Infection Control in Regional Anesthesia

INTRODUCTION

Infectious complications related to regional anesthesia are rare. Because most of the information is available in case reports and retrospective surveys, it is likely that these complications are underreported. It is hoped that recent surveillance and prospective registry projects using standardized surveillance definitions and the integration of such in national quality assurance projects (American Society of Regional Anesthesia [ASRA] Acute-POP/AQI) will generate more comprehensive data for risk assessment and evaluation of infection control recommendations in the future. Integration of a structured surveillance tool into the electronic medical record and a hospital’s quality management system will ease the workload for clinicians and facilitate surveillance compliance (Table 1).

While we have to work on reducing infectious complications associated with regional anesthesia because of the potential severe individual consequences, some studies demonstrate a reduction of surgical site infections with the use of local anesthesia—opening the research arena regarding whether the avoidance of general anesthesia, intrinsic properties of local anesthetics, or a combination of both is responsible for this observation.

The objective of this chapter is to summarize information from the literature on infections complications associated with regional anesthesia, as well as to discuss the mechanism and suggest strategies to prevent these complications.

PATHOGENESIS OF INFECTIONS ASSOCIATED WITH CENTRAL NEURAXIAL BLOCKADE

Microorganisms from exogenous or endogenous sources may gain access to the subarachnoid, epidural, or tissue space surrounding peripheral nerves in several ways. Microorganisms from the patient’s or anesthesia practitioner’s flora can be inoculated directly when a catheter or needle is inserted into those spaces. Several reports in the literature suggested that infections are on occasion caused by the anesthesia practitioner’s flora. For example, Trautmann and colleagues reported a case of meningitis caused by a Staphylococcus aureus strain that was identical by pulsed-field gel electrophoresis to the S. aureus isolated from the anesthesiologist’s nose. Rubin et al could trace to a single anesthesiologist Streptococcus salivarius as the responsible agent for six cases of meningitis following spinal anesthesia, and the Centers for Disease Control and Prevention (CDC) reported five cases in Ohio and one case in New York between 2008 and 2009 with the same organisms.

Microorganisms can also enter the epidural space by hematogenous spread from other body sites, such as infected skin, or by migrating along the catheter tract. Several case reports suggested that infection was caused by spread of bacteria from infected sites through the bloodstream to the epidural space. Others maintained that infections at distal sites are not contraindications to epidural anesthesia. For example, Newman concluded that distal infections did not increase the risk of epidural infection because traumatic injuries are often infected, and no epidural catheter-related infections were identified among over 3000 patients who had epidural neural blockades for postoperative or posttraumatic analgesia. Gritsenko and coworkers analyzed the charts of 474 patients who underwent removal of an infected hip or knee prosthesis under neuraxial anesthesia and found in 0.6% of the cases clinical signs of central neuraxial infections (meningitis or epidural abscess) and three other anesthesia-related complications, including a psoas abscess beside an epidural hematoma and back pain.

TABLE 1.Regional anesthesia surveillance system complication denitions.

 A: Essential CriteriaB: Contributory Criteria
Epidural infection
EI1: Superficial soft tissue infection
2 A and B criteria needed
Swelling
Local tenderness
Fever (>38.0°C)
Drainage
Positive culture from the area
Leukocytosis (>12/nL or CRP > 20 mg/L)
Local erythema
EI2: Epidural abscess
1 A and 3 B criteria needed
Radiological evidence of a mass in the epidural space consistent with an epidural abscess within 30 days after epidural/spinal needle/catheter placement/catheter removal or attempted epidural/spinal placementFever (>38.0°C)
Drainage
Positive culture from surgical exploration or puncture
Leukocytosis (12/nL or CRP > 20 mg/L)
Local erythema
Local tenderness
Focal back pain
Neurologic deficita
EI2NaSame as above: Classified as EI 2 N if neurologic deficit is present as a contributory criterion
EI3: Epidural infection with sepsis
1 A and 4 B criteria needed
Diagnostic criteria of EI1 or EI2 or EI2Na puncture site or abscessPositive blood culture with the same organism isolated from
Fever > 38.0°C or hypothermia < 36°C
Leukocytosis > 12 nL or leukopenia < 4 nL
BP systolic < 90 mm Hg
Tachycardia > 90 bpm
Respiratory failure (AF > 20, paCO2 < 32 mm Hg,
PaO2 < 70 mm Hg breathing spontaneously or
PaO2 /FiO2 < 175 on mechanical ventilation)
EI3NSame as above: Classified as EI3N if EI2Na criteria are present
Peripheral nerve block–associated other infection
OI1: Superficial soft tissue infectionSwelling along the catheter or needle placement track
Local tenderness along the catheter or needle placement track
Fever (>38.0°C)
Drainage
Positive culture from the area
Leukocytosis (>12/nL or CRP > 20 mg/L)
Local erythema
OI2: Abscess or deep tissue infectionEvidence of an abscess or fluid collection consistent with an infectious process by imaging or surgical exploration within 30 days after peripheral nerve block needle placement/catheter removal or attempted placementFever (>38.0°C)
Drainage
Positive culture from surgical exploration or puncture
Leukocytosis (>12/nL or CRP > 20 mg/L)
Local erythema
Local tenderness
Focal back pain
Neurologic deficita
OI2NaSame as above: Classified as OI2N if neurologic deficit is present as contributory criterionPositive blood culture with the same organism isolated from puncture site or abscess Fever > 38.0°C or hypothermia < 36°C
Leukocytosis > 12 nL or leukopenia < 4 nL
BP systolic < 90 mm Hg
Tachycardia > 90 bpm
Respiratory failure (AF > 20, PaCO2 < 32 mm Hg,
PaO2 < 70 mm Hg breathing spontaneously or
PaO2/FiO2 < 175 on mechanical ventilation)
OI3: Infection with sepsis
1 A and 4 B criteria needed
Diagnostic criteria of OI1 or OI2 or OI2NaPositive blood culture with the same organism isolated from puncture site or abscess Fever > 38.0°C or hypothermia < 36°C
Leukocytosis > 12 nL or leukopenia < 4 nL
BP systolic < 90 mm Hg
Tachycardia > 90 bpm
Respiratory failure (AF > 20, PaCO2 < 32 mm Hg,
PaO2 < 70 mm Hg breathing spontaneously or
PaO2/FiO2 < 175 on mechanical ventilation)
OI3NSame as above: Classified as OI3N if OI2Na criteria are presentNew onset of central neurologic symptoms
Headache
Stiff neck
Fever > 38.0°C
Positive CSF culture
Meningitis-specific antibiotic therapy started
Spinal or epidural block (catheter insertion/ removal) in the past 72 h
Neurologic deficit
ND1: Neurologic deficitResidual sensory and/or motor and/or autonomic block 72 h after last injection of local anesthetic without other identifiable etiology
New onset of sensory and/or motor and/or autonomic deficit 24 h after resolution of the original block without other identifiable etiology
If regional anesthetic-/analgesia-related infection is present classify, as EIXN/OIXNa
Electrophysiological evidence of new nerve damage (MEP, SEP, nerve conduction study, electromyography)
2 A and 1 B criteria neededNew loss of deep tendon reflexes
New loss of vibration sensation
New onset of neuropathic pain in affected nerve distribution area
Paresthesia in affected nerve distribution area
Sensory and/or motor and/or autonomic deficit consistent with dermatomes or nerve distribution area
aCRP: C-reactive protein; BP: Blood pressure; AF: Air flow (Respiratoty rate); CSF: cerebrospinal fluid; MEP: Motor evoked potentials; SEP: Sensory evoked potentials. If regional anesthetic-/analgesia-related infection is present, classify as EI XN/OI XN.Source: Adapted with permission from Schulz-Stübner S, Kelley J: Regional Anesthesia Surveillance System: first experiences with a quality assessment tool for regional anesthesia and analgesia. Acta Anaesthesiol Scand. 2007 Mar;51(3):305-315.

