Breast Abscesses

[suckstobeme]

Do you guys drain your own breast abscesses? Open or needle?

In the past, I've gotten a surgery consult, but I'm questioning that practice. I'm decent with an US but I have never actually attempted an US guided needle aspiration of a breast abscess, though have done it elsewhere.

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[RPedigo]

It's actually interesting because our hospital literally just came up with a joint ED/acute care surgery/breast surgery/radiology pathway for breast abscesses. The four services involved decided that the best practice for our environment was: if septic, admit and consult appropriate service. If not septic, then (1) if it is superficial (<1 cm from skin surface) I&D by ED physician or acute care surgery consultation depending on ED physician comfort. (2) if it is deep (>1cm from skin surface) needle aspiration by ED physician, antibiotics, and follow up in breast clinic or refer to radiology for ultrasound-guided aspiration the next business day and follow up in breast clinic. We had a joint conference when we approved this and the breast surgeon actually said despite most of our trepidation and concern, it's actually totally fine to I&D a breast abscess (as long as they are not lactating, as you can create a milk duct fistula apparently).

 

[southerndoc]

Most of these are handled ourselves. Our APP's do most of the I&D's unless it's a teaching case that the resident saw. If they need admission or it's a really big abscess, we luckily have a breast surgery call panel that's oddly enough available 24/7/365.

 

[thegenius]

It's actually interesting because our hospital literally just came up with a joint ED/acute care surgery/breast surgery/radiology pathway for breast abscesses. The four services involved decided that the best practice for our environment was: if septic, admit and consult appropriate service. If not septic, then (1) if it is superficial (<1 cm from skin surface) I&D by ED physician or acute care surgery consultation depending on ED physician comfort. (2) if it is deep (>1cm from skin surface) needle aspiration by ED physician, antibiotics, and follow up in breast clinic or refer to radiology for ultrasound-guided aspiration the next business day and follow up in breast clinic. We had a joint conference when we approved this and the breast surgeon actually said despite most of our trepidation and concern, it's actually totally fine to I&D a breast abscess (as long as they are not lactating, as you can create a milk duct fistula apparently).

Sounds reasonable. I think we discharged a patient the other day that had a very small abscess behind her nipple. Ain't putting a needle in that spot. But most of them end up being superficial and I drain them myself. Thankfully it's rare.

 

[namethatsmell]

we luckily have a breast surgery call panel that's oddly enough available 24/7/365.

What the wha? What universe do you work in? Do you also have pathology and sleep on call?

 

[Apollyon]

What the wha? What universe do you work in? Do you also have pathology and sleep on call?

I think his shop sees something like 160k/year.

 

[Groove]

Do you guys drain your own breast abscesses? Open or needle?

In the past, I've gotten a surgery consult, but I'm questioning that practice. I'm decent with an US but I have never actually attempted an US guided needle aspiration of a breast abscess, though have done it elsewhere.

My practice has changed over the years but, in general, I try to avoid operative procedures on the breast if at all possible. If there is an abscess that is superficial and lateral and convincing to be 100% abscess then sure, I'll drain it. If it is central, deep, near areola/nipple then I punt to surgery. If there is any question of cancer, then again...I punt to surgery. Remember, abscess can be 2/2 simple infection or can be secondary to an underlying neoplastic process and sometimes it's very difficult to tell depending on the history and exam of the pt. The last thing you want to be doing with neoplasm is sticking a scalpel or needle through it.

I consider breast to be one of those red flag, highly prone to litigation areas and treat it the same as hand. Cosmesis is huge with women regarding their boobs and therefore I punt these as much as possible unless it's something really simple.

Most "official" sources will tell you to formally consult for sensitive areas such as genitalia, breast, hand, etc.. Here is a snippet from SAEM though I'm sure I could find others. It was the first thing that popped up in the google.

There are few contraindications to this procedure, however, certain situations should prompt consideration of consultation of general or specialty surgical services: large or complex abscesses, those in sensitive areas (face, hand, breast, genitalia) or in regions in close proximity to structures such as blood vessels.

 

[GeneralVeers]

I consider breast to be one of those red flag, highly prone to litigation areas and treat it the same as hand. Cosmesis is huge with women regarding their boobs and therefore I punt these as much as possible unless it's something really simple.

Agreed. I generally won't cut on the breast either. They get ABX, instructions to use warm compresses, and surgical referral.

