Bacterial meningitis following combined spinal-epidural analgesia for labour

Efficacy of a silver colloidal gel against selected oral bacteria in vitro

Background: It is necessary to develop new strategies to protect against bacteria such as S treptococcus mutans, S treptococcus sanguis, and Streptococcus salivarius, which contribute to tooth decay and plaque formation. Our current study investigated the efficacy of a colloidal silver gel in inhibiting biofilm formation by these principal oral bacteria , in vitro. The aim of this study was to assess the efficacy of a colloidal silver gel formulation for inhibiting bacterial biofilm formation (Ag-gel) by the principal bacteria that cause plaque formation and tooth decay.

Methods: The effect of Ag-gel on viability of S. mutans, S. sanguis, and S. salivarius was assessed by quantifying their colony forming units (CFU) in presence or absence of the test gel. The effect of this formulation on biofilm-forming ability of these bacteria was studied through scanning electron microscopy.

Results: Using the CFU assays, over 6 logs of inhibition (100%) were found for S. mutans, S. sanguis, and S. salivarius for the Ag-gel-treated bacteria when compared with the control gel. In addition, the Ag-gel also inhibited biofilm formation by these three bacteria mixed together. These results were confirmed by scanning electron microscopy.

Conclusions: The Ag-gel was effective in preventing biofilm formation by S. mutans, S. sanguis, and S. salivarius. This Ag-gel should be tested for the ability to block plaque formation in the mouth, through its use as a tooth paste.

Practice Advisory for the Prevention, Diagnosis, and Management of Infectious Complications Associated with Neuraxial Techniques

Supplemental Digital Content is available in the text.

[Meningitis after spinal anesthesia]

Les méningites sont des complications rares mais graves des anesthésies péridurales et des rachianesthésies. Les méningites bactériennes sont essentiellement dues à des cocci à Gram positif, ce qui sous-entend une contamination exogène pouvant être le témoin d'une faute d'asepsie. L’évolution est le plus souvent favorable sous traitement, mais au prix d'un accroissement des dépenses de santé et parfois d'importantes séquelles neurologiques. Nous présentons un cas de méningite bactérienne au décours d'une rachianesthésie effectué pour césarienne.

Comparison of disinfective power according to application order of 70% isopropyl alcohol and 10% povidone-iodine

BACKGROUND

Many disinfectants have been used clinically in both single and combination applications, but there have been few studies on disinfective power according to sterilization sequence when using a combination of disinfectants. The purpose of this study was to evaluate the disinfective power of a combination of 70% isopropyl alcohol and 10% povidone-iodine (PVP-I) according to sterilization sequence.

METHODS

Two hundred healthy volunteers were recruited. Subjects were disinfected with a combination of 70% isopropyl alcohol and 10% PVP-I on both forearms, in varying sequence. The AP group included disinfections on the left forearm with isopropyl alcohol first followed by 10% PVP-I, while the PA group included disinfections on the right forearm with same disinfectants in reverse order. Skin cultures were obtained using cotton swabs 3 min after application of each disinfectant, and then were inoculated on blood agar plates for bacterial culture. Cultures were incubated at 37℃ under aerobic conditions for 48 hours.

RESULTS

There was no significant difference in the number of positive cultures after the 1(st) disinfection (AP, 45; PA, 36, P = 0.262) or the 2(nd) disinfection (AP, 6; PA, 13, P = 0.157), suggesting that there is no relationship between disinfective power and the sequence of the disinfectants used. The number of positive cultures significantly decreased after the 2(nd) disinfection (P < 0.01), however.

CONCLUSIONS

There was no significant difference in disinfective power according to sterilization sequence with 70% isopropyl alcohol and 10% PVP-I in healthy volunteers. The combination of 70% isopropyl alcohol and 10% PVP-I was more effective than disinfection with a single agent regardless of sterilization sequence.

Clinical and laboratory features of Streptococcus salivarius meningitis: a case report and literature review

Streptococcus salivarius is a normal member of the human oral microbiome that is an uncommon cause of invasive infections. Meningitis is a rare but increasingly reported infection caused by S. salivarius. Despite the growing number of reported cases, a comprehensive review of the literature on S. salivarius meningitis is lacking. We sought to gain a better understanding of the clinical presentation, evaluation, management, and outcome of S. salivarius meningitis by analyzing previously reported cases. In addition to a single case reported here, 64 previously published cases of meningitis were identified for this review. The collected data confirm that most patients presented with classical signs and symptoms of bacterial meningitis with a predominance of neutrophils in the cerebrospinal fluid (CSF) and hypoglycorrhachia. The majority of cases followed iatrogenic or traumatic CSF contamination. Most cases were diagnosed by CSF culture within one day of symptom onset. There was no clear evidence of predisposing co-morbid conditions in patients with meningitis, although in most case reports, limited information was given on the medical history of each patient. Outcomes were generally favorable with antibiotic management. Clinicians should suspect S. salivarius meningitis in patients presenting acutely after medical or surgical procedures involving the meninges.

Progress in analgesia for labor: focus on neuraxial blocks

Neuraxial analgesia is widely accepted as the most effective and the least depressant method of providing pain relief in labor. Over the last several decades neuraxial labor analgesia techniques and medications have progressed to the point now where they provide high quality pain relief with minimal side effects to both the mother and the fetus while maximizing the maternal autonomy possible for the parturient receiving neuraxial analgesia. The introduction of the combined spinal epidural technique for labor has allowed for the rapid onset of analgesia with minimal motor blockade, therefore allowing the comfortable parturient to ambulate. Patient-controlled epidural analgesia techniques have evolved to allow for more flexible analgesia that is tailored to the individual needs of the parturient and effective throughout the different phases of labor. Computer integrated systems have been studied to provide seamless analgesia from induction of neuraxial block to delivery. New adjuvant drugs that improve the effectiveness of neuraxial labor analgesia while decreasing the side effects that may occur due to high dose of a single drug are likely to be added to future labor analgesia practice. Bupivacaine still remains a popular choice of local anesthetic for labor analgesia. New local anesthetics with less cardiotoxicity have been introduced, but their cost effectiveness in the current labor analgesia practice has been questioned.

Modern neuraxial labor analgesia: options for initiation, maintenance and drug selection

In the present review we outline the state-of-the-art of neuraxial analgesia. As neuraxial analgesia remains the gold standar of analgesia during labor, we review the most recent literature on this topic. The neuraxial analgesia techniques, types of administration, drugs, adjuvants, and adverse effects are investigated from the references. Most authors would agree that central neuraxial analgesia is the best form to manage labor pain. When neuraxial analgesia is administered to the parturient in labor, different management choices must be made by the anesthetist: how will we initiate analgesia, how will analgesia be maintained, which local anesthetic will we use for neuraxial analgesia and which adjuvant drugs will we combine? The present manuscript tries to review the literature to answer these questions.

Fatal bacterial meningitis after spinal anaesthesia

A 37-y-old male was admitted to the ICU because of meningitis and respiratory failure with epileptic seizures. Spinal fluid grew Streptococcus salivarius. Prior to presentation the patient underwent surgical excision of a chronic toe ulcer, performed under spinal anaesthesia, which raised the suspicion of iatrogenic origin of the disease. The clinical situation deteriorated over the following d and the patient died from multi-organ failure. Careful hygiene measures are needed to prevent such a severe complication.

[Assessment of hygiene practices in anaesthesia between 1998 and 2007 in Lorraine]

OBJECTIVES

To study the assessment of hygiene practices in anaesthesia in Lorraine between 1998 and 2007, after recommendations from the French Society of Anaesthesia and Reanimation (SFAR) in December 1997, and different local actions.

STUDY DESIGN

Two surveys performed at a nine-year interval in Lorraine hospitals.

POPULATION AND METHOD

Questionnaires about risk infection management and hygiene practices were sent by post to all anaesthetists, nurse anaesthetists and recovery room nurses in 1998 (n=279) and in 2007 (n=259).

RESULTS

Between the two surveys multidrug-resistant bacteria signalling, movements of the staff in operating rooms, septic isolation protocol and management of single-use disposable anaesthesia material have been improved (p<0.05). Central venous catheters are less performed in recovery rooms and rings wearing decreased by 16% (p<0.05). Wearing of nonsterile gloves for peripheral venous catheter and intubation is not generalized (p<0.05). About half of the hospitals have cleanup procedures of anaesthesia furniture. Washing of hands by anaesthesia staff is not sometimes respected but it's more frequent for medicine preparation and between two operations. A good skin disinfection (cleaning - rinsing - drying - antiseptic) is more recurrent in 2007 (61.4%) than in 1998 (41.9%) for arterial catheter. Wearing of glasses for intubation is each times rare, about 15%.

CONCLUSION

Hygiene practices in anaesthesia in Lorraine have been improved between the two surveys by recommendations from the Sfar and the work of the Antenne Régional de Lorraine (audits, manuals, formations). Promising progress has been made but some points must still be worked on.

Neurological infections after neuraxial anesthesia

Infection is the commonest cause of serious neurologic sequelae of neuraxial anesthesia. The incidence depends on operator skill and patient population. Meningitis, a complication of dural puncture, is usually caused by viridans streptococci. The risk factors are dural puncture during labor, no mask and poor aseptic technique, vaginal infection and bacteremia. Epidural abscess is a complication of epidural catheterization, route of entry the catheter track and the organism usually the staphylococcus. Principal risk factors are prolonged catheterization, poor aseptic technique and traumatic insertion. Prevention includes wearing a mask, using a full sterile technique, avoiding prolonged catheterization and prescribing antibiotics in a high-risk situation.

Retroperitoneal infection complicated by bacterial meningitis and ventriculitis with secondary brainstem infarction

INTRODUCTION

Retroperitoneal abscesses have been previously reported to cause infectious meningitis. Cerebral infarction is a known complication of basilar meningitis.

SUMMARY OF CASE

We present a case where a comatose patient with a known retroperitoneal abscess was diagnosed via Magnetic Resonance Imaging (MRI) with extensive brainstem infarction secondary to basilar meningitis.

Aspergillus meningitis following spinal anaesthesia for caesarean section in Colombo, Sri Lanka

We report six cases of Aspergillus meningitis after spinal anaesthesia for caesarean section administered in June and July 2005. Three patients died before a fungal infection was confirmed at the first post-mortem examination in August. Thereafter anti-fungal therapy was successful in saving the lives of the other three patients. Some syringes and spinal needles supplied to the hospitals concerned were found to be contaminated with Aspergillus fumigatus. Investigators found that medical supply storage facilities were substandard following the influx of donations after the tsunami of December 2004.

Morbidity and mortality from obstetric anaesthesia in the 1990s

As anaesthetic-related maternal mortality reduces in the developed world, alternative indicators of obstetric anaesthetic quality are required. Serious morbidity is difficult to define and quantify, but can be reduced by the provision of effective critical care. Regional anaesthesia, although safer than general anaesthesia, is not without risks. Evidence-based strategies exist to reduce the risks.

Persistent Cauda Equina Syndrome with No Identifiable Facilitating Condition After an Uneventful Single Spinal Administration of 0.5% Hyperbaric Bupivacaine

We diagnosed cauda equina syndrome 15 h after uneventful single spinal administration of 0.5% hyperbaric bupivacaine 12.5 mg through a 27-gauge pencil-point type needle. No preexisting neurologic disorder was recorded. There was no pain or paresthesia during needle placement or drug injection. The sensory levels were bilateral, symmetric, and caudal to T8. Resolution of most of the symptoms occurred within a few days but some foot drop persisted for 2 yr after the procedure. Bupivacaine neurotoxicity is suggested by the absence of any other identifiable cause for this neurologic deficit.

