Abscess: Incision and Drainage Mona Kulkarni, MD Pediatric Emergency Medicine Associates Children’s Healthcare of Atlanta WellStar Health System Pediatric Sedation Services

Abscess

• Collection of pus within the dermis or subcutaneous space• Manifests as a painful, fluctuant, erythematous nodule with or

without surrounding cellulitis• A drainable abscess should undergo I and D. Consider sending

it for culture and sensitivity• Lab testing is NOT required for an uncomplicated infection and

blood cultures are not necessary unless you suspect systemictoxicity.

Children’s Healthcare of Atlanta

Abscess

• An abscess has a normally appearing epidermis and the dermiscontain an aggregate of acute inflammatory cell surrounded bya fibrinoid wall

Outpatient management

-identified the lesion and it’s greater than 5 mm in diameter -accessible area -compliant patient

-informed consent

Children’s Healthcare of Atlanta

Contraindicat ions:

• Extremely large or deep infections will likely willrequire deep sedation or surgical drainage

• Abscess of palms, soles , breast and involving thecentral triangle of the face may require consultationwith a specialist

• Not indicated for cutaneous cellulitis• Adjacent to vital nerves or blood vessels• Difficult airway or bleeding disorders

Children’s Healthcare of Atlanta

Supplies and Anesthetic

• Similar to laceration repair• Skin cleansing agent• Saline for irrigation• Lidocaine - appropriate for most abscesses• Lidocaine with epi- can reduce incidence with

bleeding• Bupivacaine- longer duration of action

Children’s Healthcare of Atlanta

Tools you need

• Scalpel• Hemostat, curved• Swab for culture• Packing material / penrose drain / vessel loop• Irrigation device• Dressing of choice

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Packing/Drains

Children’s Healthcare of Atlanta

Treatment

• For small abscesses and a compliant patient-Local anesthesia and incision, irrigation and drainage -Would consider packing if large enough

• For larger abscesses, we recommend I and D under deepsedation-NPO status needs to be met for solids and liquids-Sedation team will use ketamine and propofol for proceduralsedation-Place penrose/ vessel loop

Children’s Healthcare of Atlanta

Treatment• For all of the S. Aureus isolates, the MRSA rate is 39%

– Hospital wide• For the S aureus isolates obtained in the ED the MRSA rate is

approximately 50%• Clindamycin is about 93-97 effective for MRSA• Bactrim is also highly effective• Recent studies show that the amount of tissue damage and

debris in the abscess can cause competive inhibition of thedrug active site and inactivation of bactrim so clindamycin ispreferred by our epidemiologists

CHOA 2016 Antibiogram results

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Thank you