NYSORA Tips

  • Streptococcal species, S. aureus, and Pseudomonas aeruginosa are the most common causative agents but multiresistant species also emerge as causative pathogens as their endemic impact grows within health-care systems.
  • Microorganisms from the patient’s or anesthesia practitioner’s flora can be inoculated directly when a catheter or needle is inserted into the epidural or subarachnoid space.
  • Because it is easy to contaminate the needle or the catheters, aseptic measures.

The anesthetic agents injected into the subarachnoid or epidural space are another possible source of infection. Infections from contaminated multidose vials are likely rare because most anesthetic drugs are weak bases dissolved in acidic solutions that inhibit growth of bacteria and fungi. Besides most multidose local anesthetic solutions contain a bacteriostatic agent. Nevertheless, the case report by North and Brophy suggested that contaminated multidose vials still can be a source of infection. These authors reported an infection in which S. aureus with matching phage types were Isolated from an abscess and a multidose lidocaine vial.

A report by Wong et al described, besides other infection control violations, the use of single-dose medications for multiple patients as the culprit in an outbreak of Klebsiella pneumoniae and Enterobacter aerogenes bacteremia in a pain clinic. Breaches in aseptic technique for medication preparation can be detrimental, especially if a compound pharmacy is involved: In 2012, more than 200 patients suffered fungal infections with Exserohilum rostratum after use of contaminated methypred-nisolone injections for interventional pain procedures in multiple institutions in the United States.

To assess whether contamination of the anesthetic agent or the equipment (needles, syringes, tubing) is related to subsequent infections, investigators have cultured these items after they have been used with patients or during simulations. In four studies, 0%–29% of used catheters were contaminated, and James and coworkers found that 5 of 101 syringes used to inject anesthetic agents were contaminated. Ross and coworkers drew up 0.25% bupivacaine into control syringes and into syringes used to induce continuous lumbar epidural neural blockade (test syringe) in 18 obstetric patients. After each dose from the test syringe, the investigators cultured the contents of both the test and the control syringes. Six of 18 test syringes were contaminated with bacteria, compared with only 1 of 18 control syringes. Raedler and associates cultured 114 spinal and 20 epidural needles after use for single lumbar injections. Twenty-four cultures (17.9%) grew microorganisms: 15.7% coagulase-negative staphylococci; 1.5% yeasts; and 0.8% each enterococci, pneumococci, and micrococci. The authors concluded that it is easy to contaminate the needle, and that anesthesiologists need to improve their hygienic measures. Despite finding contaminated equipment or anesthetic solutions, no infected patient was identified; thus, none of the authors was able to correlate contamination with infection. However, Loftus and coworkers examined the contamination of intravenous stopcocks during general anesthesia and showed, for the first time, postoperative infections with the same organism. It is therefore conceivable that contamination during the placement of a regional block, and, even more likely, during handling of continuous catheter systems, can cause infections. Although the risk for such infections would be less likely than that of manipulating intravenous lines.

INFECTIONS ASSOCIATED WITH EPIDURAL BLOCKADE

The numerous case reports in the literature of infections occurring after epidural neuraxial blockade, attest to the fact that such complications do occur and can be severe (Table 2). Of 57 patients in these case reports, 41 acquired epidural or intraspinal abscesses, 1 developed a subcutaneous abscess, 2 had meningitis without epidural abscess formation, and 1 developed sepsis. Four patients had injections only, 1 patient had injections and several catheters, and the remaining patients had catheters. Among the 38 patients who had catheters and for whom the duration of catheterization was specified, the median duration of catheteriza-tion was 3 days (range 50 minutes to 6 weeks). The median time to onset of the first signs or symptoms of infection was 4 days (range 1 day to 4.8 months) after catheter placement. Staphylococcus aureus caused 27 of 43 infections from which bacterial pathogens were isolated. Pseudomonas aeruginosa caused five infections and Streptococcus spp. caused five. Methicillin-resistant S. aureus (MRSA) was isolated in one case; three patients died.

NYSORA Tips

  • Epidural catheters inserted for long-term pain control become infected more frequently than those used for short periods of time.
  • Malignancy and reduced immunocompetence might be additional risk factors for catheter infection.
  • Case reports of infections occurring after epidural neuraxial blockade point out that complications from infection can be severe and often lead to epidural or intraspinal abscesses.

It should be kept in mind that the number of reported cases does not allow us to assess the true frequency of infections after epidural neural blockade. However, several investigators have performed studies to assess this risk. When reviewing 350 reports in the literature, Dawkins in 1969 found no reports of infection after thoracic or lumbar epidural block but identified 8 (0.2%) reports of infection after 3767 sacral epidural blocks used for operative procedures and for obstetrics. More recently, Dawson reviewed the literature and found rates of deep infection ranging from 0% to 0.7% and rates of superficial infection ranging from 1.8% to 12%.

TABLE 2.Infections associated with epidural neural blockade.

