Bacterial colonization and infection rate of continuous epidural catheters in children

Methods of prolonging the effect of caudal block in children

Caudal epidural blockade is one of the most frequently administered regional anesthesia techniques in children. It is a supplement during general anesthesia and for providing postoperative analgesia in pediatrics for sub-umbilical surgeries, especially for genitourinary surgeries. However, the duration of the analgesic effect is occasionally unsatisfactory. In this review, we discuss the main advantages and disadvantages of different techniques to prolong postoperative analgesia for single-injection caudal blockade in children. A literature search of the keywords "caudal", "analgesia", "pediatric", and "children" was performed using PubMed and Web of Science databases. We highlight that analgesic quality correlates substantially with the local anesthetic's type, dose, the timing relationship between caudal block and surgery, caudal catheterization, and administration of epidural opioids or other adjuvant drugs.

Epidural Abscess Complicating Tunneled Caudal Epidural Catheter in an Infant for Postoperative Pain Management of Open Abdominal Surgery

Regional anesthesia is being used more frequently in pediatric anesthesia practice, including the perioperative care of neonates and infants. Adverse effects may be encountered during epidural needle placement, with catheter advancement, or subsequently during infusion of local anesthetic agents. Despite applying standard practice of care regarding placement of epidural catheter, epidural catheter-related infections may still occur. We present the rare occurrence of an epidural abscess in a 4-month-old infant after placement and subsequent use of a tunneled caudal epidural catheter for postoperative pain management following abdominal surgery. Magnetic resonance imaging (MRI) was the gold standard diagnostic imaging modality and was used to identify the abscess. Management included intravenous antibiotic therapy as well as hemilaminectomy with evacuation of the epidural abscess and hematoma. The patient continued to progress well with no deficits noted on neurological examination. There were no other postoperative concerns. When there is a concern for epidural catheter-related infection, the catheter should be removed immediately. The epidural catheter tip as well as any purulent discharge from the insertion site should be sent for culture and sensitivity. Urgent neurosurgical and infectious disease consultation is suggested to provide opinions regarding surgical intervention and antibiotic therapy.

A less invasive technique for delayed bladder exstrophy closure without fascia closure and immobilisation: can the need for prolonged anaesthesia be avoided?

INTRODUCTION

It is believed that the main factors enhancing security of the bladder exstrophy closure are use of osteotomy, pubic bones approximation or transferred flaps for rectus fascia closure. However, these methods increase operating time, surgical trauma and carry risks for the patient.

OBJECTIVES

To demonstrate that the goal of secure bladder exstrophy closure can be achieved easier technically and safer for the child than previously thought. The paper examines the hypothesis that less invasive bladder exstrophy closure achieved without fascia closure can reduce pain and avoid the need for immobilization and prolonged analgesia.

STUDY DESIGN

Patients aged 34 days to 15 years (n = 36) from 37 who consecutively referred to the institution with classical bladder exstrophy between 2004 and 2016 underwent modified delayed primary (25) or redo (11) closure. One boy with low weight was excluded. Patient and treatment features were analysed to determine needs for immobilisation and anaesthesia in the postoperative period, and outcomes.

PROCEDURE

Bladder exstrophy closure with proximal urethroplasty was performed with the detachment of crura from the ishiopubic rami and levators-from obturator internus muscle. Abdominal wall closure was accomplished with skin and subcutaneous fat mobilisation without rectus fascia closure. No method of immobilization was applied.

RESULTS AND LIMITATIONS

Bladder closures have been successful in all 36 children in this report after 37 months (22-138) follow up. The surgeries took time between 126 and 215 min (mean - 148). After 1 day in the ICU the majority of the patients (34/36) were returned to the ward. No bladder spasms or signs of acute pain were noted in the ward; therefore, no local anesthesia or opioids were needed. Intravenous analgesia with non-narcotic analgesics was used for all patients in the ward for an average period 2.2 days (95% CI 2-4 days).

COMPLICATIONS

Minor complications: two fistulas, which closed spontaneously; three bladder outlet obstructions, each required one endoscopic incision. No major complications of exstrophy closure such as dehiscence or bladder prolapse were occurred.

