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Prevention and diagnosis of infectious complications associated with neuraxial technique

Prevention and diagnosis of infectious complications associated with neuraxial technique. Pedro Tanaka ptanaka@stanford.edu. Severe Neurological Complications after Central Neuraxial Blockades in Sweden 1990 – 1999 Moen V et al. Anesthesiology 2004;101:815-817.

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Prevention and diagnosis of infectious complications associated with neuraxial technique

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  1. Prevention and diagnosis of infectious complications associated with neuraxial technique Pedro Tanaka ptanaka@stanford.edu

  2. Severe Neurological Complications after Central Neuraxial Blockades in Sweden 1990 – 1999 Moen V et al. Anesthesiology 2004;101:815-817. Complications According to Type of Central Neuraxial Blockade 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) Neurological Complications Related to Outcome Permanent Neurological Complication Full Recovery Damage No Information All Spinal hematoma 6 27 – 33 Cauda equina syndrome – 32 – 32 Purulent meningitis 21 6 2 29 Epidural abscess 7 4 2 13 Miscellaneous Traumatic cord lesion – 9 – 9 Cranial subdural hematoma 4 1 – 5 Paraparesis – 4 – 4 Other – 2 – 2 Total 38 85 4 127

  3. RISK OF INFECTION 0 0 0 0 0 0 0 0 0 0 0 Número de anestesias peridural 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 Tempo de cateterização (dias) Wang LP et al. Anesthesiology 1999;91:1928-1936.

  4. Epidural abcess

  5. 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

  6. S S SOURCE OF INFECTION Isolated Microorganisms from the Samples Epidural Catheter Tip Segment Subcutaneous Segment Skin OrganismN (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) Yuan HB et al. Anesthesiology 2008;108:130-137.

  7. SKIN DESINFECTION 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. Debreceni G et al. Brit J Anaesth 2007;98:131-135.

  8. CATHETER DRESSING Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis StudyTreatment 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) 0.01 0.1 1 10 100 Favors treatment Favors control Ho KM et al. J Antimic Chemoth;58:281-287.

  9. 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.

  10. 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.

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