Effusive-constrictive calcific pericarditis associated with Streptococcus salivarius. Case report and review of the literature

We report the case of a 40-year-old patient presenting with a 6-month history of dyspnea and edema, with significant worsening of his clinical manifestations for the 2 weeks before admission to our department. During this 14-day preadmission period, continuous positive airway pressure (CPAP) was prescribed elsewhere for management of a working diagnosis of obstructive sleep apnea. The patient presented to us hemodynamically compromised. Management of the patient included emergency cardiac surgery for tamponade caused by effusive-constrictive, calcific pericarditis in addition to antimicrobial treatment as a result of the growth of Streptococcus salivarius from the pericardial fluid. This is the first report in the literature of association of this microorganism with pericarditis. The use of CPAP made the patient's symptoms worse as a result of an increase of the intrathoracic pressure, which was a pathophysiological mechanism, added to the interference of the localized pericardial effusion and the effect of the pericardial constriction. In an era of rapidly increasing use of CPAP systems, clinicians should be aware of their possible detrimental effects on patients with some types of cardiopulmonary diseases.

The combined spinal–epidural technique

In recent years, the use of regional anaesthesia techniques for surgery, obstetrics and post operative pain management have increased in popularity. The combined spinal-epidural (CSE) technique has attained widespread popularity for patients undergoing major surgery below the umbilicus who may require prolonged and effective postoperative analgesia. The CSE technique is now well established in several institutions. This chapter includes the clinical experience, advantages and potential problems, and discusses future perspectives of the CSE technique.

Meningococcal meningitis after combined spinal-epidural analgesia

We present a case of bacterial meningitis in a 32-year-old parturient following combined spinal-epidural analgesia for labour. The patient made a full recovery with no residual neurological sequelae, but important lessons were learnt. Firstly, investigating obstetricians and physicians were unaware that a combined spinal-epidural technique included an intrathecal component, so did not consider treating organisms that might be acquired by this route. Anaesthetists, on the other hand, in the absence of an isolated organism, saw this as a likely combined spinal-epidural complication. Infectious disease experts eventually diagnosed community-acquired meningococcal meningitis by analysing bacterial deoxyribonucleic acid (DNA) fragments using polymerase chain reaction studies. This test and the management of suspected meningitis in the post-partum period are discussed.

Combined spinal-epidural analgesia for labor: breakthrough or unjustified invasion?

The combined spina-epidural (CSE) technique has become increasingly popular for labor analgesia. The advantages of the CSE include more rapid onset of analgesia, reduced total drug dosage, minimal or no motor blockade, and increased patient satisfaction. CSE has also been associated with more rapid cervical dilation when compared to epidural analgesia in nulliparous women in early labor. Despite these potential advantages, the indications for CSE versus epidural analgesia remain unclear and controversial. This review should allow better understanding of the benefits and risks of this technique, and bearing in mind that no ultimate neuraxial analgesic exists, it would seem that CSE should be considered a major breakthrough in the management of labor analgesia.

Goal oriented general anesthesia for Cesarean section in a parturient with a large intracranial epidermoid cyst

PURPOSE

To illustrate the anesthetic management of a term parturient with a large brain tumour scheduled for Cesarean section.

CLINICAL FEATURES

A 26-yr-old woman presented at 33 weeks gestation with a generalized grand mal seizure. Magnetic resonance imaging demonstrated a 5-cm multi-lobulated extra axial mass compatible with an epidermoid cyst, arising from the left temporal lobe associated with shift of the midline structures and compression of the brainstem. She remained stable neurologically until elective Cesarean section at 38 weeks. Immediately prior to induction of general anesthesia, the proposed incision site was infiltrated with lidocaine and the supraglottic structures anesthetized with bilateral superior laryngeal nerve blocks. Remifentanil, thiopentone sodium and succinylcholine were administered in a rapid sequence fashion following voluntary hyperventilation to an endtidal CO2 of 28 mmHg. Anesthesia was maintained with desflurane in oxygen/air and an infusion of remifentanil. Postoperative pain control was achieved using a multi-modal approach which included intraperitoneal deposition of local anesthetic, im ketorolac and rectal acetaminophen prior to emergence followed by regular administration of naproxen and acetaminophen for 72 hr.