CONCLUSIONS

The proposed less invasive technique with relieved postoperative program is the way to obtain successful bladder exstrophy closure as well as to reduce some risks for the patients. Absence of major complications, and avoiding the need for immobilisation and prolonged analgesia, contribute to the benefits of this approach.

Caudal epidural blocks in paediatric patients: a review and practical considerations

Caudal epidural blockade in children is one of the most widely administered techniques of regional anaesthesia. Recent clinical studies have answered major pharmacodynamic and pharmacokinetic questions, thus providing the scientific background for safe and effective blocks in daily clinical practice and demonstrating that patient selection can be expanded to range from extreme preterm births up to 50 kg of body weight. This narrative review discusses the main findings in the current literature with regard to patient selection (sub-umbilical vs mid-abdominal indications, contraindications, low-risk patients with spinal anomalies); anatomical considerations (access problems, age and body positioning, palpation for needle insertion); technical considerations (verification of needle position by ultrasound vs landmarks vs 'whoosh' or 'swoosh' testing); training and equipment requirements (learning curve, needle types, risk of tissue spreading); complications and safety (paediatric regional anaesthesia, caudal blocks); local anaesthetics (bupivacaine vs ropivacaine, risk of toxicity in children, management of toxic events); adjuvant drugs (clonidine, dexmedetomidine, opioids, ketamine); volume dosing (dermatomal reach, cranial rebound); caudally accessed lumbar or thoracic anaesthesia (contamination risk, verifying catheter placement); and postoperative pain. Caudal blocks are an efficient way to offer perioperative analgesia for painful sub-umbilical interventions. Performed on sedated children, they enable not only early ambulation, but also periprocedural haemodynamic stability and spontaneous breathing in patient groups at maximum risk of a difficult airway. These are important advantages over general anaesthesia, notably in preterm babies and in children with cardiopulmonary co-morbidities. Compared with other techniques of regional anaesthesia, a case for caudal blocks can still be made.

Regional anesthetics: traditions and innovations

The wide implementation of different regional anesthesia techniques is also actual in pediatric anesthesiology. Using modern methods of regional anesthesia (RA) and modern local anesthetics is a new level in development of pediatric anesthesiology. This article is about advantages of regional pediatric anesthesia in intra- and post-surgery pain management and analgesia. We analyse the techniques of spinal and epidural anesthesia, as well as their varieties such as unipolar spinal block and caudal anesthesia, compare their advantages and disadvantages. Some more techniques such as paravertebral block, TAP-block are considered as an alternative to epidural anesthesia. Methods and possibilities of ilioinguinal, iliohypogastric and TAP-blocks are also mentioned here. The use of the above-mentioned methods allows to reduce the use of narcotic analgesics and hypnotics and, as a consequence, reduces their systemic effects on the child’s body. These methods are safer for use, since they allow you to plan a safe anesthetic for each child and minimize complications.

Chlorhexidine gluconate dressings reduce bacterial colonization rates in epidural and peripheral regional catheters

Introduction. Bacterial colonization of catheter tips is common in regional anesthesia and is a suspected risk factor for infectious complications. This is the first study evaluating the effect of CHG-impregnated dressings on bacterial colonization of regional anesthesia catheters in a routine clinical setting. Methods. In this prospective study, regional anesthesia catheter infection rates were examined in two groups of patients with epidural and peripheral regional catheters. In the first group, regional anesthesia was dressed with a conventional draping. The second group of patients underwent catheter dressing using a CHG-impregnated draping. Removed catheters and the insertion sites were both screened for bacterial colonization. Results. A total of 337 catheters from 308 patients were analysed. There was no significant reduction of local infections in either epidural or peripheral regional anesthesia catheters in both CHG and conventional groups. In the conventional group, 21% of the catheter tips and 41% of the insertion sites showed positive culture results. In the CHG-group, however, only 3% of the catheter tips and 8% of the insertion sites were colonised. Conclusion. CHG dressings significantly reduce bacterial colonization of the tip and the insertion site of epidural and peripheral regional catheters. However, no reductions in rates of local infections were seen.

