Incision and drainage of perianal abscess

Incision and drainage of perianal abscess

Anesthesia type	MAC, General, spinal
Airway	Face Mask, LMA, ETT
Lines and access	PIV
Monitors	Standard
Primary anesthetic considerations
Preoperative	Airway and respiratory evaluation if considering prone position
Intraoperative	Prone position
Postoperative
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Incision and drainage (I&D) of perianal abscess is a procedure for treatment of abscesses at and around the anal verge. Patients typically have co-morbidities such as inflammatory bowel disease, malignancy, or traumatic injury leading to perianal abscesses. Many patients often have repeated I&Ds before resolution of their abscesses. These patients tend to be males in their 40-50s but can across all patient populations.

Preoperative management

Patient evaluation

System	Considerations
Airway	Standard evaluation May be prone positioning so concern for airway difficulty may change anesthetic technique
Neurologic
Cardiovascular	Standard evaluation
Pulmonary	Evaluate for any signs/symptoms or co-morbidities that would signal decreased respiratory reserve, as patient positioning may be affected (lithotomy vs prone)
Gastrointestinal
Hematologic	Blood loss from I&D of perianal abscesses is rare
Renal
Endocrine
Other	Check with surgeon for ERAS protocol

kLabs and studies

• CBC
• BMP

Regional and neuraxial techniques

• Spinal can be used if MAC/general anesthesia is contraindicated

• Epidurals can often spare the anal region.

Intraoperative management

Monitoring and access

• Standard monitors
• PIV

Induction and airway management

• If MAC: standard induction, face mask
• If general: prone position requires ETT over LMA. Standard induction unless concerned about aspiration
• If spinal: aim for L1-L2 level of analgesia, face mask for airway

Positioning

• Prone preferred
• If concerned about respiratory reserve, can consider lithotomy after discussion with surgeon

Maintenance and surgical considerations

• Standard Maintenance

• Pain is usually greatest with initial incision, requiring up front analgesia

Emergence

• Standard emergence
• Standard PONV prophylaxis

Postoperative management

Disposition

Typically outpatient procedure

Pain management

• Pain usually greatest intra-op, can be treated with rapid acting analgesics such as fentanyl, ketamine, or remifentanil given duration of procedure is short
• Post-op pain usually improved compared to pre-op, consider multi-modal adjuncts to long acting opioids if needed

Potential complications

• Sepsis
• Positioning can lead to axillary nerve damage or peroneal nerve damage (if lithotomy)
• Conversion from MAC to general

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications