Atlas of Procedures in Neonatology, 4th Edition

Miscellaneous Procedures

45

Drainage of Superficial Abscesses

An N. Massaro

Khodayar Rais-Bahrami

1. Definitions

A superficial abscess is

1. A localized collection of pus that causes fluctuant soft tissue swelling and may have associated erythema and induration (Fig. 45.1) (1,2,3 and 4)
2. Usually caused by invasion of local bacterial flora (1) or direct inoculation, i.e., animal bites ((5)) or intravenous access/skin piercing (6,7 and 8)
3. A result of bacterial organisms that cause necrosis, liquefaction, accumulation of leukocytes and debris, followed by loculation and walling off of pus (9)
4. Indications
5. To establish free drainage of contents from a superficial abscess

Surgical incision and drainage is the definitive treatment for soft tissue abscesses. Antibiotic therapy alone is ineffective in the setting of localized abscess and may even be unnecessary as an adjuvant to complete surgical drainage (1,2,10,11).

2. To identify pathogens and direct antimicrobial therapy if needed (12, 13,14 and 15)
3. To differentiate infectious from noninfectious lesions (13,16,17)
4. Contraindications
5. Carefully identify and avoid:
6. Cephalohematoma
7. Hemangioma
8. Cystic hygroma
9. Encephalocele
10. Avoid premature incision and drainage of abscesses that have not yet fully matured, i.e., in the initial stages of induration and inflammation prior to formation of pus (9). This may lead to:
11. A noncurative intervention
12. Possible extension of infectious process
13. Bacteremia

This may be avoided by the use of ultrasound with or without diagnostic needle aspiration (18,19).

1. Equipment

Sterile

1. Gloves and gown
2. Antiseptic swabs or cup containing antiseptic solution
3. 1-mL syringe
4. Nonbacteriostatic, isotonic saline without preservative
5. 23-gauge needle
6. 2 x 2-in gauze squares
7. Scalpel with no. 11 blade
8. Cotton-tipped culture swab
9. Mosquito hemostat
10. 2-in, fine-mesh, plain gauze

Nonsterile

1. Ethyl chloride spray as topical anesthetic (For larger lesions, local anesthesia with lidocaine may be used.)
2. Mask and cap
3. Adhesive tape
4. Precautions
5. Use appropriate isolation techniques to safeguard other infants.
6. Obtain blood cultures after drainage.
7. Do not suture abscess cavity following incision and drainage.
8. Débride all tissue undergoing putrefaction and digestion thoroughly (4).
9. Make skin incisions:
10. Conform with skin creases/natural folds to minimize scar formation
11. Large enough to allow for proper débridement and drainage
12. Simple linear–cruciate or elliptical skin incisions may result in more unsightly scar formation ((9)).
13. For abscesses in cosmetic areas, areas under significant skin tension (i.e., extensor surfaces), or areas with extensive scar tissue (i.e., sites of prior drainage procedures),

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a stab incision or needle aspiration alone may be preferable. (This may require multiple decompressions and/or delayed complete incision and drainage if reaccumulation occurs.)

7. Care should be taken in areas with abundant vascular and neural structures, such as the groin, posterior knee, antecubital fossa, and neck ((3)).
8. If foreign body is suspected, a radiograph should be obtained ((9)).

1. Technique (1,4,7,8)
2. Spray roof of abscess with ethyl chloride until skin becomes white. (If local anesthesia is required, lidocaine can be injected subcutaneously with a 25-gauge needle into the dome of the abscess).
3. Prepare as for major procedure if abscess is to be drained, or for minor procedure if needle aspiration alone is to be performed (seeChapter 4).
4. Prepare local area with antiseptic (e.g., iodophor).
5. Aspiration [may be performed in combination with incision and drainage for confirmation of presence of pus and collection of material for culture, or alone if abscess is in area where incision is not preferable (see E.6)].
6. Attach sterile needle to syringe.
7. Insert needle into pustule, abscess cavity, or advancing border of cellulitis.
8. Aspirate the material deep within the lesion.
9. If no material is aspirated, inject 0.1 to 0.2 mL of nonbacteriostatic saline and withdraw immediately.
10. Process aspirated material immediately: Gram stain and culture for anaerobic and aerobic organisms; Giemsa stain for suspected herpes. Perform other special stains as warranted.
11. Incision and drainage
12. Insert scalpel blade and incise at point of maximum fluctuance. The size of the incision should be as small as possible yet allow for continued adequate drainage (i.e., length of the abscess cavity).
13. Obtain specimen for culture with cotton-tipped applicator, if not obtained by prior aspiration with syringe and needle.
14. Evacuate exudate from abscess with gentle pressure from finger or hemostat wrapped in gauze. Use caution when probing abscess with finger in cases of suspected retained foreign bodies or fragments—for this reason, hemostat wrapped in gauze is the preferred method ((9)).
15. If necessary, insert mosquito hemostat into abscess cavity and spread blades to break septa and to release remaining collections of pus (Fig. 45.2A). Recognize that this may cause discomfort and should be done rapidly.
16. Lavage area with sterile saline to remove residual pus (optional).
17. If indicated, insert plain, ½-in gauze into abscess cavity to stop bleeding and/or to serve as a wick to promote drainage (Fig. 45.2B).
18. Apply dry, sterile dressing.
19. Remove half of gauze packing in 24 hours and remainder within 48 hours. (Some larger wounds may require multiple packing changes).
20. Check abscess wound, and apply sterile warm soaks for 20 to 30 minutes, three times a day, until healing has commenced, as indicated by:
21. Cessation of drainage
22. Formation of granulation tissue
23. Resolution of local tissue inflammation
24. Complications
25. Introduction of infection into sterile abscess or hematoma
26. Local bleeding
27. Injury to blood vessels, nerves, or tendons (deep to abscess cavity) (3)
28. Incomplete drainage with recurrent abscess formation (2,4)
29. Systemic infection (20,21)
30. Scar formation at drainage site, requiring skin graft (22)
31. Reduction of breast size following incomplete drainage of breast abscess (23)

