A. Introduction

Welcome to this lesson on incision and drainage (I&D) of abscesses. This lesson will cover the procedure for performing I&D. We’ll discuss how to identify abscesses, the steps involved in the procedure, and how to manage potential complications.

• Introduce the topic: This section provides an overview of the lesson and its objectives.
• Review what you will learn in this lesson: This outlines the key skills and knowledge you will gain.
• Explain the importance of proper abscess management in the ICU: In the ICU, patients are often critically ill, and infections can lead to sepsis and increased mortality. Prompt and effective abscess management, including I&D, is crucial to control infection, reduce pain, and prevent further complications.
• Define abscesses and discuss why I&D is often necessary: Abscesses are localized collections of pus that often require I&D because antibiotics alone may not be sufficient to penetrate the walled-off infection and promote healing.
• Give a quick overview of what we will cover in this lesson: This provides a roadmap of the topics to be discussed.

B. Understanding Abscesses

Let’s define abscesses and discuss their formation and characteristics.

Define an abscess.

• An abscess is a localized collection of pus, typically caused by a bacterial infection.

Discuss the formation of abscesses:

• Bacterial infection: Bacteria invade tissue, often through a break in the skin.
• Inflammatory response: The body’s immune system responds to the infection, leading to inflammation.
• Pus accumulation: White blood cells, bacteria, and cellular debris accumulate, forming pus.
• Walling off of infection: The body forms a capsule around the infection, preventing it from spreading but also making it harder for antibiotics to reach.

Discuss the common locations of abscesses.

• Skin and subcutaneous tissue
• Perianal area
• Bartholin’s glands
• Dental
• Internal organs (less common, require imaging and specialized intervention)

Discuss the signs and symptoms of an abscess:

• Localized swelling: A visible bump or bulge.
• Redness: Erythema around the affected area.
• Warmth: Increased temperature at the site.
• Pain: Tenderness or discomfort that may worsen with pressure.
• Tenderness: Pain upon touch.
• Fluctuance (a tense, fluid-filled sensation): A hallmark sign indicating pus accumulation.

Discuss the importance of recognizing abscesses.

• Early recognition prevents complications like sepsis.
• Prompt treatment reduces patient discomfort.
• Accurate identification guides appropriate management (I&D vs. antibiotics).

C. Indications and Contraindications

It is important to know when to perform I&D, and when not to.

Discuss the indications for I&D:

• Localized abscess with signs of inflammation: The presence of redness, swelling, and warmth suggests an abscess.
• Pain and tenderness: The abscess is causing significant discomfort.
• Fluctuance: A compressible or boggy area, indicating pus.
• To prevent spread of infection: Draining the abscess helps to remove the source of infection and prevent complications.

Discuss the contraindications for I&D:

• Abscesses in certain locations (e.g., peritonsillar, retropharyngeal): These may be close to major blood vessels or airways, requiring specialized surgical expertise.
• Abscesses associated with underlying conditions (e.g., immunocompromised): Patients with weakened immune systems may require more extensive management and closer monitoring.
• Non-fluctuant lesions (may not be ready for I&D): If there is no fluctuance, there may not be a significant collection of pus to drain.
• Small, early abscesses (may resolve with antibiotics alone): In some cases, antibiotics can resolve the infection before a large abscess forms.

Discuss when to refer to a specialist.

• Abscesses in complex anatomical locations (e.g., head and neck, deep in the abdomen).
• Large or complicated abscesses.
• Patients with significant comorbidities or immunocompromised.
• Failure of initial I&D.

D. Equipment and Supplies

You must have the correct equipment and supplies for performing I&D.

Discuss the equipment and supplies needed for I&D:

• Personal protective equipment (PPE): gloves, mask, eye protection
• Skin preparation solution (e.g., chlorhexidine, povidone-iodine): To sterilize the area.
• Sterile drapes: To maintain a sterile field.
• Local anesthetic (e.g., lidocaine): To numb the area.
• Syringe and needle for anesthetic: To administer the anesthetic.
• Scalpel (typically #11 blade): For making the incision.
• Forceps (e.g., hemostats): For grasping and manipulating tissue.
• Curved hemostats or scissors for blunt dissection: For breaking up loculations.
• Gauze pads: For absorption of drainage and cleaning.
• Wound culture swab (if indicated): For microbiological analysis.
• Irrigation solution (e.g., sterile saline): For cleaning the abscess cavity.
• Packing material (e.g., iodoform gauze): To keep the incision open.
• Dressing materials: To cover and protect the wound.
• Needle holder and suture (if needed for large or gaping wounds): To close a portion of the wound.
• Suction device (if available): To remove large amounts of drainage.
• Light source: To provide adequate visualization.

Discuss how to select the appropriate equipment.

• Choose a scalpel blade (#11) appropriate for the size and location of the abscess.
• Select forceps and hemostats that are suitable for the depth and extent of the abscess cavity.
• Ensure the availability of adequate lighting for visualization.