Author
(Reference)
YearIndicationEpidural SiteFilter UsedCatheter
Duration
Type of InfectionTime From
Insertion to
Symptoms
Signs and Symptoms MicroorganismOutcome
Edwards and Hingson311943Vaginal delivery CaudalNSNSEpidural abscess, bacteremiaNSNSStaphylococcus
aureus
Died 31 days after delivery
Ferguson and Kirsch32a1974Postoperative analgesiaThoracicNS2 daysEpidural empyema4 days
10 days
14 days
Fever, headache, meningism
Urinary retention
Paraparesis
Staphylococcus
epidermidis
Sensory impairment, spastic weakness, walks with crutches
Saady33a1976Postoperative analgesiaThoracicYes1.7 daysEpidural abscess4 days
8 days
9 days
10 days
14 days
Fever
Chills, abdominal pain right upper quadrant
Headache, stiff neck
Urinary retention
Lower extremity paraparesis, no anal tone
S. aureusSensory impairment, walks with minimal assistance
North and Brophy719791. PriapismLumbarNo3 daysEpidural abscess1 dayFever
Stiff neck, dysphagia, back pain, absent ankle jerks
S. aureusFull recovery
2. Fractured ribs, chest injuryThoracicYes4 daysEpidural abscess10 daysFever
Stiff neck, sensory loss T2 to T6
S. aureusSensory impairment
Wenningsted Torgard et al45b1982Lower back pain LumbarNS6 daysSkin abscess, spondylitis, bacteremia10 daysFeverS. aureusWedge formation of two vertebral bodies
McDonogh and Cranney351984Fractured ribsThoracicYes3.3 daysEpidural abscess2.5 days
19 days
Fever
Paralysis left leg, weakness, right leg, urinary retention, sensory deficit T7 to 8
S. aureusResidual left-side weakness, uses walking frame, urinary retention
Konig et al361985Knee surgeryLumbarNS4 daysParavertebral and epidural abscesses, osteomyelitis, phlegmonous duritis, myelitis2 weeksPain, lower extremity paraparesisS. epidermidisNearly complete recovery
Sollmann et al371987Phantom limb painNSNS6 weeksLarge encapsulated “spinal” abscess compressing dura at L4–L56 weeks,
5 months
Severe back pain
Severe sciatica
Pseudomonas
aeruginosa
Persistent pain
Fine et al381988Neuralgic pain syndromeThoracicYes3 daysSite infection, epidural abscess9 daysFever, chills, urinary retentionNo culture obtainedSensory impairment
Ready and Helfer3919891. Vaginal deliveryLumbarNS50 minMeningitis1 dayHeadache, stiff neck, fever, back pain, nuchal rigidityStreptococcus uberisFull recovery
2. Cesarean sectionNSNS3 daysCellulitis meningitis3.5 days
5.5 days
Fever
Headache, nuchal rigidity, photophobia, hyperacusis
Enterococcus faecalisFull recovery
Berga and Trierweiler401989Vaginal deliveryLumbarNSNSMeningitis1 dayHeadacheStreptococcus
sanguis
Full recovery
Goucke and Graziotti411990Back painLumbarNS3 epidural injectionsBacteremia, epidural abscess3.3 weeks after last injectionBack pain, fever, urinary retentionS. aureusDied 7 weeks after laminectomy
Lynch and Zech421990Intra- and postoperative analgesiaLumbarYes3 daysSpondylitis3 daysFever, chills, headache, back painP. aeruginosa9-month recovery, wears lumbar brace, some lumbar pain
Strong4319911. Herpes zosterbThoracicYes2.5 days
3 daysc
Epidural abscess4.4 weeksPain, headache, stiff neck, fever, right flank painS. aureusFull recovery
2. Reflex sympathetic dystrophyCervicalYes5 days
5 daysc
Cellulitis
Epidural abscess
16 days
7 weeks
Cellulitis
Neck pain radiating to left arm
Culture negativeFull recovery
Klygis and Reisberg441991Vaginal deliveryNSNSNSEpidural abscess1.5 daysBack pain, paresthesias medial thigh and plantar surface of feet, feverGroup G
streptococci
Full recovery
Dawson et al451991Postoperative analgesiaThoracicYes4 daysEpidural abscess12 days
18 days
Numbness and weakness in leg, urinary incontinence
Paraplegia
S. aureusLoss of motor function, requires indwelling urinary catheter, able to take few steps with help
Waldmann1421991Cervical radiculopathyC6NSNSEpidural abscess72 hStiff neck and chillsS. aureusQuadraparetic with partial function of upper extremities and able to walk
Ferguson46 1992Intra- and postoperative analgesiaLumbarYes4 daysCellulitis, epidural infection7 daysFever, back painS. aureusNot specified
NganKee and Jones471992Cesarean sectionLumbarYes50 hEpidural abscess5 daysFever, back pain, rigors, bacteremia, paresthesias, weakness of both legsS. aureusFull recovery after 8 weeks
Sowter et al481992Intra- and postoperative analgesiaThoracicYes5 daysEpidural abscess3.6 weeksBack pain, urinary retention, paresthesias and weakness both legsS. aureusParaplegic with indwelling urethral catheter
Shintani et al491992Herpes zosterLumbarNS3 daysMeningitis, epidural abscess3 daysHeadache, nausea, vomiting, fever, somnolence, back painMethicillinresistant
S. aureus
Full recovery
Nordstrom and Sandin501993Fractured ribs ThoracicYes6 daysEpidural abscess19 daysBack pain, numbness both legs, fever, paresis urethral sphincterS. aureusIncomplete recovery of motor function 4 months after laminectomy
Mamourian et al701993PVDL3–L4NS48 hEpidural abscess72 hLower extremity radicular pain and weakness, urinary retentionS. aureusFull recovery
Low back painNSNSSingle shotEpidural abscess2 weeksWorsening pain, leg weakness, urinary retentionS. aureusDied from ventricular tachycardia
PVDNSNSSingle shotEpidural abscess24 h, 4 daysFever, leg spasmS. aureusNo neurologic deficit
Davis et al51 1993Vaginal deliveryLumbarNSLess than 1 dayMeningitis1.7 daysHeadache, vomiting, confusion, delirium, feverGroup β-hemolytic
streptococci
Full recovery
Ania52b1994Lumbar painNSNS8 daysMeningitis1 day, 3 daysHeadache, chills, vomitingS. aureusFull recovery
Tabo et al711994Herpes zosterL3–L4NS3 daysEpidural abscess4 daysFever, fatigue, pain S. aureusFull recovery
Borum et al531995Vaginal deliveryLumbarYes1 daysEpidural abscess4 daysLow back pain, tingling both lower extremitiesS. aureusFull recovery
Liu and Pope541996Extracorporeal shockwave lithotripsyNSNSNSMeningitis6 daysWeakness both lower extremitiesStreptococcus
pneumoniae
Full recovery
Dunn et al<55 1996Intra- and postoperative analgesiaNSNS1 dayEpidural abscess, osteomyelitis1 dayNeck and back painS. aureusMild hip and loin pain 5 months after the operation
14 daysBack pain, nausea, vomiting, fever
Cooper and Sharpe56b1996Chronic back painNot specifiedNSInjectionMeningitis, cauda equina syndrome3 daysIncreased back pain, chills, profuse sweatingS. aureusIncontinent of stool
13 daysLeg weakness, incontinent of stool
Barontini et al571996Transurethral resection of prostateLumbarNSNSEpidural abscess2 daysFever, leg weaknessNo culture obtainedParaplegia
4 daysChills, pain, flaccid paraparesis of leg
Pinczower and Gyorke151996Postoperative analgesiaLumbarNS4 daysL1 vertebral osteomyelitis3 weeksLow back painP. aeruginosaFull recovery
Wang et al721996RSDL2–L3 and L3–L4 (total of 4 catheters during 4 weeks)NS4 weeks Small epidural abscess with meningeal irritation?Nuchal rigidity, back pain, nausea, photophobia, severe headacheNot identifiedFull recovery
Bengtsson
et al17
19971. Analgesia after a traumatic amputationL3–L4, T12–L1 Yes1 day,c 4 daysMeningitis4 daysFever, pain and erythema at 2nd insertion site, stiff neckP. aeruginosaFull recovery
2. Analgesia for phantom pains after an amputationLumbarYes3 daysSoft tissue and interspinal abscess3 daysFever, severe headache, erythema, S. aureus and swelling at insertion site, back pain radiating to right thighNo culture obtainedRadicular pain in lower back
3. Analgesia for painful foot ulcersLumbar tunneled catheterYes16 daysPsoas abscess at L2 to L5 tracking to L3–L4 intraspinal level11 days, 14 daysFever, pain radiating from backS. aureusFull recovery
Sarrubbi and Vasquez5819971. Analgesia for reflex sympathetic dystrophyL1–L2NS3 daysEpidural abscess3 daysHigh fever, cloudy drainage at catheter exit siteS. aureusRecovered to her baseline
2. Surgical anesthesia and postoperative analgesiaNSNS2 daysEpidural abscess and meningitis2 daysBilateral leg weakness and double visionS. aureusAmbulated with a walker at 3 months
5 daysFlaccid paralysis, double vision from 3rd-nerve palsy, meningism, sensory level L1
Iseki et al591998Analgesia for herpes zoster11 epidural injections then catheters at
T6–T7,
T8–T9,
T7–T8
NS4 days,c
1 day,
6 days
Epidural abscess at T6–T7 and inflammation of the perivertebral muscles at T5 to T76 days after the final catheterizationFever, elevated white blood count and C-reactive proteinMethicillinresistant
S. aureus
Full recovery
O’Brien and Rawluk601999Analgesia for low back pain1 epidural injectionNSNot applicableEpidural abscess3 monthsBack pain, bilateral lower extremity painMycobacterium
fortuitum
Full recovery
Halkic et al612001Postoperative analgesiaT11–T12NS4 daysSpondylodiscitis at L5–S14 daysLumbar pain radiating to the groinPropionibacterium
acnes
Full recovery
Phillips et al6220021. Postoperative analgesiaThoracicNS3 daysEpidural abscess4 daysFeverS. aureusFull recovery
5 daysLow backache, headache, tenderness at insertion site
2. Postoperative analgesiaThoracicNS3 daysEpidural abscess3 weeksPain at insertion site, weakness in lower extremities, urinary retentionMethicillinresistant
S. aureus
Died of a pulmonary embolus and cardiac arrest
Royakkers et al6320021. Postoperative analgesiaL2–L3Yes4 daysEpidural abscess3 daysFeverS. aureusFull recovery
4 daysElevated ESR, WBC, C-reactive protein
5 daysErythema at exit site
7 daysPus at insertion site
2. Postoperative analgesiaT7–T8NS5 daysEpidural abscess6 daysErythema and pus at insertion siteS. aureusFull recovery
3. Postoperative analgesiaT10–T11NS3 daysEpidural abscess7 daysSigns of local infection, back pain, fever to 39°CS. aureusFull recovery
Hagiwara et al642003Postoperative analgesiaLow thoracicNSNSEpidural abscess4.8 monthsFever, back pain, neck stiffness, coma, and quadriplegiaMethicillinresistant
S. aureus
Nearly full recovery
Evans and Misra652003Labor analgesiaLumbarYesNSEpidural abscess7 daysBack and leg painNSIncomplete recovery
9 daysHot and cold flushes, flu-like illness, pain from back down both legs
11 daysFever, dehydration, tachycardia
12 daysUnable to bear weight or pass urine, sensation decreased below knees
Yue and Tan662003Low back painCaudalNS in abstractNS in abstractDiskitis4 weeksLow back pain, elevated serum acute-phase reactants, radiographic evidence of L4–L5 diskitisP. aeruginosaFull recovery
Hagiwara et al692003ColectomyLumbarNSNSEpidural abscess144 days Fever, severe back painMethicillinresistant
S. aureus
Slight gait disturbance
Volk et al1792005Hip replacementLumbarYes3 daysSubdural empyema and paraspinal abscess16 daysFever, back pain, mild headacheNSFull recovery
Aiba et al672009NSNSNSNSWide epidural abscessNSNSNSNS
Radif and Dalsgaard682009NSNSNS2 daysSubcutaneous abscess and meningitis2 daysPain, later fever and neck rigidityNSFull recovery
Pitkänen et al1132013Abdominal surgeryThoracicNS9 daysEpidural abscess NSNSFull recovery
Herniated diskNSNSSeveral injectionsEpidural abscess NSNSFull recovery
Multiple traumaThoracicNS14 daysEpidural abscess NSNSFull recovery
Chronic pain NSNSNSMeningitisNSNSFull recovery
Chronic painNSNS14 daysSepsisNSNSFull recovery
ESR = erythrocyte sedimentation rate; NS = not specified; PVD = peripheral vascular disease; WBC = white blood cell count.aAlthough discrepancies exist in the two reports, these articles may report the same patient.bPatient was given epidural anesthetic agents and epidural steroids.cPatient had more than one epidural catheter.Source: Adapted with permission from Mayhall CG: Hospital Epidemiology and Infection Control, 3rd ed. Philadelphia: Lippincott, Williams and Wilkins; 2004

