Atlas of Procedures in Neonatology, 4th Edition
Drainage of Superficial Abscesses
An N. Massaro
A superficial abscess is
- 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)
- 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)
- A result of bacterial organisms that cause necrosis, liquefaction, accumulation of leukocytes and debris, followed by loculation and walling off of pus (9)
- 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).
- To identify pathogens and direct antimicrobial therapy if needed (12, 13,14 and 15)
- To differentiate infectious from noninfectious lesions (13,16,17)
- Carefully identify and avoid:
- Cystic hygroma
- 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:
- A noncurative intervention
- Possible extension of infectious process
This may be avoided by the use of ultrasound with or without diagnostic needle aspiration (18,19).
- Gloves and gown
- Antiseptic swabs or cup containing antiseptic solution
- 1-mL syringe
- Nonbacteriostatic, isotonic saline without preservative
- 23-gauge needle
- 2 x 2-in gauze squares
- Scalpel with no. 11 blade
- Cotton-tipped culture swab
- Mosquito hemostat
- 2-in, fine-mesh, plain gauze
- Ethyl chloride spray as topical anesthetic (For larger lesions, local anesthesia with lidocaine may be used.)
- Mask and cap
- Adhesive tape
- Use appropriate isolation techniques to safeguard other infants.
- Obtain blood cultures after drainage.
- Do not suture abscess cavity following incision and drainage.
- Débride all tissue undergoing putrefaction and digestion thoroughly (4).
- Make skin incisions:
- Conform with skin creases/natural folds to minimize scar formation
- Large enough to allow for proper débridement and drainage
- Simple linear–cruciate or elliptical skin incisions may result in more unsightly scar formation ((9)).
- 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),
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.)
- Care should be taken in areas with abundant vascular and neural structures, such as the groin, posterior knee, antecubital fossa, and neck ((3)).
- If foreign body is suspected, a radiograph should be obtained ((9)).
FIG. 45.1. Superficial abscess in the site of a Broviac central venous line insertion in the left anterior chest wall.
- Technique (1,4,7,8)
- 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).
- 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).
- Prepare local area with antiseptic (e.g., iodophor).
- 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)].
- Attach sterile needle to syringe.
- Insert needle into pustule, abscess cavity, or advancing border of cellulitis.
- Aspirate the material deep within the lesion.
- If no material is aspirated, inject 0.1 to 0.2 mL of nonbacteriostatic saline and withdraw immediately.
- Process aspirated material immediately: Gram stain and culture for anaerobic and aerobic organisms; Giemsa stain for suspected herpes. Perform other special stains as warranted.
- Incision and drainage
- 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).
- Obtain specimen for culture with cotton-tipped applicator, if not obtained by prior aspiration with syringe and needle.
- 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)).
- 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.
- Lavage area with sterile saline to remove residual pus (optional).
- 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).
- Apply dry, sterile dressing.
- Remove half of gauze packing in 24 hours and remainder within 48 hours. (Some larger wounds may require multiple packing changes).
- Check abscess wound, and apply sterile warm soaks for 20 to 30 minutes, three times a day, until healing has commenced, as indicated by:
- Cessation of drainage
- Formation of granulation tissue
- Resolution of local tissue inflammation
- Introduction of infection into sterile abscess or hematoma
- Local bleeding
- Injury to blood vessels, nerves, or tendons (deep to abscess cavity) (3)
- Incomplete drainage with recurrent abscess formation (2,4)
- Systemic infection (20,21)
- Scar formation at drainage site, requiring skin graft (22)
- Reduction of breast size following incomplete drainage of breast abscess (23)
FIG. 45.2. Drainage of a superficial abscess. A: Breaking the septa with a clamp. B: Packing the wound.
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