sterile bandage and some medical tape. It’s usually a good idea to go back to the doctor’s office in 2 or 3 days after the procedure. This is so they can take out the packing (if it was used) and check that the wound is healing properly. After that, the wound is usually left to heal on its own over time.
Sometimes doctors use other methods to treat abscesses. For example, they might use a needle to draw out the pus instead of making a cut. But this is less common because it may not be as effective and could be more invasive. There’s also a technique called loop drainage that might cause less pain or scarring. Some studies suggest it could be better than traditional I&D, but it’s not used very often yet.
Possible Complications of Incision and Drainage
Usually, the process of draining an abscess (known as incision and drainage or I&D) is well-handled by patients. The main issue that people might experience is pain. If the abscess isn’t drained properly, the infection can spread to the tissues around it and make the person’s condition worse.
What Else Should I Know About Incision and Drainage?
Cutting into and draining an abscess (a painful, swollen, infected area) is a routine procedure that is done often in many medical settings. It’s the go-to treatment for abscesses that are under the skin, regardless of whether antibiotics are also being used.