Epidural abscess following epidural catheterization in a chronic pain patient: a diagnostic dilemma

[Evaluation of antibacterial filters for peridural obstetrical anesthesia]

OBJECTIVES

To assess the antibacterial efficiency of filters used in obstetrics when epidural top-ups are performed.

STUDY DESIGN

Observational prospective study.

PATIENTS AND METHODS

We aseptically collected 201 antibacterial filters that had been used for top-ups with ropivacaine +/- sufentanil for epidural analgesia during labour. We flushed them first with 2 mL of saline and then with 2 mL of a solution containing 1.5 x 10(6) Staphylococcus epidermidis/mL. The filtrates were incubated at 37 degrees C for 72 h. Number of top-ups and duration of epidural analgesia are expressed as median (extremes).

RESULTS

3 (1-10) top-ups were performed for labour analgesia over a period of 6.5 h (1.8-18). After filtering, all the solutions were found to be sterile. Especially, when using Staphylococcus epidermidis solutions, bacteria were not found beyond any filter. These results suggest the integrity of the filter membrane after several boluses. No infection related to epidural analgesia was reported.

CONCLUSION

Antibacterial filters provide a good protection against a potentially contaminated procedure during epidural top-ups.

The effect of repeated epidural sympathetic nerve block on "failed back surgery syndrome" associated chronic low back pain

STUDY OBJECTIVE

To assess the therapeutic benefits of repeated epidural local anesthetic administration on pain perception and straight leg raise (SLR) in patients suffering from chronic low back pain.

DESIGN

Prospective, randomized, controlled, single-blind study protocol.

PATIENTS

50 ASA physical status I, II, and III patients at least 18 years of age, who had previously undergone spine surgery.

INTERVENTIONS

All participants were admitted to hospital for the 5-day duration of the study. Following epidural catheterization, fluoroscopy was performed to verify correct placement of the epidural catheter. On the first study day, all patients received depomedrol 80 mg, in 10-ml 1% lidocaine, epidurally. Thereafter, patients were randomized into two equal groups. In Group Bupivacaine (B) 10-ml 0.125% bupivacaine was administered. In Group Saline (S), an equal volume of saline was administered. Epidural injections were performed twice daily (09H00 and 14H00) for 4 days. Sympathetic blockade was confirmed by the presence of peripheral vasodilatation. Sensory blockade was assessed using loss of pin prick and temperature sensation. SLR as well as patient-generated 100-mm visual analog score (VAS) for pain were performed prior to each injection, at 15 minutes after injection, and hourly for 2 hours thereafter. Similar parameters were measured 1 week, 1 month, and 3 months after discharge.

MEASUREMENTS AND MAIN RESULTS

46 patients completed the study. VAS for pain was marginally lower in Group B. However, statistical significance was not demonstrated. During the hospitalization period, the SLR in both study groups significantly (0.008) improved with time. However, no difference between the groups was demonstrated. In both groups, 1 week, 1 month, and 3 months after discharge, the SLR was comparable to prestudy recordings. In Group B, at 1 week, 1 month, and 3 months after discharge, patient-generated VAS for pain were significantly (p = 0.002) higher when compared to pain scores at the time of patient discharge.

[Evaluation of aseptic measures in the performance of epidural catheterization and perception of its risk of infection. Results of a survey in Languedoc-Roussillon]

OBJECTIVE

To assess the level of aseptic practice in epidural catheterization, to determine the perception of its infectious risk and the knowledge of epidural abscess symptoms.

STUDY DESIGN

Cross-sectional regionwide retrospective survey.

MATERIAL

Questionnaire sent after telephone call to 160 anaesthesiologists performing epidural anaesthesia in Languedoc-Roussillon.

RESULTS

Replies were obtained from 96 anaesthesiologists working in 26 centres. Handwashing techniques were various: 53% onefolded with an antiseptic preparation, 38% twofolded and 9% used a simple soap; 41% did never wear a long-sleeved sterile surgical gown and only 53% wored simultaneously a cap; a surgical mask and a sterile gown; 4% of the Tuohy needles were reusable; 21% of the dressings permitted continuous inspection of the site of puncture; 12.5% admitted not to know epidural abcess symptoms and 30% ignored the most adapted radiological diagnostic means.

CONCLUSIONS

Good aseptic practice in epidural catheterization should be clarified by a consensus conference. There is an obvious lack of knowledge concerning features of epidural abscess.

Epidural abscess complicating epidural anesthesia and analgesia. An analysis of the literature

BACKGROUND

Epidural abscess is a serious complication of epidural block. Because of its low incidence, the risk factors and the symptoms and cause of epidural abscess related to epidural anesthesia and analgesia are not well known by anesthesiologists.

METHODS

A computer-assisted search of the literature on epidural catheter-related abscess was performed to describe the clinical course and bacteriology of this complication, to determine possible risk factors, and to assess the index of suspicion among physicians.

RESULTS

Forty-two patients with a catheter-related epidural abscess were identified. Only in 15 patients was the correct diagnosis considered initially. The time from insertion of the epidural catheter to symptoms varied between 1 and 60 d. Initial symptoms included back pain, fever, and leukocytosis. The time from symptoms to treatment was a few hours to 108 d. Interval from first symptoms to treatment was significantly longer in patients with persistent neurologic deficits compared with patients who completely recovered. Staphylococcus aureus was the most common etiologic agent. Outcome was reported in 39 patients, but only 19 made a full recovery.

CONCLUSION

The index of suspicion among anesthesiologists, other physicians and nurses taking care of patients with epidural catheters must be increased for this complication; this should shorten the interval from symptoms to treatment and lower the incidence of neurological sequelae.

Introducing epidural fentanyl for on-ward pain relief after major surgery

BACKGROUND

Epidural opioids have been recommended for analgesia after major surgery. In this report we describe how we introduced a low-cost, on-ward, nurse-based acute pain service using epidural fentanyl after major surgery in the University Hospitals of Oulu and Kuopio.

METHODS

In order to evaluate the feasibility of epidural fentanyl infusion administered by ward nurses, we prospectively assessed pain and side effects during fentanyl infusion (median duration 41 h) after major surgery in 305 consecutive patients in Kuopio.

RESULTS

92% of the patients on the ward who had received epidural fentanyl infusion at 31-54 micrograms h-1 reported at most three episodes of severe pain (/Numerical Rating Scale > 3/ 10) during the initial postoperative days, but there were some patients (8%) who reported several episodes (> 3) of more severe pain (Numerical Rating Scale > 3). Three patients (0.9%) showed a diminished respiratory rate (< 10/min), but only one of them (0.3%) was somnolent. One other patient (0.3%) was not arousable until the cessation of infusion. Nausea and pruritus were minor problems in our patients, but a majority needed a urinary catheter.

CONCLUSION

With well-trained nurses, careful monitoring and appropriate protocols, epidural fentanyl infusion proved to be a feasible method for pain relief after major surgery on a surgical ward.

Infections following epidural catheterization

Seventy-eight patients with culture-positive epidural catheters, were studied. Fifty-nine had symptoms of exit site infection and 11 patients had clinical meningitis, two of whom also had an epidural abscess. This corresponds to a local infection incidence of at least 4.3% and an incidence of central nervous system infection of at least 0.7% at Odense University Hospital. This degree of infection is of the same magnitude as that reported for intravascular devices. We found that the patients with generalized symptoms of infection had been catheterized for a longer time, and were older than patients with only local symptoms of infection. The microorganisms isolated from the tips of the epidural catheters were coagulase-negative staphylococci (41%), Staphylococcus aureus (35%), Gram-negative bacilli (14%) and others (10%). The Gram-negative bacilli and S. aureus caused serious infections more frequently than the others. We discuss the symptoms and diagnosis of spinal epidural abscess and suggest a proposal for prophylactic and diagnostic guidelines for epidural catheter-related infections.

The risk of infection from epidural analgesia in children: a review of 1620 cases

We reviewed cases to determine whether suspected or confirmed epidural infection was associated with epidural analgesia for 1620 infants, children, and adolescents treated over a 6-yr period at Children's Hospital, Boston. Postoperative patients (1458/1620) received epidural infusions for a median of 2 days (range, 0-8 days). No postoperative patient had an epidural abscess. One 10-yr-old with terminal malignancy received thoracic epidural analgesia via two successive catheters over a 4-wk period. She had Candida colonization of the epidural space along with necrotic epidural tumor. A second oncology patient and two patients with reflex sympathetic dystrophy were evaluated for epidural abscess, but none was found. We conclude that the risk of epidural infection is quite low in pediatric postoperative patients receiving short-term catheterization. Use of prolonged epidural analgesia in the management of chronic pain in children requires careful monitoring of warning signs of infection.

Epidural infection associated with epidural catheterization in a cancer patient with back pain: case report

Single epidural injections of local anaesthetic/steroid mixtures and epidural catheterization are useful in controlling pain when other measures fail. However, epidural infection is a recognized risk of these procedures, but can be difficult to diagnose. This case report illustrates the complexity of diagnosis and management of epidural infection.