CONCLUSION

In a parturient with a large intracranial tumour, general anesthesia combined with multi-modal balanced analgesia met the predefined anesthetic management goals and was associated with a favourable outcome.

[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.

Complications of Regional Anaesthesia

The complications of failure, neural injury and local anaesthetic toxicity are common to all regional anaesthesia techniques, and individual techniques are associated with specific complications. All potential candidates for regional anaesthesia should be thoroughly evaluated and informed of potential complications. If there is significant risk of injury, then these techniques should be avoided. Central neural blockade (CNB) still accounts for more than 70% of regional anaesthesia procedures. Permanent neurological injury is rare (0.02 to 0.07%); however, transient injuries do occur and are more common (0.01 to 0.8%). Pain on injection and paraesthesiae while performing regional anaesthesia are danger signals of potential injury and must not be ignored. The incidence of systemic toxicity to local anaesthetics has significantly reduced in the past 30 years, from 0.2 to 0.01%. Peripheral nerve blocks are associated with the highest incidence of systemic toxicity (7.5 per 10000) and the lowest incidence of serious neural injury (1.9 per 10000). Intravenous regional anaesthesia is one of the safest and most reliable forms of regional anaesthesia for short procedures on the upper extremity. Brachial plexus anaesthesia is one of the most challenging procedures. Axillary blocks are performed most frequently and are safer than supraclavicular approaches. Ophthalmic surgery is particularly suited to regional anaesthesia. Serious risks include retrobulbar haemorrhage, brain stem anaesthesia and globe perforation, but are uncommon with skilled practitioners. Postdural puncture headache remains a common complication of epidural and spinal anaesthesia; however, the incidence has decreased significantly in the past 2 to 3 decades from 37 to approximately 1%, largely because of advances in needle design. Backache is frequently linked with CNB; however, other causes should also be considered. Duration of surgery, irrespective of the anaesthetic technique, seems to be the most important factor. The syndrome of transient neurological symptoms is a form of backache that is associated with patient position and use of lidocaine (lignocaine). Disturbances of micturition are a common accompaniment of CNB, especially in elderly males. Hypotension is the most common cardiovascular disturbance associated with CNB. Severe bradycardia and even cardiac arrest have been reported in healthy patients following neuraxial anaesthesia, with a reported incidence of cardiac arrest of 6.4 per 10 000 associated with spinal anaesthesia. Prompt diagnosis, immediate cardiopulmonary resuscitation and aggressive vasopressor therapy with epinephrine (adrenaline) are required. New complications of regional anaesthesia emerge occasionally, e.g. cauda equina syndrome with chloroprocaine, microspinal catheters and 5% hyperbaric lidocaine, and epidural haematoma formation in association with low molecular weight heparin. Even so, after 100 years of experience, most discerning physicians appreciate the benefits of regional anaesthesia.

Streptococcus salivarius acute meningitis with latent petromastoiditis

A 48-y-old woman, with a previous history of neurosurgical intervention for a trigeminal neurinoma, presented with acute meningitis due to Streptococcus salivarius. There were significant changes in the petrous region, as revealed by MRI, leading to the diagnosis of associated latent subacute mastoiditis.

Mortality from peripartum meningitis

A young primigravid parturient had an uneventful labour under epidural analgesia and delivered a healthy male infant. She returned 48 hours later with fever, vomiting and severe headache, but was misdiagnosed as having endometritis. Further signs of meningitis appeared six hours later, however she succumbed to the infection and died four weeks later despite intensive care and high-dose antibiotic management. Causes of meningitis in the peripartum period are discussed. The possibility of a causal association between the patient's epidural analgesia and her infection are considered and preventive measures discussed.