 

[deleted497653]

I agree—- no cutting on the breast. Abx and referral or admission if they look bad enough

 

[Rendar5]

Any cosmetic area such as the face or the breast, I will consider doing an aspiration of an abscess, but I will almost never incise and drain it. I once saw an abscess that was incised and drained by a family medicine doctor, and the breast tissue splayed open at the site.

If it looks bad I won’t touch it. If it looks like classic mastitis I’ll aspirate if I can reach it easily

 

[RoyBasch]

I have gone back and forth on these over the years. But the expert opinion I get from the breast surgeons is that aspiration is generally superior to open I&D for breast abscesses. That being said. The patient may need serial aspirations. For big abscesses, I admit the patient and the breast surgeon is consulted. They usually do aspiratons q48hours until gone. If the abscess is small/superficial. I will discuss with breast surgeon, and they usually recommend an aspiration be done in the ER and start PO ABx. I will do the aspiration but specifically advise the patient that they may need serial aspirations and the next one needs to be done in breast clinic (not serial ER visits). I then coordinate close f/u with the breast surgeon. These conversations and consultations are then documented in the note.

 

[WilcoWorld]

My practice has changed over the years but, in general, I try to avoid operative procedures on the breast if at all possible. If there is an abscess that is superficial and lateral and convincing to be 100% abscess then sure, I'll drain it. If it is central, deep, near areola/nipple then I punt to surgery. If there is any question of cancer, then again...I punt to surgery. Remember, abscess can be 2/2 simple infection or can be secondary to an underlying neoplastic process and sometimes it's very difficult to tell depending on the history and exam of the pt. The last thing you want to be doing with neoplasm is sticking a scalpel or needle through it.

I consider breast to be one of those red flag, highly prone to litigation areas and treat it the same as hand. Cosmesis is huge with women regarding their boobs and therefore I punt these as much as possible unless it's something really simple.

Most "official" sources will tell you to formally consult for sensitive areas such as genitalia, breast, hand, etc.. Here is a snippet from SAEM though I'm sure I could find others. It was the first thing that popped up in the google.

There are few contraindications to this procedure, however, certain situations should prompt consideration of consultation of general or specialty surgical services: large or complex abscesses, those in sensitive areas (face, hand, breast, genitalia) or in regions in close proximity to structures such as blood vessels.

Yeah, I avoid I&D on breasts, eyelids & scrotums (never seen a penile abscess, but I'd probably pass on that too).

 

[dchristismi]

I actually have seen a penile abscess. It was exceptionally weird. I ended up aspirating it because I wasn't sure what I was dealing with, and when the frank pus came out, I simply called urology...

 

[southerndoc]

I think his shop sees something like 160k/year.

http://huddyhealthcare.com/wp-content/uploads/2018/11/Huddy-Article_Wellstar.pdf?CID=mvbrief_acep

Expected to increase to 180k/yr when our new ED opens in 2020 and to 200k/yr by 2025.

Can't wait for the new ED. 5 dedicated CT machines, dedicated MRI, on-site STAT lab, 12 shock/trauma rooms. Should be awesome! Got the Fitbit ready to see how many steps I do in a shift since it'll be on 2 floors (granted in a pod system).

 

[deleted547339]

http://huddyhealthcare.com/wp-content/uploads/2018/11/Huddy-Article_Wellstar.pdf?CID=mvbrief_acep

Expected to increase to 180k/yr when our new ED opens in 2020 and to 200k/yr by 2025.

Can't wait for the new ED. 5 dedicated CT machines, dedicated MRI, on-site STAT lab, 12 shock/trauma rooms. Should be awesome! Got the Fitbit ready to see how many steps I do in a shift since it'll be on 2 floors (granted in a pod system).

Impressive.

 

[deleted547339]

@Winged Scapula - any thoughts?

 

[GeneralVeers]

http://huddyhealthcare.com/wp-content/uploads/2018/11/Huddy-Article_Wellstar.pdf?CID=mvbrief_acep

Expected to increase to 180k/yr when our new ED opens in 2020 and to 200k/yr by 2025.

Can't wait for the new ED. 5 dedicated CT machines, dedicated MRI, on-site STAT lab, 12 shock/trauma rooms. Should be awesome! Got the Fitbit ready to see how many steps I do in a shift since it'll be on 2 floors (granted in a pod system).

Nice...but what's the hourly?

 

[GonnaBeADoc2222]

No chance I'm cutting into or sticking a needle into a breast. That's what surgeons are for.

Too often EPs are asked to expand their scope of practice into other realms that may or may not be reasonable because of our other skill sets.

