Atlas of Primary Care Procedures, 1st Edition

General Procedures

1

Incision and Drainage of Abscesses

It is an old axiom of medicine that pus collections must be drained for healing to occur. Pus that becomes locally trapped under the skin and produces an inflammatory reaction is called an abscess (i.e., furuncle or boil). Carbuncles are aggregates of infected follicles. Cellulitis may precede or occur in conjunction with an abscess. An abscess is not a hollow sphere; it is a cavity formed by fingerlike loculations of granulation tissue and pus that extends outward along planes of least resistance. A paronychia is a localized abscess that involves a nail fold.

Abscesses are most commonly found on the extremities, buttocks, groin, axilla, breast, and areas prone to friction or minor trauma.Staphylococcus aureus and Streptococcus species are the most common causative agents, but other microorganisms, including gram-negative and anaerobic bacteria, may be present. Enteric organisms are common in perianal abscesses.

Abscesses may follow one of two courses. The abscess may remain deep and slowly reabsorb. Alternatively, the overlying epithelium may attenuate (i.e., pointing), allowing the abscess to spontaneously rupture to the surface and drain. Rarely, deep extension into the subcutaneous tissue may be followed by sloughing and extensive scarring. Conservative therapy for small abscesses includes warm, wet compresses and antistaphylococcal antibiotics. The technique of incision and drainage (I&D) is a time-honored method of draining abscesses. Routine cultures and antibiotics are usually unnecessary if an abscess is properly drained.

After I&D, instruct the patient to watch for signs of cellulitis or recollection of pus. Train patients or family to change packing, or arrange for the patient's packing to be changed as necessary. Cellulitis, bacteremia, and gangrene are rare complications and occur most commonly in patients with diabetes or other diseases that interfere with immune function. I&D of a perianal abscess may result in a chronic anal fistula and may require a fistulectomy by a surgeon.

P.4

INDICATIONS

  • An abscess that is not spontaneously resolving

CONTRAINDICATIONS

  • Consider more aggressive therapy, closer observation, wound culture, and antibiotic therapy in patients with diabetes, debilitating disease, compromised immunity, or facial abscesses located within the triangle formed by the bridge of the nose and the corners of the mouth. The latter infections carry a risk of septic phlebitis with intracranial extension.

P.5

PROCEDURE

Prep and drape the area in a sterile fashion. Administer a field block with local anesthetic (see Chapter 23). The skin overlying the top of the abscess also is anesthetized.

(1) Administer a field block with local anesthetic.

PITFALL: Avoid injecting into the abscess cavity, because local anesthetics usually work poorly in the acidic milieu of an abscess.

P.6

The abscess is ready for drainage when the skin has thinned and the underlying mass becomes soft and fluctuant (i.e., pointing). A no. 11 surgical blade is inserted and drawn parallel to the lines of lesser skin tension, creating an opening from which pus may be expressed (Figure 2A). Often, an up-and-down incision with the no. 11 blade is adequate. Avoid extending the incision into non-effaced skin. Apply pressure around the abscess to expel pus from the wound (Figure 2B).

(2) Make an up-and-down incision with a no. 11 surgical blade, and apply pressure around the abscess to expel the pus from the wound.

PITFALL: Abscesses can explode upward on entry. Wear protective eyewear if the abscess contents appear to be under pressure.

PITFALL: Abscesses most often recur because of an incision that is not wide enough to prevent immediate closure.

P.7

Insert a probe, cotton-tipped applicator, hemostats, or curette through the opening, and draw it back and forth to break adhesions and dislodge necrotic tissue. If a culture is desired, obtain it from deep in the abscess cavity.

(3) Insert a probe through the opening, and draw it back and forth to break adhesions and dislodge necrotic tissue.

If the cavity is large enough, pack it with a ribbon of plain or iodoform gauze to promote drainage and prevent premature closure. Grasp the end of the ribbon with a pair of forceps, and place it through the incision to the base on the abscess (Figure 4A). Fold additional ribbon into the cavity until it is filled. Leave approximately 1–2 cm of gauze on the surface of the skin (Figure 4B). Apply a sterile dressing over the area.

(4) If the cavity is large enough, pack it with plain or iodoform gauze to promote drainage and prevent premature closure.

P.8

CODING INFORMATION

P.9

CPT® Code

Description

2002 Average 50th Percentile Fee

10040*

Acne surgery

$95

10060*

I&D of single or simple abscess

$120

10061

I&D of multiple or complex abscesses

$275

10080*

I&D of pilonidal cyst, simple

$144

10081

I&D of pilonidal cyst, complicated

$338

10140*

I&D of hematoma, seroma, or fluid collection

$150

10160*

Puncture aspiration of abscess, hematoma, bulla, or cyst

$120

10180

I&D, complex, of postoperative wound infection

$424

21501

I&D of deep abscess of neck or thorax

$605

23030

I&D of deep abscess of shoulder

$579

23930

I&D of deep abscess of upper arm or elbow

$642

23931

I&D of deep abscess of upper arm or elbow bursa

$525

25028

I&D of deep abscess of forearm or wrist

$675

26010*

I&D of simple abscess of finger

$204

26011*

I&D of complicated abscess of finger or felon

$448

26990

I&D of deep abscess of pelvis or hip joint area

$763

26991

I&D of infected bursa of pelvis or hip joint area

$686

27301

I&D of deep abscess of thigh or knee region

$777

27603

I&D of deep abscess of leg or ankle

$730

28001*

I&D of bursa of the foot

$377

40800*

I&D of abscess, cyst, or hematoma in the vestibule of the mouth, simple

$138

40801

I&D of abscess, cyst, or hematoma in the vestibule of the mouth, complicated

$375

41000*

Intraoral I&D of abscess, cyst, or hematoma of tongue or floor of the mouth, lingual

$217

41005*

Intraoral I&D of abscess, cyst, or hematoma of tongue or floor of the mouth, sublingual, superficial

$227

41006

Intraoral I&D of abscess, cyst, or hematoma of tongue or floor of the mouth, sublingual, deep

$468

41800*

I&D of abscess, cyst, or hematoma from dentoalveolar structures

$187

54015

I&D of deep abscess of penis

$375

54700

I&D of abscess of epididymis, testis, or scrotal space

$395

55100*

I&D of abscess of scrotal wall

$276

56405*

I&D of abscess of vulva or perineum

$242

56420*

I&D of abscess of Bartholin's gland

$190

67700*

I&D of abscess of eyelid

$184

69000*

I&D of abscess of external ear, simple

$138

69005

I&D of abscess of external ear, complicated

$438

CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING

Standard skin tray supplies are shown in Appendix A. A suggested anesthesia tray that can be used for this procedure is listed in Appendix G. Skin preparation recommendations appear in Appendix H.

BIBLIOGRAPHY

Habif TP. Clinical dermatology: a color guide to diagnosis and therapy, 2nd ed. St Louis: Mosby, 1996:201.

Hedstrom SA. Recurrent staphylococcal furunculosis: bacterial findings and epidemiology in 100 cases. Scand J Infect Dis 1981;13:115–119.

Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med 1985;14:15–19.

Meislin HW, Lerner SA, Graves MH, et al. Cutaneous abscesses: anaerobic and aerobic bacteriology and outpatient management. Ann Intern Med 1977;87:145–149.

Usatine RP. Incision and drainage. In: Usatine RP, May RL, Tobinide EL, Siegel DM, eds. Skin surgery: a practical guide. St Louis: Mosby, 1998:200–210.


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