The combined spinal-epidural technique

Epidural and spinal blocks are well-accepted regional techniques, but they have several disadvantages. The CSE technique can reduce or eliminate the risks of these disadvantages. CSE block combines the rapidity, density, and reliability of the subarachnoid block with the flexibility of continuous epidural block to extend duration of analgesia. The CSE technique is used routinely at many institutions, particularly for major orthopedic surgery and in obstetrics. It has been used in tens of thousands of patients without any reports of major problems. Although at first sight the CSE technique appears to be more complicated than epidural or spinal block alone, intrathecal drug administration and siting of the epidural catheter are both enhanced by the combined, single-space, needle-through-needle method. Concerns about the epidural catheter entering the theca via the small puncture hole are now considered to be unfounded, but as with all epidural catheter techniques, vigilant monitoring of the patient during and after any injection is paramount. CSE is an effective way to reduce the total drug dosage required for anesthesia or analgesia. The intrathecal injection achieves rapid onset with minimal doses of local anesthetics and opioids, and the block can be prolonged with low-dose epidural maintenance administration. In addition, the sequential CSE method can be used to extend the dermatomal block with minimal additional drugs or even saline. Reduction in total drug dosage has made truly selective blockade possible. Many studies have confirmed that low-dose CSE with local anesthetic and opioid, or low-dose epidural block alone, will provide effective analgesia with minimal motor and proprioceptive block. Such neurologic selective blockade has made it possible for most patients to walk and bear down normally in labor or postoperatively. There remains concern about the risk of infection being increased when the CSE technique is used in place of epidural block alone. Despite a recent flurry of reports of meningitis with CSE procedures, there is no evidence the CSE block is more hazardous than epidural or subarachnoid block alone. Arguably, the single-space, needle-through-needle CSE technique will continue to improve with new needle designs and other advances to improve further the success rate and reduce complications, such as neurotrauma, PDPH, and infection. Over the past decade it has become clear that the CSE technique is a significant advance in regional blockade.

[Meningitis after locoregional spinal anesthesia]

OBJECTIVE

Meningitis is a severe and an uncommon complication of both spinal and epidural anaesthesia. This review summarizes the knowledge on epidemiology, clinical and microbiological diagnosis and the ways to prevent them.

DATA SOURCES

Articles published in English and French language since 1989 has been collected on Medline database, using "meningitis", "spinal anaesthesia" and "epidural anaesthesia" as keywords.

DATA SYNTHESIS

Bacterial meningitis are usually in relation with Gram positive bacterias which is a clue for an exogenous contamination. Another unusual ways of contamination are blood circulating bacterias and spreading of local infection. Aseptic meningitis has been described, in relation to introduction of irritant agents in subarachnoid space. Lumbar puncture must be done each time meningitis suspected so that it can assert the diagnosis and guide antibiotherapy. Easy hygienic guidelines has been widely published to prevent meningitis. Usually, antibiotherapy alone is sufficient to treat meningitis but with an unjustified cost and sometimes severe persistent neurologic sequelae.

CONCLUSION

The unexpected appearance of meningitis during the wearing-off of a spinal anesthesia is exceptional; the possibility of death or serious sequela must be taken into account. The sources of contamination are quite frequently exogenous, the germs coming most often from the patient's cutaneous flora or the anesthetist's ENT flora. Prevention of this risk involves a rigorous respect for cutaneous disinfection and hygiene procedures. The anesthetist's medico-legal responsibilities will be called upon in case of exogenous contamination.