You don't see general surgeons doing vascular surgery, even though they're "surgeons."

Even crazily specialized fields like ophtho punt to other ophthos when the patient doesn't neatly fit into their little specialized box. "Oh I'm retina I don't do orbits..."

 

[mimelim]

No chance I'm cutting into or sticking a needle into a breast. That's what surgeons are for.

Too often EPs are asked to expand their scope of practice into other realms that may or may not be reasonable because of our other skill sets.

You don't see general surgeons doing vascular surgery, even though they're "surgeons."

Even crazily specialized fields like ophtho punt to other ophthos when the patient doesn't neatly fit into their little specialized box. "Oh I'm retina I don't do orbits..."

I just want to point out that there are plenty of general surgeons doing vascular surgery across the country. To the point that I'd imagine that the bulk of dialysis and venous work is done by non-vascular surgeons. Part of that is because of reimbursement, part of that is because of availability of vascular surgeons. Depending on the locale, the arterial work will also be done by non-vascular surgeons. Both endo AND open.

 

[GeneralVeers]

I just want to point out that there are plenty of general surgeons doing vascular surgery across the country. To the point that I'd imagine that the bulk of dialysis and venous work is done by non-vascular surgeons. Part of that is because of reimbursement, part of that is because of availability of vascular surgeons. Depending on the locale, the arterial work will also be done by non-vascular surgeons. Both endo AND open.

I've never seen this in the 10+ hospitals I work at. General surgeons never place dialysis grafts in community hospitals. They won't even touch them when they are on call and these patients come in bleeding or have another complication.

 

[deleted547339]

I've never seen this in the 10+ hospitals I work at. General surgeons never place dialysis grafts in community hospitals. They won't even touch them when they are on call and these patients come in bleeding or have another complication.

I have worked with several general surgeons who do vascular procedures, including AVF/grafts.

 

[TheComebacKid]

When it comes to "more invasive" or cosmetically sensitive areas, I don't see why an ED doctor should be doing any of those things if the patient is stable and you have a consultant available to do it.

We have our emergent procedures which we all should be able to do irrespective if they are invasive or non-invasive. Then we have our non-emergent procedures i.e. lac repairs, joint reduction, extremity I&Ds etc which are all low risk to the patient both medically and cosmetically. Makes little sense to me to cut into breast tissue in the ED if the patient can be admitted and a breast surgeon who has more training can ensure a safer and better cosmetic outcome. If a patient is septic from a breast abscess and needs source control, I still don't think that needs to be done in the ED as we should focus on primary resuscitation with fluids and antibiotics first. Although I'm not sure if it's been studied, I will postulate that door to breast abscess I&D time in the ED is hardly associated with better outcomes.

When it comes to superficial abscesses in nontoxic patients who we are planning to discharge, I suppose we could entertain doing that, but again, doesn't seem worth it to me to take on the risk of a bad outcome for the patient for a non-emergent procedure. I am confident in my ability to drain these with ultrasound guidance and achieve patient comfort and source control but I'm not terribly confident in my ability to ensure a good cosmetic outcome

 

[Rendar5]

When it comes to "more invasive" or cosmetically sensitive areas, I don't see why an ED doctor should be doing any of those things if the patient is stable and you have a consultant available to do it.

We have our emergent procedures which we all should be able to do irrespective if they are invasive or non-invasive. Then we have our non-emergent procedures i.e. lac repairs, joint reduction, extremity I&Ds etc which are all low risk to the patient both medically and cosmetically. Makes little sense to me to cut into breast tissue in the ED if the patient can be admitted and a breast surgeon who has more training can ensure a safer and better cosmetic outcome. If a patient is septic from a breast abscess and needs source control, I still don't think that needs to be done in the ED as we should focus on primary resuscitation with fluids and antibiotics first. Although I'm not sure if it's been studied, I will postulate that door to breast abscess I&D time in the ED is hardly associated with better outcomes.

When it comes to superficial abscesses in nontoxic patients who we are planning to discharge, I suppose we could entertain doing that, but again, doesn't seem worth it to me to take on the risk of a bad outcome for the patient for a non-emergent procedure. I am confident in my ability to drain these with ultrasound guidance and achieve patient comfort and source control but I'm not terribly confident in my ability to ensure a good cosmetic outcome

Which is exactly why you should needle aspirate these. If it’s something that you want to send home just aspirate and discharge with antibiotics to a general surgeon. You don’t need to worry about cosmeticdamagefroma simple needle poke

 

[southerndoc]

Nice...but what's the hourly?

