Overview
Definition:
Incision and drainage (I&D) of an abscess is a fundamental surgical procedure involving the creation of an opening to allow purulent material to exit, facilitating healing and preventing systemic spread
In children, this procedure often requires careful consideration of pain management and psychological preparedness, frequently necessitating sedation or anesthesia.
Epidemiology:
Cutaneous abscesses are common pediatric infections, particularly in the toddler and preschool age groups
Perianal abscesses and those in other common locations (e.g., limbs, trunk) are frequently encountered
The incidence varies by socioeconomic factors, hygiene, and prevalence of skin colonization by bacteria like Staphylococcus aureus.
Clinical Significance:
Prompt and effective I&D of pediatric abscesses is crucial to alleviate pain, prevent the extension of infection, reduce the risk of systemic sepsis, and minimize scarring
Inadequate or delayed management can lead to serious complications
Sedation planning is paramount to ensure patient comfort, safety, and procedural success in this age group.
Age Considerations
Infants And Toddlers:
Higher risk of separation anxiety and gagging reflex
Requires careful selection of agents and monitoring due to immature metabolic pathways
Shorter procedures often managed with lighter sedation or topical anesthesia.
Older Children And Adolescents:
Can often cooperate with local anesthesia and reassurance
May tolerate longer procedures with mild to moderate sedation
Psychological preparation is key to reduce fear and anxiety.
Specific Abscess Locations:
Perianal abscesses may require deeper sedation due to anal sphincter manipulation
Deep soft tissue or intra-abdominal abscesses necessitate a multidisciplinary approach, often with general anesthesia.
Clinical Presentation
Symptoms:
Localized swelling and tenderness
Erythema and warmth over the affected area
Fever, malaise, and irritability, especially in younger children
Pain, which may be exacerbated by movement or palpation
Difficulty with specific functions depending on location (e.g., difficulty walking with a lower limb abscess, pain with defecation for perianal abscess).
Signs:
Fluctuant palpable mass
Red, inflamed skin
Signs of systemic illness may include fever (temperature >38°C or 100.4°F), tachycardia, and leukocytosis
Tenderness on palpation
Possible purulent discharge if the abscess has spontaneously ruptured or is close to the surface.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the presence of a tender, fluctuant, erythematous, localized swelling
Laboratory investigations (CBC, CRP) may support the diagnosis of infection but are not diagnostic of an abscess
Imaging (ultrasound, CT scan) may be used to confirm the presence, size, and depth of the abscess, especially for deep-seated or complex cases, or when surgical drainage is not straightforward.
Sedation Planning
Pre Sedation Assessment:
Thorough history including allergies, previous anesthetic/sedation experiences, current medications, and comorbidities
Physical examination focusing on airway, cardiovascular, and respiratory systems
NPO status assessment according to established guidelines (e.g., 2 hours for clear liquids, 4 hours for breast milk, 6 hours for formula/light meal).
Sedation Goals:
Patient comfort and amnesia
Immobility during the procedure
Adequate analgesia
Maintenance of physiological stability
Rapid recovery with minimal side effects
Minimization of psychological distress.
Sedation Options:
Local anesthesia (lidocaine with or without epinephrine) for superficial, small abscesses
Topical anesthetics (EMLA cream) for initial skin numbing
Minimal sedation (e.g., oral midazolam) for anxious children
Moderate sedation (e.g., IV midazolam, ketamine, fentanyl) for cooperative children
Deep sedation or general anesthesia for extensive, deep, or complex abscesses, or uncooperative patients
Combination agents (e.g., ketamine-midazolam) may be used.
Monitoring Requirements:
Continuous monitoring of vital signs (heart rate, respiratory rate, blood pressure, oxygen saturation)
Capnography is recommended for moderate to deep sedation
Pulse oximetry is mandatory
Trained personnel to monitor the patient throughout the procedure and during recovery
Availability of resuscitation equipment and drugs.
Management
Initial Management:
Pain control with appropriate analgesics
Application of warm compresses to promote localization and spontaneous drainage if possible
Antibiotics are generally not indicated prior to drainage for simple cutaneous abscesses but may be considered for large, rapidly advancing, or systemic signs of infection.
Surgical Management:
Incision and drainage: sterile preparation, local infiltration with anesthetic, linear incision over the point of maximal fluctuance and erythema
Gentle exploration with a hemostat or blunt probe to break loculations and ensure complete drainage
Irrigation of the cavity with sterile saline
Placement of a drain (e.g., iodoform gauze, Penrose drain) if cavity is large or deep, or if there is a risk of early re-closure.
Wound Care Post Drainage:
Sterile dressing changes
Advise parents on daily dressing changes and keeping the wound clean and dry
Warm soaks may be beneficial
Encourage gentle movement to prevent stiffness
Removal of drains when purulent discharge has ceased (typically 24-72 hours).
Antibiotic Therapy:
Antibiotics are usually reserved for cases with: suspected cellulitis extending beyond the abscess, systemic signs of infection (fever, sepsis), immunocompromised patients, or specific high-risk locations (e.g., perianal abscesses, deep soft tissue infections)
Empiric coverage for Staphylococcus aureus and Streptococcus pyogenes is common, often with cephalexin, clindamycin, or trimethoprim-sulfamethoxazole depending on local resistance patterns and patient factors.
Complications
Early Complications:
Inadequate drainage leading to recurrence
Spread of infection to surrounding tissues (cellulitis)
Phlebitis or thrombophlebitis if IV access is used
Hemorrhage
Nerve injury (rare)
Allergic reactions to anesthetic agents.
Late Complications:
Abscess recurrence if not fully evacuated or if loculations remain
Scarring and disfigurement
Chronic draining sinus tract
Osteomyelitis (rare, especially with deep bone proximity)
Fistula formation (particularly with perianal abscesses).
Prevention Strategies:
Thorough surgical technique ensuring complete evacuation and breaking of loculations
Appropriate wound care and follow-up
Judicious use of antibiotics when indicated
Careful selection and monitoring of sedation.
Prognosis
Factors Affecting Prognosis:
Promptness of diagnosis and treatment
Completeness of drainage
Patient's immune status
Presence of comorbidities
Adherence to wound care instructions.
Outcomes:
Generally excellent with complete resolution and minimal sequelae
Most children recover fully with appropriate management
Recurrence rates are low with proper technique and follow-up.
Follow Up:
Follow-up is typically required to assess wound healing, ensure no recurrence, and remove drains
The frequency depends on the abscess size, location, and patient's condition
For most superficial abscesses, a single follow-up visit within a week is sufficient
Perianal abscesses and deep infections may require more extensive follow-up.
Key Points
Exam Focus:
The primary goal of I&D is to achieve complete pus evacuation
Sedation is integral to pediatric abscess management, balancing patient comfort with safety
Understand age-appropriate sedation agents and monitoring protocols
Recognize indications for antibiotics.
Clinical Pearls:
Always have adequate lighting and suction available
Break all loculations with a hemostat or probe to prevent early re-closure
Consider epinephrine in local anesthetic for hemostasis but avoid in distal extremities
Document sedation agents, doses, and patient's response meticulously.
Common Mistakes:
Anticipating spontaneous drainage without incision
Incomplete drainage due to failure to break loculations
Over-reliance on antibiotics without drainage
Inadequate sedation leading to patient distress and procedural failure
Insufficient post-procedural monitoring.