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References

1. Meislin HW, McGehee MD.Management and microbiology of cutaneous abscesses. JACEP. 1978;7:186.
2. Meislin HN, Lerner SA, Graves MH, et al. Cutaneous abscesses: anaerobic and aerobic bacteriology and outpatient management.Ann Intern Med. 1977;87:145.
3. Albom M.Surgical gems: surgical management of a superficial cutaneous abscess. J Dermatol Surg Oncol. 1976;2:120.
4. MacFie J, Harvey J.The treatment of acute superficial abscesses: a prospective clinical trial. Br J Surg. 1977;64:264.
5. Brook I.Microbiology and management of human and animal bite wound infections. Primary Care. 2003;30:25.
6. Schnall SB, Holton PD, Lilley JC.Abscesses secondary to parenteral abuse of drugs. J Bone Joint Surg Am. 1994;76:1526.
7. Murphy EL, DeVita D, Liu H, et al. Risk factors for skin and soft tissue abscess among injection drug users: a case-control study.Clin Infect Dis. 2001;33:35.
8. Folz BJ, Lippert BM, Kuelkens C, Werner JA.Hazards of piercing and facial body art: report of three patients and literature review.Ann Plast Surg. 2000;45:374.
9. Butler KH.Incision and drainage. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia: WB Saunders; 2004:717.
10. Llera JL, Rios AM, Aten MF, et al. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med. 1985; 14:15.
11. Lee MC, Rios AM, Aten MF, et al. Management and outcome of children with skin and soft tissue abscesses caused by community-acquired methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J. 2004;23:123.
12. Goetz J, Tafari N, Boxerbaum B.Needle aspiration in Haemophilus influenzae type B cellulitis. Pediatrics. 1974;54: 504.
13. Rudoy R, Nakashima G.Diagnostic value of needle aspiration in Haemophilus influenzae type B cellulitis. J Pediatr. 1979;94:924.
14. Allen CH, Patel B, Endom EE.Primary bacterial infections of the skin and soft tissues: changes in epidemiology and management.Clin Ped Emerg Med. 2004;5:246.
15. Zetola N, Francis JS, Nuermberger EL, Bishai WR.Community-acquired methicillin-resistant Staphylococcus aureus: an emerging threat. Lancet Infect Dis. 2005;5:275.
16. Jarratt M, Ramsdell W.Infantile acropustulosis. Arch Dermatol. 1979;115:834.
17. Kahn G, Rywlin A.Acropustulosis of infancy. Arch Dermatol. 1979;115:831.
18. Cardinal E. Bureau NJ, Aubin B, Chhem RK.Role of ultrasound in musculoskeletal infections. Radiol Clin North Am. 2001;39:191.
19. Loyer EM, DuBrow RA, David CL, et al. Imaging of superficial soft-tissue infections: sonographic findings in cases of cellulites and abscess. AJR: Am J Roentgenol. 1996;166:149.
20. Fine BC, Sheckman PR, Bartlett JC.Incision and drainage of soft-tissue abscesses and bacteremia [letter]. Ann Intern Med. 1985;103:645.
21. Blick PWH, Flowers MW, Marsden AK, et al. Antibiotics in surgical treatment of acute abscesses. Br Med J. 1980;281:111.
22. Feder H, McLean WC, Moxon R.Scalp abscess secondary to fetal scalp electrode. J Pediatr. 1976;89:808.
23. Rudoy R, Nelson J.Breast abscess during the neonatal period. Am J Dis Child. 1975;129:1031.