Sent via PM.

 

[southerndoc]

I've never seen this in the 10+ hospitals I work at. General surgeons never place dialysis grafts in community hospitals. They won't even touch them when they are on call and these patients come in bleeding or have another complication.

There is one in Cartersville, GA who does it. In fact, he took a AAA to the OR one day. He does CEA's all the time.

 

[The White Coat Investor]

I don't do them either. But I don't have a really good reason. We had a breast surgeon who was awesome and available 24/7/365. She went elsewhere, not due to that. The calls were actually pretty rare.

 

[thegenius]

No chance I'm cutting into or sticking a needle into a breast. That's what surgeons are for.

Too often EPs are asked to expand their scope of practice into other realms that may or may not be reasonable because of our other skill sets.

You don't see general surgeons doing vascular surgery, even though they're "surgeons."

Even crazily specialized fields like ophtho punt to other ophthos when the patient doesn't neatly fit into their little specialized box. "Oh I'm retina I don't do orbits..."

It just depends on where the abscess is. If it's deep I don't think any ER doc is going to touch it. But superficial breast abscesses are basically no different than any other area. If you have an informed conversation with the patient about risks / benefits, and they agree to the, lets say 1 cm incision, then it's fine. It's not like you are resecting a tumor around an IVC that is fraught with danger.

Where I work, referring a woman with a breast abscess to a surgeon can take months, or never happen.

 

[gro2001]

When it comes to "more invasive" or cosmetically sensitive areas, I don't see why an ED doctor should be doing any of those things if the patient is stable and you have a consultant available to do it.

We have our emergent procedures which we all should be able to do irrespective if they are invasive or non-invasive. Then we have our non-emergent procedures i.e. lac repairs, joint reduction, extremity I&Ds etc which are all low risk to the patient both medically and cosmetically. Makes little sense to me to cut into breast tissue in the ED if the patient can be admitted and a breast surgeon who has more training can ensure a safer and better cosmetic outcome. If a patient is septic from a breast abscess and needs source control, I still don't think that needs to be done in the ED as we should focus on primary resuscitation with fluids and antibiotics first. Although I'm not sure if it's been studied, I will postulate that door to breast abscess I&D time in the ED is hardly associated with better outcomes.

When it comes to superficial abscesses in nontoxic patients who we are planning to discharge, I suppose we could entertain doing that, but again, doesn't seem worth it to me to take on the risk of a bad outcome for the patient for a non-emergent procedure. I am confident in my ability to drain these with ultrasound guidance and achieve patient comfort and source control but I'm not terribly confident in my ability to ensure a good cosmetic outcome

I think you are basically right. However, resources and access to them may change your perspective slightly. Folks needing admission are always easy, but most of these will not be septic from their abscess. Admitting them would be a waste of a bed (not an insignificant concern at some of the hospitals I've worked at) as well as expose them to the risks of an inpatient admission (always a significant concern in my mind). At my current hospital breast surgery follow up is going to be a minimum of two weeks away, most likely closer to 8-12 weeks. In this situation, for abscess that look easily drainable and the patient is otherwise dischargeable, it becomes very tempting to aspirate in addition to prescribing antibiotics. If I could get them breast surgery clinic follow up with 2-3 days, I might never aspirate a breast abscess again. However, it's impossible for me to get 2-3 day follow up for anything.

 

[Xerxes1729]

I get that an incision results in a scar, and that the cosmetic outcome will be influenced by where you incise, how you orient the incision, how big it is, etc. But what is the feared cosmetic complication of an 18g needle puncture? I'm lucky enough to have a surgeon who will see these in his office promptly that I don't have to drain them, but if I didn't have that option, I have a hard time justifying not attempting aspiration.

 

[thegenius]

I get that an incision results in a scar, and that the cosmetic outcome will be influenced by where you incise, how you orient the incision, how big it is, etc. But what is the feared cosmetic complication of an 18g needle puncture? I'm lucky enough to have a surgeon who will see these in his office promptly that I don't have to drain them, but if I didn't have that option, I have a hard time justifying not attempting aspiration.

Nothing fearsome about doing a needle drainage.

Again, really depends on where, how big, and how deep the abscess is.

I think patient consent, and understanding about cosmetic results is key. A 1 cm superficial incision with an 11 blade made by a surgeon, breast surgeon, ER, or a donkey will all heal the same. It's not like a plastic surgeon can make a more straight 1 cm incision than me.

I, though, would not do any incisions around the nipple or anything into or very close to the milk ducts.