Ultrasound-guided abscess drainage

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Author: Mikael Häggström [notes 1]

Planning

Coagulation

Superficial

This procedure counts as conferring a relatively low risk of clinically significant bleeding when being superficial, such as in the neck, thoracic wall, abdominal wall or limbs, and the following bleeding precautions refer to such cases.[1]

Required lab test

Prothrombin time (PT or INR):

  • Inpatients: within 24 hours
  • Outpatients with a healthy liver: Within 2 weeks
  • Outpatients with liver disease and no additional acute disease since then: Within 1 week

Lab interpretation

  • INR should be corrected if over 2.0
  • If partial thromboplastin time (aPTT or APTT) has been tested, it should be corrected if over 1.5 times its normal upper limit.
  • If platelet count has been performed, transfusion is indicated if it is below 50 x 109/L (equals 50,000/µL).

Anticoagulant medication

  • Coumarin (warfarin): Normally stop 3-5 days before, in order to reach INR ≤ 2.0
  • Low-molecular-weight heparin (LMWH): Stop 1 preceding dose
  • Dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis) and edoxaban (Savaysa, Lixiana):
  • Glomerular filtration rate over 30 ml/min: Stop 24 hours before
  • Glomerular filtration rate less than 30 ml/min: Stop 48 hours before
  • Clopidogrel (Plavix), prasugrel (Efient), ticagrelor (Brilinta, Brilique, and Possia): Stop 5 days before
  • Dipyridamole (Persantine): Stop 48 hours before
  • NSAIDs (including aspirin): No need to stop

Thorax or abdomen

This procedure counts as conferring a moderate risk of clinically significant bleeding being deeper into the thorax or abdomen, and the following bleeding precautions refer to such cases.[2]

Required lab test

Prothrombin time (PT or INR):

  • Inpatients: within 24 hours
  • Outpatients with a healthy liver: Within 2 weeks
  • Outpatients with liver disease and no additional acute disease since then: Within 1 week

Lab interpretation

  • INR should be corrected if over 1.5
  • If partial thromboplastin time (aPTT or APTT) has been taken, it should be corrected if over 1.5 times its normal upper limit.
  • If platelet count has been performed, transfusion is indicated if it is below 50 x 109/L (equals 50,000/µL).

Anticoagulant medication

  • Coumarin (warfarin): Normally stop 3-5 days before, in order to reach INR ≤ 1.5
  • Low-molecular-weight heparin (LMWH): Stop 1 preceding dose
  • Dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis) and edoxaban (Savaysa, Lixiana):
  • Glomerular filtration rate over 30 ml/min: Stop 2 days (48 hours) before
  • Glomerular filtration rate less than 30 ml/min: Stop 3 days (72 hours) before
  • Clopidogrel (Plavix), prasugrel (Efient), ticagrelor (Brilinta, Brilique, and Possia): Stop 5 days before
  • Dipyridamole (Persantine): Stop 2 days (48 hours) before
  • NSAIDs (including aspirin): No need to stop

Procedure

1. Ask for any allergic reaction to local anesthetics
2. Check proper puncture location with ultrasonography.

  • The puncture location can be marked by a skin impression (such as a pen with withdrawn nib), or with a skin marker (which may, however, disappear during washing).
  • For more superficial abscesses, consider memorizing the expected depth and direction of the catheter insertion in order to do it without simultaneous ultrasonography.

3. The skin area is washed with an antiseptic
4. Wear at least sterile gloves, and use sterile coverage on the ultrasound probe if using it during the puncture.

Various settings of a 6 French pigtail catheter with locking string, obturator (also called stiffening cannula) and puncture needle.
A. Overview
B. Both puncture needle and obturator engaged, allowing for direct insertion.
C. Puncture needle retracted. Obturator engaged. Used for example in steady advancement of the catheter on a previously inserted guidewire.
D. Both obturator and puncture needle retracted, when the catheter is in place.
E. Locking string is pulled (bottom center) and then wrapped and attach to the superficial end of the catheter.

5. Preferably use a pigtail catheter. For liver abscesses the sizes range between 6–14 French, with a median of 10 French.[3]
6. Have a scalpel ready for skin incision
7. Infuse local anesthetic, such as 10 - 20 ml of 1% carbocaine, along the planned puncture direction
8. Make a skin incision large enough for the catheter to pass
9. Insert the catheter with the cannula until reaching within the abscess.
10. Loosen the cannula from the catheter, and advance the catheter only.
11. Withdraw the cannula
12. Check for return, and note the color of any fluid. Attach plug, syringe or bag to the external tip.
13. Twist any pigtail of the catheter
14. Fixate the external part to the skin

Report

  • Size of catheter.
  • Presence or absence of complications.
  • Color of the fluid.
See also: General notes on reporting

Notes

  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Radlines:Authorship for details.

References

  1. The coagulation section follows local practice at: NU Hospital Group, Sweden
  2. The coagulation section follows local practice at: NU Hospital Group, Sweden
  3. Dulku, Gurjeet; Mohan, Geeta; Samuelson, Shaun; Ferguson, John; Tibballs, Jonathan (2015). "Percutaneous aspiration versus catheter drainage of liver abscess: A retrospective review ". Australasian Medical Journal: 7–18. doi:10.4066/AMJ.2015.2240. ISSN 18361935.