Neurological complications in obstetric regional anaesthesia

Neurological complications after obstetric central neural blocks are rare events. Although central neural blockade does cause neurological complications, there must be awareness that neurological deficits may either develop spontaneously (e.g. epidural abscess/haematoma) or as a result of the labour and delivery process (maternal obstetric palsies). We have attempted to review as completely as possible the published survey and case reports in the English literature on neurological complications of obstetric regional blockade obtained from Medline spanning the period 1966 to November 1998. We also performed cross-checking of our references to find important missing articles, e.g. papers published in journals not included in Index Medicus at the time of publication, such as the International Journal of Obstetric Anesthesia. We wish to provide some insight to the incidences, pathophysiology, clinical features, investigations, treatment and prognosis of these complications. Maternal obstetric palsies and case reports of spontaneous epidural abscess/haematoma are also discussed. It is often difficult, if not impossible, to determine the exact aetiology, but unfortunately for the anaesthetists, regional blockade is usually incriminated till proven otherwise. Although we cannot eliminate the occurrence of neurological complications completely, preventive measures can still be taken to decrease their incidence (e.g. aseptic technique). There must also be regular monitoring after neural blockade for the development of neurological complications. Early diagnosis and prompt appropriate treatment will usually lead to complete resolution of the neurological deficit even in cases of epidural haematoma/abscess.

The effect of facial hair and sex on the dispersal of bacteria below a masked subject

Surgical face masks prevent the dispersal of bacteria from the upper airway to surfaces immediately in front of and below the face during talking. However, mask wiggling has been reported to increase dermabrasion and bacterial contamination of surfaces immediately below the face. Facial hair and recent shaving may alter the quantity of particles shed by dermabrasion when the mask is wiggled. We investigated the effect of mask wiggling in 10 bearded and 10 clean-shaven male subjects, and 10 female subjects. Wiggling the mask significantly increased the degree of bacterial shedding onto agar plates 15 cm below the lips in bearded males (p = 0.03) and females (p = 0.03), but not in clean-shaven males. At rest without mask wiggling the bearded subjects shed significantly more bacteria than clean-shaven males (p = 0.01) or females (p = 0.001). To reduce the risks of contamination of the sterile field when face masks are worn females and bearded males should avoid wiggling the face mask. Bearded males may also consider removing their beards.

Speed of onset of regional analgesia in labour: a comparison of the epidural and spinal routes

This study compares the speed of onset of effective analgesia in two randomly assigned groups of patients requesting analgesia in labour. Patients in the combined spinal-epidural group (n = 69) were given a subarachnoid injection of 1.5 ml containing bupivacaine 2.5 mg and fentanyl 25 microg for initiation of analgesia. Patients in the epidural group (n = 73) were given an epidural injection of 10 ml containing bupivacaine 12.5 mg and fentanyl 50 microg. Mean (SD) onset times to the first pain-free contraction were 10.0 (5.7) min in the combined spinal-epidural group and 12.1 (6.5) min in the epidural group (p = 0.054). Patients in the combined spinal-epidural group suffered a higher incidence of motor weakness and proprioceptive deficit than those in the epidural group (p = 0.01). The incidence of technique failure and side-effects was similar in the two groups. It is our contention that the statistically nonsignificant difference in onset times does not justify the additional potential for side-effects and the extra cost of the equipment involved in the combined spinal-epidural technique.

Combined spinal-epidural techniques

The combined spinal-epidural technique has been used increasingly over the last decade. Combined spinal-epidural may achieve rapid onset, profound regional blockade with the facility to modify or prolong the block. A variety of techniques and devices have been proposed. The technique cannot be considered simply as an isolated spinal block followed by an isolated epidural block as combining the techniques may alter each block. This review concentrates on technical and procedural aspects of combined spinal-epidural. Needle-through-needle, separate-needle and combined-needle techniques are described and modifications discussed. Failure rates and causes are reviewed. The problems of performing a spinal block before epidural blockade (potential for unrecognised placement of an epidural catheter, inability to detect paraesthesia during epidural placement, difficulty in testing the epidural, delay in positioning the patient) are described and evaluated. Problems of performing spinal block after epidural blockade (risk of catheter or spinal needle damage) are considered. Mechanisms of modification of spinal blockade by subsequent epidural drug administration are discussed. The review considers choice of technique, needle type, patient positioning and paramedian vs. midline approach. Finally, complications associated with combined spinal-epidural are reviewed.