Performance of aseptic technique during neuraxial analgesia for labor before and after the publication of international guidelines on aseptic technique

Background

Aseptic technique and handwashing have been shown to be important factors in perioperative bacterial transmission, however compliance often remains low despite guidelines and educational programs. Infectious complications of neuraxial (epidural and spinal) anesthesia are severe but fortunately rare. We conducted a survey to assess aseptic technique practices for neuraxial anesthesia in Israel before and after publication of international guidelines (which focused on handwashing, jewelry/watch removal and the wearing of a mask and cap).

Methods

The sampling frame was the general anesthesiology workforce in hospitals selected from each of the four medical faculties in Israel. Data was collected anonymously over one week in each hospital in two periods: April 2006 and September 2009. Most anesthesiologists received the questionnaires at departmental staff meetings and filled them out during these meetings; additionally, a local investigator approached anesthesiologists not present at these staff meetings individually. Primary endpoint questions were: handwashing, removal of wristwatch/jewelry, wearing mask, wearing hat/cap, wearing sterile gown; answering options were: "always", "usually", "rarely" or "never". Primary endpoint for analysis: respondents who both always wash their hands and always wear a mask ("handwash-mask composite") - "always" versus "any other response". We used logistic regression to perform the analysis. Time (2006, 2009) and hospital were included in the analysis as fixed effects.

Results

135/160 (in 2006) and 127/164 (in 2009) anesthesiologists responded to the surveys; response rate 84% and 77% respectively. Respondents constituted 23% of the national anesthesiologist workforce. The main outcome "handwash-mask composite" was significantly increased after guideline publication (33% vs 58%; p = 0.0003). In addition, significant increases were seen for handwashing (37% vs 63%; p = 0.0004), wearing of mask (61% vs 78%; p < 0.0001), hat/cap (53% vs 76%; p = 0.0011) and wearing sterile gown (32% vs 51%; p < 0.0001). An apparent improvement in aseptic technique from 2006 to 2009 is noted across all hospitals and all physician groups.

Conclusion

Self-reported aseptic technique by Israeli anesthesiologists improved in the survey conducted after the publication of international guidelines. Although the before-after study design cannot prove a cause-effect relationship, it does show an association between the publication of international guidelines and significant improvement in self-reported aseptic technique.

Perioperative management of classic bladder exstrophy

The exstrophy-epispadias complex is a rare congenital malformation of the genitourinary system, abdominal wall muscles, and pelvic structures. Modern surgical repairs focus on reconstruction of the bladder and its adjacent structures, with the goal of achieving urinary continence, a satisfactory cosmetic result, and a high quality of life. Complex surgery in neonates and young children, as well as a prolonged postoperative course require close collaboration between surgeons, anesthesiologists, intensivists, pediatricians, and an experienced nursing staff. This article will review the spectrum of bladder exstrophy anomalies, the surgical repair, and the perioperative interdisciplinary management.

Risk of catheter-associated infection in young hematology/oncology patients receiving long-term peripheral nerve blocks

BACKGROUND

Continuous peripheral nerve blocks (CPNBs) are increasingly used to control postoperative and chronic pain. At our pediatric oncology institution, the duration of CPNBs is often prolonged. The risk of catheter-associated infection with prolonged CPNBs has not been previously investigated.

AIM

We analyzed the incidence of CPNB-related infection and its relation to catheter duration, catheter site, intensive care stay, and antibiotic coverage.

METHODS

All CPNBs placed at our institution between August 1, 2005 and October 31, 2010 were studied. Primary diagnosis and the site, indication, duration, and infectious adverse effects of CPNBs were obtained from our Pain Service QI database. Patients' age and sex, antibiotic administration, and number of days in intensive care were collected from patients' medical records.

RESULTS

The use of 179 catheters in 116 patients was evaluated. Mean age at CPNB placement was 15.1 years (median, 14.7; range, 0.4-26.9). The most frequent indication for CPNB was surgery (89.4%), most commonly orthopedic (78.8%). Mean CPNB duration was 7.2 days (median, 5.0; range, 1-81 days). Two cases (1.12%) of CPNBs developed signs of infection, both associated with femoral catheters. The infections were mild and necessitated catheter removal at days 10 and 13, respectively.