Scott and Hibbard surveyed all obstetric units in the United Kingdom and identified one epidural abscess in approximately 506,000 epidural neural blocks. In contrast, Palot and colleagues identified three cases of meningitis in 300,000 patients who had undergone epidural blocks. Three smaller series of obstetric epidural neural blockades (some 12,000 patients) did not identify any infections. Similarly, in a recent study by the French SOS group on complications of regional anesthesia, Auroy and coworkers did not identify any infections in 29,732 epidural neural blocks given for obstetrical procedures. Together, the results of these five studies suggest that four or five serious infectious complications (ie, epidural abscesses or meningitis) occur per 1 million obstetric epidural neural blocks.

A number of studies have assessed infections associated with epidural neural blockades performed for operative procedures or for short-term pain relief. However, these studies reported fewer patients than the studies of epidural neural blockade for obstetric procedures. Findings from 10 studies are summarized in Table 3. Brooks and collaborators found four infections among 4832 (0.08%) patients undergoing epidural neuraxial blockade for surgical procedures or for labor and delivery. All four infections occurred in healthy young women who underwent cesarean sections; two infections were superficial (0.04%), and two involved the epidural space (0.04%). In contrast, Holt and colleagues reported 53 (1.8%) local infec-tions and 11 (0.4%) central nervous system infections related to approximately 3000 epidural catheters.The median duration of catheterization was 8 days for patients with local infections and 15 days for those with generalized symptoms (p = .01). Catheters removed from patients with clinical symptoms were more heavily colonized than those removed from asymptomatic patients. However, 59 of 78 catheters with positive cultures were removed because patients were symptomatic, suggesting that this observation may have been affected by ascertainment bias.

Given that the incidence of infections identified in all studies has been low, the results reported by investigators who calculated the upper boundaries of the infection risk associated with epidural neural blockade are particularly important because they provide a better estimate of the true risk than do studies that reported only the number of infections and the number of procedures. For example, Strafford and coworkers did not identify skin infections or epidural abscesses among 1458 pediatric patients who had epidural analgesia to control perioperative pain. These investigators calculated the incidence of clinical infection to be 0 with a 95% confidence interval from 0% to 0.03%, or three infections per 10,000 procedures. Auroy and colleagues, as noted previously, did not identify any infections among 29,732 procedures done for deliveries. They calculated 95% confidence intervals of 0/10,000 to 1/10,000 procedures. Darchy and associates evaluated 75 patients, 9 (12%; incidence density rate of 2.7/100 catheter-days) of whom acquired local infections. None of the patients acquired deep infections. Based on these data, Darchy and associates estimated the upper risk of spinal space infections to be 4.8% for catheters that remained in place for 4 days. Of note, these estimates are considerably higher than those of Strafford and coworkers and higher even than the rates found by Du Pen and collaborators among patients with epidural catheters for long-term pain control.

TABLE 3.Infections after epidural neural blockades done for surgical procedures or short-term pain relief.

Author (Reference)Year PublishedNumber of PatientsNumber of Infections
Hunt et al2819771021 cellulitis
Sethna et al8219921200 children0
Darchy et al831996759 local infections, 4 of which were associated with catheter infections
McNeeley et al841997910
Abel et al85199843920
Grass et al86 199851931 exit site infection
Kost-Byerly et al87 1998210 children21/170 (12.3%) of caudal catheters, 1/40 (2.5%) lumbar catheters were associated with cellulitis
Phillips et al62200224013 epidural infections
Auroy et al81200255611 meningitis
Volk et al140 20095057136 exit site infections
Source: Data from Mayhall CG: Hospital Epidemiology and Infection Control, 3rd ed. Philadelphia: Lippincott, Williams and Wilkins; 2004.