Epidural abscess in an obstetric patient

Epidural abscess is a rare complication of epidural block and occasionally presents in the post partum period. A case is described where a thoracolumbar abscess presented with backache and headache 10 days after an apparently uneventful block for labour and caesarean section. The abscess was treated medically with a satisfactory outcome. The literature is reviewed in order to assess several recent reports of infectious complications of epidural block in obstetric patients.

Obstetrical anesthesia for a parturient with a ventriculoperitoneal shunt and third ventriculostomy

PURPOSE

To describe the anesthetic considerations for a primiparous woman whose history included four neurosurgeries: ventriculoperitoneal (VP) shunt insertion, evacuation of a subdural hematoma, shunt revision, and third ventriculostomy for hydrocephalus secondary to aqueductal stenosis.

CLINICAL FEATURES

A 37-yr-old GI, P0 woman with a VP shunt and third ventriculostomy was assessed in the Obstetrical Anesthesia Clinic at 36 wk. gestation to consider analgesic options for labour and delivery and review anesthetic management in the event that an operative delivery was required. A third ventriculostomy had been performed when increased intracranial pressure and neurological symptoms reappeared despite the previous VP shunt. Pregnancy was uneventful and vaginal delivery was anticipated. She presented in spontaneous labour at 40 wk. gestation. She declined analgesia throughout her four and a half hour labour A mediolateral episiotomy was performed to facilitate spontaneous delivery of a 4,182 g female infant. Mother and baby were discharged home without incident after two days. She denied any problems, including headaches, on follow up at two and four weeks.

CONCLUSION

A review of the literature concerning pregnant patients with shunts found that both regional and general anesthesia has been used with no reports of complications directly related to anesthesia. No published cases describing labour analgesia for patients with third ventriculostomy were found. Two neurosurgeons advised that regional anesthesia was not contraindicated in such patients and that analgesia should be based on obstetrical considerations and the neurological status of the patient.

Infectious complications of epidural anaesthesia and analgesia

Clinically overt infections of the epidural catheter skin entry site occur in approximately 5% of patients after a few days; deep catheter tract infections occur in approximately 5% of patients after more prolonged epidural analgesia. This indicates that potentially serious epidural infectious complications are ever-present risks of epidural anaesthesia and analgesia. This review focuses on risk factors and guidelines for routine epidural analgesia that may minimize the risks of serious infectious complications.

[Nosocomial meningitis in the adult]

Cerebrospinal fluid (CSF) has anti-infectious defense abilities similar to those of the serum of a neutropenic patient. A septic inoculation as in case of nosocomial meningitis (NM), results rapidly in microbial proliferation with major alterations to the blood brain barrier, cerebral oedema and loss of autoregulation of the cerebral blood flow. Arterial hypotension during NM may induce focal or global cerebral ischaemia. The incidence of NM is increasing, staphylococci and Gram negative bacilli being the most frequent pathological agents. Clinical symptoms are not specific in this postoperative and post-traumatic context. In this context, the analysis of pleocytosis and the increased protein content of CSF is disturbing. Numerous clinical conditions may cause NM. Among them, NM from spinal puncture is an important issue for anaesthetists, while combined epidural and spinal anaesthesia carry the highest risks. Cutaneous contamination plays a major role. Half of the post-operative infections after neurosurgery are due to NM, and CSF leakage, iterative operations and surgery in contaminated conditions are the main risk factors. Antibioprophylaxis for postoperative NM is validated for clean and clean-contaminated surgery. Some consider that only procedures of more than two hours require this prophylaxis. Prophylaxis is targeted on staphylococci. Other preventive measures (drainage of less than 24 h, head shaving and prevention of CSF leakage) are of major importance. Antibiotherapy should be guided by the same considerations as for community acquired meningitis, associated with specific issues in the surgical context (presence of foreign material and CSF blockage).