Surgical - Abscess (superficial)

Indications

Superficial abscess (0.5-5cm diameter)

confirmed by

Clinical examination, ultrasound or needle aspiration

Contraindications (absolute in bold)

Location with high complication rate:

Facial (septic phlebitis or cosmetic concerns)

Anterior and lateral neck (potentially arising from congenital cysts)

Hand (excluding paronychia)

Breast (high risk of scarring, may require excision of lactiferous ducts)

Perianal (risk of fistulae)

Adjacent to vital nerves or blood vessels (groin, axilla)

Complex abscess:

Larger abscesses (>5cm diameter)

Recurrent abscesses

Following recent surgery

Multiple interconnected abscesses

Inaccessible location

Alternatives

Referral to relevant surgical team

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Failure (incomplete drainage)

Pain

Bleeding

Progressive infection

Bacterial endocarditis (antibiotic prophylaxis suggested for high-risk groups)

Wound dehiscence

Recurrence

Scar formation (scaring is expected)

Procedural hygiene

Standard precautions

Aseptic non-touch technique

PPE: aprons, surgical mask, protective eyewear or shield, sterile gloves, sterile ultrasound cover and gel

Area

Procedure room or bed space with adequate space and lighting

Staff

Procedural clinician

Equipment

10ml syringe with 25g needle and drawing up needle (for anaesthetic infiltration)

20ml syringe with 18g blunt needle (for irrigation)

Scalpel with handle (size 11-15)

Swab for bacterial culture

Small curved haemostat

0.9% saline (for irrigation)

Penrose drain, sterile rubber band or silicon vessel loop (for loop drainage technique only)

Sterile gauze and tape

Positioning

Supine, in position of comfort to optimising access to abscess

Medication

Premedication 30-60 minutes prior to procedure (paracetamol, ibuprofen, codeine, oxycodone)

Lignocaine 1-2% with adrenaline 1:100,000 (maximum 7mg/kg) or

Lignocaine 1-2% without adrenaline (maximum 3mg/kg)

Consider additional intranasal fentanyl, IV opiates, regional nerve block or procedural sedation

Sequence (anaesthetic infiltration)

Insert 25g needle parallel to skin with bevel up

Inject anaesthetic as soon as the bevel is beneath the skin

Slowly advance the needle or initially insert it to the hub, and infiltrate as the needle is withdrawn

Infiltrate the entire area to be incised, avoiding the abscess cavity (painful and without anaesthetic benefit)

Aim to perform the injection with one puncture, or the minimum number possible

Allow 10 minutes for anaesthetic to take effect prior to incision (time increased due to acidic tissue pH)

Sequence (incision and drainage - suitable for all abscesses)

Using the scalpel make a stab incision directly over the centre of the fluid collection

Aim to make the incision in line with skin creases and natural folds (minimising scaring)

Maintain pressure until the abscess cavity is opened with purulent drainage (avoiding puncture of back wall)

Extend the excision to the full length of the abscess cavity (allowing adequate drainage and entry of haemostat)

Consider obtaining a swab from the interior of the cavity for a bacterial culture (see discussion below)

Allow wounds to drain spontaneously and then gently express any additional contents

Using the haemostat, probe the depth of the abscess in a circular motion identifying deep tracks into tissues

Opening the haemostat regularly to break open any loculations

Irrigate the wound with 0.9% saline until clear of purulent exudate

Leave the abscesses open to heal by secondary intention

Place an absorbent gauze dressing over the abscess and tape in place

Sequence (loop drainage - reduces pain and scarring when treating larger abscesses)

Using the scalpel make a 5-10mm incision over one end of the fluid collection

Aim to make incision in line with skin creases natural folds (minimising scaring)

Maintain pressure until the abscess cavity is opened with purulent drainage (avoiding puncture of back wall)

Consider obtaining a swab from the interior of the cavity for a bacterial culture (see discussion below)

Allow wounds to drain spontaneously and then gently express any additional contents

Using the haemostat, probe the abscess in a circular motion identifying deep tracks and breaking loculations

Determining the opposite edge of the abscess with the haemostat and tent the skin at this site

Using the scalpel make another incision over the top of the haemostat (maximum 4cm from the first incision)

Irrigate the wound through the incisions with 0.9% saline until clear of purulent exudate

Place the edge of the drain (Penrose drain, sterile rubber band, or vessel loop) into one of the incision openings

Place the curved haemostat into the other incision, grasp the drain, and then pull it back through the hole

Tie a knot in the drain at least four times but with no tension on the skin (tie over a syringe)

Place an absorbent gauze dressing over the abscess and tape in place

Post-procedure care

Ongoing care

Consider admission and IV antibiotics if systemically unwell or progressive cellulitis

Provide tetanus immunisation (if not immunised in last 5 years)

Prescribe five days course antibiotics (Bactrim 160+800mg bd or clindamycin 450mg tds)

Arrange follow-up in 2-3 days for review

Loops drains should be moved daily to encourage drainage and removed when drainage ceased (maximum 7-10 days)

Patient advice

Remove bandage to soak the wound several times a day in warm, soapy water

The wound should then be re-dressed each time with dry gauze until fully healed

Return if feeling more unwell with fever or chills, increased pain, redness or re-accumulation of pus

The wound should initially be reviewed in 2-3 days, and may require further visits

If drainage has stopped by the time of the initial wound check, loop drains can be removed

Tips

Ultrasound is better than clinical judgement for determining the presence and size of an abscess

Needle aspiration can also assist confirmation of an abscess if clinical exam is uncertain

Avoid infiltration of local anaesthetic into the abscess (increases pain with no anaesthetic benefit)

Use adequate doses of anaesthetic and allow time to work (acidic infected tissue reduces anaesthetic efficacy)

Face shielding prior to incision is important as many abscesses are under pressure

Cruciate or elliptical incisions cause increased scarring and should be avoided

Discussion

Antibiotics alone are ineffective at treating abscessed, and needle aspiration has a 75% failure rate. The treatment of choice for abscesses in the emergency department is incision and drainage.

Abscess drainage has been rated as the second most painful common emergency department procedure after nasogastric insertion. Adequate local anaesthesia of an abscess cavity can be difficult to achieve due to the acidic pH of infected tissue. The problem can often be overcome by infiltrating more local anaesthetic and allowing additional time for it to work however it is worthwhile considering addition modalities of pain relief.

We recommend antibiotics with activity against MRSA after incision and drainage of a skin abscess. Antibiotics must cover MRSA (e.g. trimethoprim + sulfamethoxazole or clindamycin) which grows in 50% of abscess cultures. Expert opinion varies but recent meta-analysis suggests higher cure rates and lower chance of recurrence with antibiotics even for small abscesses. These benefits must be balanced against the risk of antibiotics. It is also reasonable to omit antibiotics, especially for smaller abscesses (<2cm) in the otherwise healthy, or patients with multiple antibiotic allergy.

Cultures will not often affect management but may be useful in treatment failure. We suggest they are obtained in those with severe infection and very young or old when treatment failure might have serious consequences. We also suggest they are collected for those who may harbour atypical organisms (history of treatment failure, recurrent infection or immunosuppression).

We have suggested avoiding primary closure in the emergency department. Primary closure using non-absorbable sutures and vertical mattress technique is an option for small abscesses <5cm with minimal skin erythema. This may result in faster healing with less recurrence and less scaring, but the available evidence is limited.

We have not recommended packing abscesses drained in the emergency department. Packing abscesses <5cm in diameter does not appear to reduce requirements for further drainage procedures and is painful.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

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