In general, epidural catheters inserted for long-term pain control become infected more frequently than those used for short periods of time. Du Pen and associates identified 30 superficial (9.3/10,000 catheter-days), 8 deep catheter track (2.5/10,000 catheter-days), and 15 epidural space (4.6/10,000 catheter-days) infections among 350 patients who had long-term epidural catheters. Similarly, Zenz and colleagues identified two cases of meningitis among 139 patients (1.4%, or 2.1/10,000 catheter-days) treated for pain due to malignancy. Coombs reported that 10 of 92 (10.9%) cancer patients acquired local infections, and 2 (2.2%) acquired meningitis. Malignancy and reduced immunocompetence might be additional risk factors in the population with long-term catheters.

Whether newly developed transparent dressings with integrated chlorhexidine patches might be beneficial for this vulnerable population remains to be seen.

INFECTIONS ASSOCIATED WITH SUBARACHNOID BLOCKADE

Case reports in the literature indicated that serious infections can occur as complications of subarachnoid neural blockade (Table 4). Of the 471 infections reported in these case reports, 272 were meningitis, 4 were epidural abscesses, 2 were soft tissue abscesses, 2 were infections of a disk or of a disk space, 1 developed cerebral and spinal abscesses, and 1 was a case of severe necrotizing fasciitis. In the last case mentioned, the authors speculated about a contaminated reused multiuse vial of local anesthetic as the cause. The median time to onset of signs or symptoms of infection was 1 day (range 1 hour to 2 months) for all infections and 18 hours (range 1 hour to 10 days for meningitis). Streptococcal species caused 24 of the 37 infections from which bacterial pathogens were identified; S. aureus caused 2 infections; Pseudomonas spp. caused 4; and an extended spectrum betalactamase Serratia marcescens caused 1. Compared with infections after epidural neural blockade, infections associated with subarachnoid neural blockade were more likely to be caused by streptococci, and patients were more likely to recover fully. Table 5 reviews data from 10 studies or reviews that, if taken together, suggest that the rate of infection was approximately 3.5 per 100,000 sub-arachnoid neural blockades.

INFECTIONS ASSOCIATED WITH COMBINED EPIDURAL AND SUBARACHNOID BLOCKADE

At present, there are few reports in the literature about infectious complications as a result of using combined epidural-subarachnoid (CSE) neural blockade. In 11 case reports of infections with a total number of 12 patients after combined procedures (Table 6), the median time to onset of signs or symptoms of infection was 21 hours (range 8 hours to 9 days) for all infections and 18 hours (range 8 hours to 3 days) for meningitis. Signs or symptoms of epidural abscesses were first noted 1–9 days after the procedures. Streptococcal species caused three of six cases of meningitis, and S. aureus caused all three epidural abscesses. Ten of twelve patients recovered fully. Cascio and Heath assessed rates of infection associated with combined procedures and identified one case of meningitis after about 700 (≈0.1%) CSE neural blockades.

INFECTIONS ASSOCIATED WITH PERIPHERAL NERVE BLOCKS

Continuous regional anesthetic techniques utilizing peripheral nerve blocks have become more popular in recent years for postoperative pain management, especially for orthopedic procedures. Only a few studies have addressed infectious complications related to these procedures. The study by Auroy and coworkers of French anesthesiologists did not identify any infections after 43,946 peripheral blocks. Bergman and colleagues identified 1 patient among 368 patients (405 axillary catheters) who had a local S. aureus skin infection in the axilla after 48 hours of axillary analgesia. The patient recovered fully with antibiotic treatment. Meier and colleagues reported eight superficial skin infections among 91 patients who had continuous interscalene catheters for an average of 5 days. Nseir described a case of fatal streptococcal necrotizing fasciitis following axillary brachial plexus block. Adam reported a psoas abscess complicating a femoral nerve block catheter.

Cuvillion and coworkers obtained cultures of 208 femoral catheters when they were removed after 48 hours. Of the catheters, 54% were colonized with potentially pathogenic bacteria (71% Staphylococcus epidermidis, 10% Enterococcus spp., and 4% Klebsiella spp.). These investigators also reported three episodes of transient bacteremia, but they did not identify any abscesses or episodes of clinical sepsis. None of the groups provided information about the aseptic techniques used for catheter insertion.

Compère reported a single infection in 400 continuous popliteal sciatic nerve blocks (0.25%), while Volk and coworkers from the German regional anesthesia network reported in 2009 a 1.3% incidence of infectious complications for peripheral blocks in 3724 procedures compared to a higher rate for neuraxial techniques (2.7% in 5057 procedures).

Between 2002 and 2009, Reisig and coworkers collected data on 10,549 peripheral catheter procedures in an observations study that included the implementation of a comprehensive infection control bundle. While the definitions of inflammation and infection used in this study remain somewhat vague, they could show a rate of 4.2% for inflammation and 3.2% for infections in 3491 procedures before the intervention and a reduction to 2.6% for inflammation and 0.9% for infections in 7053 procedures after the interventions.

Other reports included cases of osteomyelitis following digital blocks and hematoma block for fracture repair, as well as orbital cellulites from sub-Tenon anesthesia,mediastinitis following continuous interscalene block, Aspergillus caldi-oustus infection after unspecified lower back nerve block, and two cases with sepsis after femoral nerve catheters.

All these reports emphasize the importance of maintaining strict asepsis when performing continuing peripheral nerve blocks.

TABLE 4.Infections associated with subarachnoid neural blockade.