CONCLUSION

Nerve block catheter-associated infections are infrequent at our institution despite prolonged CPNB use. Both patients with infection had femoral catheters and prolonged catheter (≥ 10 days) use.

Neuraxial analgesia in neonates and infants: a review of clinical and preclinical strategies for the development of safety and efficacy data

Neuraxial drugs provide robust pain control, have the potential to improve outcomes, and are an important component of the perioperative care of children. Opioids or clonidine improves analgesia when added to perioperative epidural infusions; analgesia is significantly prolonged by the addition of clonidine, ketamine, neostigmine, or tramadol to single-shot caudal injections of local anesthetic; and neonatal intrathecal anesthesia/analgesia is increasing in some centers. However, it is difficult to determine the relative risk-benefit of different techniques and drugs without detailed and sensitive data related to analgesia requirements, side effects, and follow-up. Current data related to benefits and complications in neonates and infants are summarized, but variability in current neuraxial drug use reflects the relative lack of high-quality evidence. Recent preclinical reports of adverse effects of general anesthetics on the developing brain have increased awareness of the potential benefit of neuraxial anesthesia/analgesia to avoid or reduce general anesthetic dose requirements. However, the developing spinal cord is also vulnerable to drug-related toxicity, and although there are well-established preclinical models and criteria for assessing spinal cord toxicity in adult animals, until recently there had been no systematic evaluation during early life. Therefore, in the second half of this review, we present preclinical data evaluating age-dependent changes in the pharmacodynamic response to different spinal analgesics, and recent studies evaluating spinal toxicity in specific developmental models. Finally, we advocate use of neuraxial drugs with the widest demonstrable safety margin and suggest minimum standards for preclinical evaluation before adoption of new analgesics or preparations into routine clinical practice.

Two continuous femoral nerve block strategies after TKA

PURPOSE

The purposes of this study were to compare the pain score, systemic opioid consumption, and range of motion (ROM) between the group where the use of continuous femoral nerve block (CFNB) was discontinued on postoperative day 3 (POD 3) and the group where it was discontinued on POD 7 within an established clinical pathway for postoperative recovery after total knee arthroplasty (TKA) and to assess the treatment-related side effects and complications, as well as the functional status of these two groups of patients at 2 years after surgery.

METHODS

This prospective, randomized, double-blinded trial compared the analgesic efficacy and the functional outcomes between group A (n = 30) where continuous femoral nerve block was performed until POD 3 (discontinued prior to the initiation of range of motion (ROM) exercises) and group B (n = 33), where the continuous femoral nerve block was performed until POD 7 (discontinued during the ROM exercise) after TKA.

RESULTS

The resting pain scores of group B were lower than those of group A but there was no significant difference between the two groups (n.s., P = 0.387). However, the peak pain scores during ROM exercise, beginning on POD3 through to POD14, were significantly lower in group B than in group A (P = 0.001). The cumulative morphine IV-PCA requirements through the POD 2 were similar in the two groups (n.s., P = 0.811). However, the cumulative oral oxycodone consumption during hospitalization was significantly lower in group B than in group A, P < 0.0001. Group B showed significantly greater satisfaction with their method of analgesia than group A (P = 0.001). Group A scored 2.0 (2.0-3.0), whereas group B scored 1.0 (1.0-2.0). At 2 years, there was no significant difference in the functional outcomes (the knee flexion and extension angle, the Knee Society Score, and WOMAC pain, stiffness, and function scale).

CONCLUSION

The study group who received 7-day continuous femoral nerve block after TKA showed superior analgesia and higher patient satisfaction during the hospital stay than those given 3-day continuous femoral nerve block. Despite the additional time, effort and cost to place and manage continuous femoral nerve catheters, the 7-day continuous femoral nerve block can be recommended as an effective and safe regional component of a multimodal analgesia strategy after TKA.

The national pediatric epidural audit

BACKGROUND

This paper describes a prospective audit of children receiving epidural infusion analgesia (EIA) in Great Britain and Ireland. The aim was to quantify the risks associated with this technique.