Discuss how to ensure a sterile field.

• Perform hand hygiene.
• Wear sterile gloves.
• Use sterile drapes to isolate the area.
• Clean the skin with an antiseptic solution.
• Use sterile instruments.

E. Procedure

Here are the steps involved in performing an I&D procedure.

Step 1: How to prepare the patient and the area

• Obtain informed consent
• Explain the procedure to the patient
• Position the patient comfortably
• Expose the area
• Clean the skin with a skin preparation solution
• Apply sterile drapes

Step 2: How to administer local anesthesia

• Use the correct needle size
• Inject slowly and steadily
• Infiltrate the area around the abscess
• Consider a field block for larger areas
• Aspirate before injecting

Step 3: How to perform the incision

• Use a scalpel with a #11 blade
• Make a linear incision over the point of maximum fluctuance
• The incision should be large enough to allow for adequate drainage and exploration
• The incision should be made in the direction of skin tension lines, if possible

Step 4: How to drain the abscess

• Gently express the pus
• Use curved hemostats to enter the abscess cavity and break up loculations (pockets of infection)
• Explore the cavity to ensure complete drainage
• Obtain a wound culture if indicated (e.g., if the abscess is large, recurrent, or in an immunocompromised patient)

Step 5: How to irrigate the cavity

• Irrigate the abscess cavity with sterile saline
• Use a syringe with a catheter tip or a small irrigation device
• Irrigate until the drainage is clear

Step 6: How to pack the wound

• Loosely pack the abscess cavity with iodoform gauze or other packing material
• Packing helps to keep the incision open for continued drainage and prevents premature closure
• Leave a small portion of the packing material outside the wound for easy removal

Step 7: How to apply a dressing

• Apply a sterile dressing to cover the wound
• Choose a dressing that will absorb any drainage
• Secure the dressing with tape

Discuss pain management.

• Administer local anesthetic adequately.
• Consider oral analgesics (acetaminophen, NSAIDs).
• Reassess pain levels post-procedure.

F. Post-Procedure Care

Proper care after the procedure is important to promote healing and prevent complications.

Discuss post-procedure instructions:

• Keep the wound clean and dry
• Change the dressing as needed
• Take pain medication as prescribed
• Take antibiotics as prescribed (if indicated)
• Return for follow-up wound checks and packing removal
• Watch for signs of infection (increased pain, redness, swelling, warmth, pus, odor)

Explain how to remove the packing:

• Usually after 24-48 hours
• Gently remove the packing material
• Assess the wound
• Repack if necessary

Discuss wound re-evaluation.

• Assess for healing.
• Look for signs of complications.
• Determine if repacking is needed.

Discuss when to seek medical attention.

• Increased pain, swelling, or redness.
• Fever.
• Purulent drainage or foul odor.
• Bleeding that won’t stop.
• Return of the original symptoms.

G. Complications

Problems can sometimes occur after I&D.

Discuss potential complications:

• Infection or recurrence of the abscess: The abscess may not be completely drained, or a new infection may develop.
• Bleeding: Excessive bleeding during or after the procedure.
• Pain: Persistent or worsening pain.
• Cellulitis (spreading infection): Infection spreads to the surrounding skin.
• Fistula formation (abnormal connection): A channel develops between the abscess cavity and another structure.
• Scarring: The procedure can result in a scar.

Explain how to recognize, manage, and prevent complications.

• Recognize: Monitor for signs and symptoms.
• Manage: Treat with antibiotics, further drainage, or surgery.
• Prevent: Use sterile technique, ensure adequate drainage, and provide appropriate post-procedure care.

Discuss the management of specific complications.

• Infection: Antibiotics, re-drainage.
• Bleeding: Direct pressure, cauterization.
• Cellulitis: Antibiotics.

H. Documentation

Accurate and complete documentation of the procedure is essential.

Discuss what to document:

• Patient identification and consent
• Date and time of the procedure
• Location and size of the abscess
• Description of the drainage (amount, color, odor)
• Type of anesthesia used
• Procedure performed
• Wound appearance after drainage
• Packing material used (if any)
• Post-procedure instructions given to the patient
• Any complications encountered

Emphasize the importance of clear and concise documentation.

• Facilitates communication among healthcare providers.
• Provides a record of the procedure.
• Protects the healthcare provider legally.

Discuss medicolegal considerations.

• Informed consent.
• Proper technique.
• Adequate follow-up.
• Accurate documentation.

I. Hands-on Skills Practice

You will now practice the I&D procedure.

You will work in small groups.

Each group will have the necessary equipment and supplies (模拟脓肿, scalpels, etc.).

You will practice:

• Identifying abscesses
• Administering local anesthesia
• Performing the I&D procedure on a simulated abscess
• Packing the wound
• Applying a dressing