Author
(Reference)
Year
Indication
IndicationType of
Infection
Incubation
Period
Signs and
Symptoms
MicroorganismOutcomeComments
Corbett and Rosenstein9619711. Vaginal deliveryMeningitis36 hFever, headache, stiff neckPseudomonas
aeruginosa
Full recovery Three patients infected when a physician rinsed the spinal needle stylet in saline used for consecutive deliveries
2. Vaginal deliveryMeningitis3 daysFever, headache, stiff neck, neck pain, nuchal rigidityP. aeruginosa Full recovery
3. Vaginal deliveryMeningitis4 daysFever, headache, nauseaP. aeruginosa Full recovery
Siegel et al971974Vaginal deliveryLeft subgluteal abscess4 hButtock pain radiating to thighMimeaeFull recovery
14 daysSevere pain sacroiliac joint
Loarie and Fairley131978Debride necrotic heel ulcersEpidural abscess2 daysFever, back pain, urinary retentionStaphylococcus
epidermidis,
Bacteroides
Full recovery Insulin-dependent diabetic
15 daysBilateral lower extremity weakness, absent anal sphincter tone
Berman and Eisele141978Transurethral evacuation of clot from bladderMeningitis1 hShaking chill, fever, back pain, headache, confusionEnterococcusNot specified
Beaudoin and Klein981984Debride and drain infected footEpidural abscess4 days after last subarachnoid neural blockadeBack pain, pain radiating to upper thighsPseudomonas spp.Full recovery35-year-old insulindependent diabetic, received 5 subarachnoid neural blockades in 10 days
Abdel-Magid and Kotb991990HemorrhoidectomyEpidural abscess15 daysBack pain, leg weakness, urinary retention, fever, bilateral absent ankle reflexesProteus spp.Full recovery
Roberts and Petts1001990Remove retained placentaMeningitis18 hHeadache, photophobia, fever, chills, positive Kernig sign, quadriceps weaknessCulture negativeFull recoveryAntibiotics started before the lumbar puncture
Lee and Parry1011991Cesarean sectionMeningitis16 hSevere headache
22 hNausea, photophobia, decreasing mental status, fever, nuchal rigidity, positive Kernig sign
Blackmore et al1021993HerniorrhaphyMeningitis and bacteremia16 hFever, vomiting, obtundationStreptococcus mitisFull recovery
Ezri et al103 1994HemorrhoidectomyMeningitis10 daysFeverEscherichia coli
25 daysMalaise, headache, photophobia, dizziness, feverFull recovery
Mahendru et al1041994Foot amputationEpidural abscess3 weeksBack pain, bilateral lower extremity paresis and weaknessNo culture obtainedDied from esophageal carcinomaInsulin-dependent diabetic
Gebhard and Brugman1051994Knee arthroscopyDiskitis 2 monthsBack and thigh pain, elevated sedimentation ratePropionibacterium
acnes
Full recovery
Newton et al1061994Vaginal deliveryMeningitis12 hHeadache, photophobia, declining mental status, feverStreptococcus
salivarius
Full recovery
Schneeberger et al919961. Knee arthroscopy Meningitis12 hFever, meningeal signsStreptococcus
sanguis
Full recovery
2. Knee arthroscopy Meningitis12 hHeadacheS. mitisFull recovery
2 daysFever, meningeal signs
3. Varicose vein strippingMeningitis24 hHeadache, fever, impaired consciousness, meningeal signsS. salivariusFull recovery
4. Varicose vein strippingMeningitis12 hHeadache, feverStreptococcus
cremoris
Communicating hydrocephalusHydrocephalus may have been preexisting
Horlocker et al10919971. Urologic procedureDisk space infection1 day Low back pain Staphylococcus
aureus
Full recovery
4 monthsIncapacitating low back pain
2. Examination under anesthesiaParaspinal abscess1 day Low back painS. aureusFull recovery
11 daysFever
Kaiser et al107 1997HysterectomyMeningitis12 hHigh fever, severe headache, lumbar pain, lethargy, Glasgow score of 12, nuchal rigidity, positive Kernig and Brudzinski signsS. salivariusFull recovery
Laurila et al73 1998ArthroscopyMeningitis16 hHeadache, nausea, vomitingS. salivariusFull recoveryAnesthesiologist
wore mask and gloves and used chlorhexidinealcohol solution for skin preparation
Fernandez et al1081999Arthroscopic meniscectomyMeningitis18 h Severe headache, nausea, vomiting, high fever, nuchal rigidityS. mitisFull recovery
Yaniv and Potasman952000Extracorporeal shock wave lithotripsy for ureterolithiasisMeningitis12 hFever, severe headache, meningeal signs, elevated white blood cell countS. salivariusMinor sequelae, mild paresthesia of right thighAnesthesiologist wore gown, sterile gloves, face mask
Trautmann et al82002Arthroscopic knee repairMeningitis1 dayFever, nausea, stiff neckS. salivariusFull recoveryBoth patients underwent their operations the same day
Arthroscopic knee repairMeningitis1 dayHeadache, nausea, stiff neckS. salivariusFull recovery
Rubin et al1020076 surgical casesMeningitisNSFever, stiff neckS. salivariusFull recovery Single anesthesiologist with possible violation of aseptic technique
Cervero111 2009SurgeryMeningitisNSNSS. salivariusNS
CDC11 2010Intrapartum (6 cases)MeningitisNSNSS. salivariusFull recovery Not wearing a mask in 5 cases
Hadzic et al1102012Orthopedic surgeryMeningitis1 dayHeadache, fever ESBL Serratia marcescensFull recovery Multiresistant organisms need to be considered for empiric treatment depending on local endemic situation
Kundra et al1122012Cesarean deliveryNecrotizing fasciitis5 daysSkin necrosis from puncture site to the gluteal regionNSFull recoveryReused contaminated multidose vial as likely cause
Pitkänen et al1132013Knee arthroscopyCerebral and spinal abscesses2 monthsHeadache, stiff neckNSDeath
Knee surgeryMeningitisNSNSNSFull recovery
PhimosisMeningitisNSNSNSFull recovery
Knee arthroscopyMeningitisNSNSNSFull recovery
Prostate hyperplasiaMeningitisNSNSNSFull recovery
Knee arthroscopyMeningitisNSNSNSFull recovery
Source: Adapted with permission from Mayhall CG: Hospital Epidemiology and Infection Control, 3rd ed. Philadelphia: Lippincott, Williams and Wilkins; 2004.

TABLE 5.Frequency of meningitis after subarachnoid neural blockade.

Author (Reference)YearNumber of PatientsNumber of Infections Rate of Meningitis
Evans1161945250000
Scarborough1171958500000
Dripps and Vandam1181954846000
Moore and Bridenbaugh119196611,57400
Lund and Cwik120 1968>21,00000
Sadove et al1211961>20,0003≈15/100,000
Arner122195221,23014.7/100,000
Horlocker et al1091997421700
Auroy et al8120025640 obstetrical00
Auroy et al81200235,439 nonobstetrical 12.8/100,000
Pugely et al12320136030 Total knee
replacements
?0
Total>141,0905≈3.5/100,000
Source: Adapted with permission from Mayhall CG: Hospital Epidemiology and Infection Control, 3rd ed. Philadelphia: Lippincott, Williams and Wilkins; 2004.

PREVENTION OF INFECTIONS ASSOCIATED WITH REGIONAL ANESTHESIA

Anesthesiologists disagree about the necessity of certain infection control precautions. For example, several surveys indicated that only 50%–66% of anesthesia staff wore masks when performing epidural and subarachnoid neural blockades.

NYSORA Tips

  • Wearing a mask during insertion of indwelling neuraxial or peripheral nerve catheters is suggested.
  • Sterile gown should be warn during insertion of epidural or nerve block catheters.
  • Sterile ultrasound transducer cover should be routinely used with ultrasound-guided procedures.
  • Surveillance for catheter site infections is one of the most effective methods for reducing the incidence and consequence of indwelling catheter–related infections.

The review of studies on infections associated with epidural anesthesia indicated that there is no consensus regarding patient risk factors for infectious complications of epidural neural blockade. Few studies assess risk factors for infection associated with epidural or subarachnoid neural blockades, possibly in part because these infections are uncommon. In fact, only one case-control study was performed to evaluate risk factors for infections associated with epidural neural blockade. Dawson and colleagues evaluated epidural neural blockades performed for postoperative pain relief and found that procedures done between April and August had a sixfold higher risk than those done during other months (95% CI 1.28–28.12, p = .009). The risk of infection was lower if a bag rather than a syringe was used to administer the anesthetic agent (odds ratio 0.17, 95% CI 0.02–1.34, p = .05). Of the two risk factors identified by this study, only the latter, use of syringes, could be addressed by practice changes.

Assuming that the respiratory tract of anesthesia personnel could be a source of infection, Philips and associates conducted a simulation to assess the efficacy of masks. They seated anesthesia staff with and without masks in a room with controlled environment and asked them to speak in front of blood agar plates placed 30 cm away. The number of bacteria on the plates was significantly lower when masks were worn. However, the clinical significance of this finding is unknown.

Chlorhexidine has been shown to reduce the risk of catheter-associated bloodstream infections significantly compared with povidone-iodine. Several investigators have tried to determine whether a particular disinfectant provides more effective skin antisepsis before epidural neural blocks than do other agents. However, none of the studies was large enough to assess rates of infection; instead, the outcomes evaluated were catheter or skin colonization.

