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Prevention and diagnosis of infectious complications associated
with neuraxial technique
Pedro Tanaka
Severe Neurological Complications after Central Neuraxial Blockades in Sweden 1990 – 1999 Moen V et al. Anesthesiology 2004;101:815-817.
EB CSE SB Continuous SB Total
Spinal hematoma 21 (7/14) 4 (1/3) 7 (0/7) 1 (1/0) 33 (9/24)Cauda equina syndrome 8 (4/4) 4 (0/4) 18 (13/5) 2 (1/1) 32 (18/14) Purulent meningitis 5 (1/4) 1 (0/1) 20 (14/6) 3 (2/1) 29 (17/12)Epidural abscess 12 (5/7) 1 (0/1) 13 (5/8)Traumatic cord lesion 8 (3/5) 1 (0/1) 9 (3/6)Cranial subdural hematoma 3 (1/2) 2 (2/0) 5 (3/2)Paraparesis 3 (1/2) 1 (1/0) 4 (2/2)Other 2 (0/2) 2 (0/2)Total 62 (22/40) 9 (1/8) 50 (30/20) 6 (4/2) 127 (57/70)
Complications According to Type of Central Neuraxial Blockade
Permanent NeurologicalComplication Full Recovery Damage No Information All
Spinal hematoma 6 27 – 33Cauda equina syndrome – 32 – 32Purulent meningitis 21 6 2 29Epidural abscess 7 4 2 13Miscellaneous
Traumatic cord lesion – 9 – 9Cranial subdural hematoma 4 1 – 5Paraparesis – 4 – 4Other – 2 – 2
Total 38 85 4 127
Neurological Complications Related to Outcome
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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Tempo de cateterização (dias)
Wang LP et al. Anesthesiology 1999;91:1928-1936.
RISK OF INFECTION
Epidural abcess
DIFFERENTIAL DIAGNOSIS
Epidural Abscess Epidural Hemorrage
Age of patient Any age 50% over 50 years
Previous history Infection * Anticoagulants
Onset 1 - 3 years Sudden
Generalized symptoms Fever, malaise, back pain Sharp, transient back and leg pain
Sensory involvement None or paresthesias Variable, late
Motor involvement Flaccid paralysis, later spastic Flaccid paralysis
Segmental reflexes Exacerbated * - later obtunded Abolished
MRI / CT / Myelogram Signs of extradural compression Signs of extradural compression
Cerebrospinal fluid Increased cell count Normal
Blood data Rise in sed rate Abn cogs
* Infrequent findings
SOURCE OF INFECTION
Organism N (n*) % N (n*) % N (n ) %
CNS 12 (7) 42.9 9 (5) 42.9 35 (10) 40.2
Propionibacterium acnes 9 32.1 8 38.1 35 (6) 40.2
Corynebacterium sp. 1 (1) 3.6 1 4.8 10 (1) 11.5
Micrococcus sp. 2 7.1 0 0.0 0 0.0
Enterococcus sp. 1 (1) 3.6 1 (1) 4.8 2 2.3
Staphilococcus aureus 1 (1) 3.6 1 (1) 4.8 1 (1) 1.1
Acinetobacter baumanil 1 (1) 3.6 1 (1) 4.8 1 (1) 1.1
Acinetobacter sp. 1 3.6 0 0.0 1 (1) 1.1
Peptostreptococcus spp 0 0.0 0 0.0 2 2.3
Total # 28 (11) 21 (8) 87 (20)
Isolated Microorganisms from the Samples
Epidural Catheter
Tip Segment Subcutaneous Segment Skin
SS
Yuan HB et al. Anesthesiology 2008;108:130-137.
Efficacy of spray disinfection with a 2-propanol and benzalkonium chloride containing solution before epidural catheter insertion—a prospective, randomized,clinical trial
In this study, spray disinfection was equally efficacious compared with the
conventional skin disinfectant technique.
SKIN DESINFECTION
Debreceni G et al. Brit J Anaesth 2007;98:131-135.
Study Treatment Control OR (random) Weight OR (random)or sub-category n/N n/N 95% CI % 95% CI
01 CNS infection by epidural catheters Mann 14 0 / 29 2 / 26 4.46 0.17 [ 0.01, 3.63 ]
Subtotal (95% CI) 29 26 4.46 0.17 [ 0.01, 3.63 ]
Total events: 0 (Treatment), 2 (Control)
Test for heterogeneity: not applicable
Test for overall effect: Z = 1.14 (P = 0.25)
Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis
CATHETER DRESSING
0.01 0.1 1 10 100
Favors treatment
Favors control
Ho KM et al. J Antimic Chemoth;58:281-287.
PRACTICE ADVISORY – PRELIMINARY REPORT
Handwashing Sterile Gloves Surgical mask
Removal of jewelry Consider ATB previous to the block
in bacteremic patient Chlorhexidine
Horlocker T. ASA newsletter 2009;73:35-37.
REGIONAL ANESTHESIA IN THE FEBRILE PATIENT
May safely undergo to spinal anesthesia Remove catheters in the presence local
erythema Early diagnosis
Risk increase in the immunocompromised patient
Wedel DL et al. Reg Anesth Pain Med 2006;31:324-333.