Kasuda and colleagues randomly assigned 70 patients to have their skin prepared with either a 0.5% alcoholic solution of chlorhexidine or 10% povidone-iodine. After a median of 49 ± 7 hours, the investigators removed the catheters and obtained cultures of the insertion sites and catheter tips. There was no difference in rates of positive cultures.

Kinirons and associates (the only investigators who reported a power calculation) obtained cultures from catheters removed from 96 children who had epidural catheters longer than 24 hours. The colonization rate was lower for catheters removed from children whose skin was prepared with a 0.5% alcoholic solution of chlorhexidine (1/52 catheters, 0.9/100 catheter-days) than for those removed from children whose skin was prepared with povidone-iodine (5/44 catheters, 5.6/100 catheter-days) (relative risk 0.2, 95% CI 0.1–1.0).

TABLE 6.Infections associated with combined subarachnoid and epidural neural blockade.

Author
(Reference)
YearIndicationType of
Infection
Time of
Symptom Onset
Signs and SymptomsMicroorganismOutcomeComments
Cascio and Heath1241995Vaginal deliveryMeningitis16 h after delivery,
≈ 20 h after insertion
Fever, headache, chills, photophobia, mild nuchal rigidityStreptococcus
salivarius
Full recoveryAnesthesiologist wore mask, cap, and sterile gloves and used povidone-iodine spray for skin antisepsis
Harding et al12519941. Vaginal deliveryAseptic meningitis21 h after the injectionSevere headache, faint feeling, shortness of breath, urinary retention, aphasia,
tingling right side of
face, neck stiffness, positive Kernig sign, low-grade temperature
No growthFull recoveryAnesthesiologist scrubbed, wore sterile gown and gloves, and used alcoholic chlorhexidine for skin antisepsis
2. Vaginal delivery converted to emergency cesarean sectionMeningitis3 days after the operationHeadache, fever, vomiting, severe stiff neck, elevated white blood cell count, hypotension, bradycardiaStaphylococcus
epidermidis
Full recoveryAlcoholic chlorhexidine used for skin antisepsis
Stallard and Barry1261994Analgesia during labor, subsequent cesarean sectionMeningitis18 h after the operationAcute confusion, fever, aphasia, ignored left side, elevated white blood cell countNo growthFull recoveryDid three procedures to achieve adequate analgesia; anesthesiologist used alcoholic chlorhexidine for skin antisepsis and wore mask, gown, and gloves
Aldebert and Sleth1271996Vaginal deliveryMeningitis8 h after punctureHeadache, nausea, fever, agitation, nuchal rigidity, positive Babinski signNonhemolytic streptococcusFull recoveryAnesthesiologist wore mask, gown, cap, and sterile gloves
Dysart and Balakrishnan1281997Cesarean sectionEpidural abscess9 days after the operationBackache, fever, foot drop, weakness of ankle eversion and inversion, absent ankle jerk reflex, decreased pinprick sensation from L5 to perianal region, elevated erythrocyte sedimentation rateStaphylococcus
aureus
Nearly full recovery; patient had residual numbness in L5 distributionAnesthesiologist wore a mask, gown, and gloves and used chlorhexidine for skin antisepsis
Schroter et al1291997Anesthesia for vascular surgeryEpidural abscess1 day after procedureBack pain, fever, slight nuchal rigidity, erythema and induration at puncture site and purulent drainage from puncture site, elevated white blood cell countS. aureusFull recoveryAnesthesiologist wore a mask, surgical hood, sterile gloves, and gown and used povidone-iodine for skin antisepsis
Bouhemad et al130 1998Cesarean sectionEpidural abscess14 h after deliveryFever, severe headache, photophobia, drowsiness, stiff neck,S. salivariusFull recoveryAnesthesiologist wore gown, gloves, face mask, and cap and used tincture of iodine for skin antisepsis
Rathmell et al1142000Labor analgesia in patient with multiple traumaEpidural abscess7 days after catheter placementBack pain, purulent discharge from insertion siteS. aureusFull recovery
Phillips et al62 2002Surgical anesthesia and postoperative analgesiaEpidural abscess Ll–L2Day 6Discomfort at the epidural site and severe radicular pain in L2 dermatome, erythema and swelling at site, decreased strength, light touch, and pinprick, and loss of ankle jerk reflexS. aureusDischarged from hospital 3 months after first operationAnesthesiologist wore a cap, gown, and sterile gloves and used 10% povidone-iodine for skin antisepsis
Sandkovsky et al131
2009DeliveryMeningitisNSNSStreptococcus
spp.
NS
Pitkänen et al1132013Total hip arthroplastyEpidural abscessNSNSNSFull recovery
Source: Adapted with permission from Mayhall CG: Hospital Epidemiology and Infection Control, 3rd ed. Philadelphia: Lippincott, Williams and Wilkins; 2004

Sato and coworkers enrolled 60 patients who were undergoing back operations under general anesthesia. After preparing the site with either 0.5% alcoholic chlorhexidine or 10% povidone-iodine, the investigators obtained skin biopsies. Cultures from skin prepared with the alcoholic chlorhexidine were less likely to be positive (5.7%) than were cultures from skin prepared with povidone–iodine (32.4%; p < .01). However, microscopy was as likely to identify bacteria in the hair follicles of skin prepared with the alcoholic solution of chlorhexidine (14.3%) as skin prepared with povidone-iodine (11.8%).

This has led to the recommendation to use alcoholic chlorhexidine for skin preparation despite some concerns about potential neurotoxicity. The latter might be the reason American Society of Anesthesiologists (ASA) members were equivocal on the issue during the consensus process, while external experts were in favor of the recommendation.

Sviggum et al published the experiences from the Mayo Clinic analyzing almost 12,000 spinal anesthetics between 2006 and 2010 that used alcoholic chlorhexidine. They did not observe any change in neurological complications, considering the practice to be safe. Unfortunately, no data about infectious complications were reported.

The safety of alcoholic chlorhexidine was underlined in an experimental study by Doan and coworkers. They found damage to neuronal cell cultures with chlorhexidine as well as with 10% iodine they could also show that a relevant toxic concentration of skin disinfectants cannot be reached if the puncture is performed through dry skin. Therefore, allowing the skin to completely dry once disinfected before performing the block is more important than the choice of the solution in order to prevent any neurotoxic effect.

Malhotra et al demonstrated in a study of 309 healthy volunteers that single application of 0.5% chlorhexidine gluconate in 70% ethanol was as effective as two applications.The fact that infections rarely complicate neuraxial blockades suggests that the infection control practices used for these procedures are usually adequate. Given the very low rates of infection associated with epidural and subarachnoid neural blockade, it will be difficult to prove that additional infection control practices such as wearing masks and using full barrier precautions (ie, the anesthesiologist wears a cap, mask, sterile gloves, and sterile gown and uses a large drape to cover the patient) reduce the risk of infection. However, bacteria that colonize the skin, respiratory tract, or water caused most reported infections after epidural and subarachnoid neural blockades. Masks have been shown to decrease spread of organisms when anesthesiologists are talking. Thus, a mask would allow the anesthesiologist to talk to the patient while doing the procedure and could decrease the risk of contaminating the insertion site with oral or respiratory flora. This has also been incorporated in the ASA “Practice Advisory for the Prevention, Diagnosis, and Management of Infectious Complications Asso-ciated With Neuraxial Techniques.”

Furthermore, epidural and subarachnoid neural blockades are at least as invasive as placing central venous catheters, and the consequences of subsequent infections are at least as bad as those for catheter-associated bloodstream infections. Because the use of full barrier precautions reduces the incidence of catheter-related bloodstream infections, aseptic measures similar to those used for placing central venous catheters should be used during the placement of catheters that will remain in place for several days or longer. While the ASA practice advisory still uses the term hand washing before putting on sterile gown and gloves, hand disinfection with an alcoholic hand rub (with 70% alcohol) is the internationally preferred standard.

Anesthesia personnel should observe their patients closely for signs and symptoms of infection so that infections can be diagnosed and treated immediately. Pegues and coworkers reviewed medical records from 1980 to 1992 of patients who had short-term epidural catheters to identify those who acquired infections. They followed patients prospectively from January 1993 until June 1993.170 In 1990, they introduced a standardized procedure for inspecting temporary epidural catheters. During the entire 12.5-year period, the investigators identified seven infections, all of which occurred after catheters were inspected routinely. The increased incidence of infection could have resulted from ascer-tainment or misclassification bias associated with the retrospective review or from increased use of epidural catheters for pain management during the later time period. On the other hand, it could indicate that infections were not diagnosed when catheters were not inspected routinely for signs of infection.

Because it may be difficult to draw up opioids in a sterile manner from ampoules, some have suggested that these drugs be drawn through a filter into a syringe, which is then double wrapped and sterilized in ethylene oxide. However, the benefit of such extreme precautions is highly hypothetical.Brooks and coworkers were among the first to implement and report on structured infection control measures for continuous neuraxial blocks in their hospital. In 2008, we reviewed the literature and compared the infection control recommendations of the ASRA and the German Society of Anesthesiology and Intensive Care (DGAI) and noticed some discrepancies, especially regarding the use of masks and gowns or filters. In 2010, new guidelines by the ASA were developed in a consensus process among ASA members and external experts to clarify some of the issues. However, the evidence supporting many of the recommendations remains sparse, and extrapolation from other areas of practical implementation of infection control is needed.

The ASA “Practice Advisory for the Prevention, Diagnosis, and Management of Infectious Complications Associated With Neuraxial Techniques” has published the following guide-lines for the placement of neuraxial blocks:

  • Before performing neuraxial techniques, a history and physical examination relevant to the procedure and review of relevant laboratory studies should be conducted to identify patients who may be at risk of infectious complications. Consider alternatives to neuraxial techniques for patients at high risk.
  • When neuraxial techniques are indicated in a known or suspected bacteremic patient, consider administering preprocedure antibiotic therapy.
  • Selection of neuraxial technique should be determined on a case-by-case basis, including consideration of the evolving medical status of the patient.
  • Lumbar puncture should be avoided in the patient with a known epidural abscess.
  • Aseptic techniques should always be used during the preparation of equipment (eg, ultrasound) and the placement of neuraxial needles and catheters, including the following:
    • Removal of jewelry (eg, rings and watches); hand washing; and wearing of caps, masks (covering both mouth and nose and consider changing before each new case), and sterile gloves
    • Use of individual packets of antiseptics for skin preparation
    • Use of chlorhexidine (preferably with alcohol) for skin preparation, allowing for adequate drying time
  • Sterile draping of the patient.
  • Use of sterile occlusive dressings at the catheter insertion site.
  • Bacterial filters may be considered during extended continuous epidural infusion.
  • Limit the disconnection and reconnection of neuraxial delivery systems to minimize the risk of infectious complications.
  • Consider removing unwitnessed accidentally disconnected catheters.Catheters should not remain in situ longer than clinically necessary.The following recommendations are given for the diagnosis and management of infectious complications after neuraxial block:
  • Daily evaluation of patients with indwelling catheters for early signs and symptoms (eg, fever, backache, headache, erythema, and tenderness at the insertion site) of infectious complications should be performed throughout the patients’ stay in the facility.
  • To minimize the impact of an infectious complication, promptly attend to signs or symptoms.
  • If an infection is suspected:
    • Remove an in situ catheter and consider culturing the catheter tip.
    • Order appropriate blood tests.
    • Obtain appropriate cultures.
    • If an abscess is suspected or neurologic dysfunction is present, imaging studies should be performed, and consultation with other appropriate specialties should be promptly obtained.
  • Appropriate antibiotic therapy should always be administered at the earliest sign or symptom of a serious neuraxial infection.
  • Consultation with a physician with expertise in the diagnosis and treatment of infectious diseases should be considered.

TABLE 7. Summary of recommendations for infection control practice.

 SingleShot
PNB
Continuous
Catheter PNB
Single-Shot
Neuraxial
Block
Continuous
Neuraxial Catheter
Long-Term
Implanted Device/
Catheter (eg,
Intrathecal Pump)
2% chlorhexidine in 70% alcohol
skin prepa
+++++
Small sterile drape(+)+
Large sterile drape++++
Sterile gloves+++++
Sterile gown+ (especially for stimulating catheters)(+)+
Mask++++
Hair cover++++
Prophylactic antibiotics----+ single perioperative dose
Filter on injection/infusion system-(+)-(+)NA
OR or special procedure room+
Tunneling of catheter + (to prevent dislocation)+ if used for more than 3 days
Preparation of injection/ infusion solution under sterile conditions (pharmacy)(+) for continuous infusion(+) for continuous infusion
+ strongly recommended; (+) consider; – not recommended; NA = not applicable; PNB = peripheral nerve block.
aAlternatively, 10% povidone-iodine or 80% alcohol or a mixture of 70%–80% alcohol with povidone-iodine for at least 3 minutes. Choice of agent also depends on type of block (eg, eye blocks, etc.).

However, guidelines and standard operating procedures alone are not enough to ensure proper aseptic technique. Friedman and coworkers showed in a videotape analysis of 35 epidural placements by second-year residents a significant increase in manual skills with growing experience, but there was no increase in aseptic technique. This highlights the need for a special focus on aseptic technique in residency and during infection control audits of anesthesia providers.

PERIPHERAL BLOCKS AND PERIPHERAL CONTINUOUS CATHETERS

Recent studies indicated that infection control protocols similar to the recommendations for neuraxial block can reduce the incidence of infectious complications associated with placement of continuous peripheral nerve catheters. Unfortunately, the effectiveness of each step is hard to assess, a problem familiar from all the other recommended approaches in infection con-trol, such as the ones for prevention of central line–associated bloodstream infections or ventilator-associated pneumonia.

With the increasing use of real-time ultrasound, the correct handling of the ultrasound probe becomes an additional concern. To maintain the aseptic field, the cable and the probe should be covered with a sterile sheath to avoid contamination in the case of needle contact. Sterile contact gel or sterile saline should be used within the sheath. Puncture aids fixating the needle to the probe must be sterile. After the procedure, ultrasound probes need to be cleaned removing any residual gel and disinfected with an appropriate disinfectant that cannot damage the probe. Alternative techniques using ultraviolet light to disinfect ultrasound probes are under investigation.

SUMMARY

Although rare, infectious complications from regional anesthe-sia and analgesia do occur and can be serious. Recent guidelines offer practice recommendations especially for neuraxial blocks. Table 7 summarizes the key recommendations for decreas-ing the risk of infections related to regional anesthesia proce-dures. Surveillance systems should be implemented as part of national quality assurance programs to allow benchmarking and process optimization as well as providing data from large population databases, which would be beneficial in addressing some of the unanswered questions about infections after regional anesthesia procedures.

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