METHODS

In order to obtain sufficient data on the number of pediatric epidurals performed and the incidence of unwanted events, a decision was taken, at an Annual Meeting of Great Britain and Ireland Paediatric Pain Services, to establish a national audit of EIA practice in these centers. Each site sent a monthly return of the numbers of EIA performed to the coordinating center. If an incident occurred then the referring site completed a more detailed form and the child was followed up for 1 year if possible. Incidents were graded by severity 13, serious to minor. These data were collected over the 5-year period (2001-2005).

RESULTS

(i) Ninety six incidents were reported in 10 633 epidurals performed. (ii) Fifty six were associated with the insertion or maintenance of EIA; most were of low severity (1 : 189). (iii) Five incidents were graded as 1 (serious) (approximately 1 : 2000). (iv) Nine incidents were graded as 2 (approximately 1 : 1100). (v) Only one child has residual effects from a grade 1 incident 12 months after surgery (approximately 1 : 10 000). (vi) Forty incidents were also reported that were felt to be associated with the use of EIA; 33 of these incidents were the development of pressures sores. Four incidents of compartment syndrome were reported, in each of these cases the presence of EIA did not mask the condition.

CONCLUSIONS

Epidural infusion analgesia in children does have risks associated with the technique. The occurrence of compartment syndrome does not appear to be masked by the presence of working EIA. As a result of this audit we can now provide parents with better information, thereby improving the process of informed consent.

Inflammation and infection complications of 2285 perineural catheters: a prospective study

BACKGROUND

Perineural catheters (PNCs) are increasingly being used. Few data are available on the infectious complications of PNCs. The incidence and localization of local inflammation and infection associated with PNCs were assessed.

METHODS

PNCs placed under sterile conditions for regional anesthesia and post-operative analgesia were evaluated prospectively. Local inflammation was defined as redness, swelling or pain on pressure at the catheter insertion site. Infection was defined as purulent material at the catheter insertion site with or without the need for surgical intervention.

RESULTS

In total, 2285 PNCs were evaluated: 600 axillary, 303 interscalene, 92 infraclavicular, 65 psoas compartment, 574 femoral, 296 sciatic and 355 popliteal. Local inflammation occurred in 4.2% and infection in 3.2%. The duration of PNC placement was a risk factor (P < 0.05). Surgical intervention was necessary in 0.9%. No late complications occurred in any patient. Interscalene catheters were associated with an increased risk of infection (4.3%; P < 0.05). Anterior proximal sciatic catheters were associated with a lower risk of local inflammation (1.7%; P < 0.05) and infection (0.4%; P < 0.05). Staphylococcus epidermidis and Staphylococcus aureus were isolated in 42% and 58% of catheter tip cultures, respectively.

CONCLUSION

In the present study population, infection of PNCs was a rare occurrence, but the incidence increased with the duration of PNC placement, and close clinical monitoring is required.

Innovative approaches to neuraxial blockade in children: the introduction of epidural nerve root stimulation and ultrasound guidance for epidural catheter placement

Continuous epidural blockade remains the cornerstone of pediatric regional anesthesia. However, the risk of catastrophic trauma to the spinal cord when inserting direct thoracic and high lumbar epidural needles in anesthetized or heavily sedated pediatric patients is a concern. To reduce this risk, research has focused on low lumbar or caudal blocks (ie, avoiding the spinal cord) and threading catheters from distal puncture sites in a cephalad direction. However, with conventional epidural techniques, including loss-of-resistance for localization of the needle, optimal catheter tip placement is difficult to assess because considerable distances are required during threading. Novel approaches include electrical epidural stimulation for physiological confirmation and segmental localization of epidural catheters, and ultrasound guidance for assessing related neuroanatomy and real-time observation of the needle puncture and, potentially, catheter advancement. The present article provides a brief and focused review of these two advances, and outlines recent clinical experiences relevant to pediatric epidural anesthesia.

Paediatric caudal extradural catheterisation: an evaluation of a purpose designed equipment set

Using a purpose designed set of equipment, the Caudal Extradural Catheter Tray, Oxford Set (B Braun Medical Ltd, Sheffield, UK) we have evaluated the ease of cannulation of the caudal space, and the subsequent success in threading extradural catheters and obtaining satisfactory analgesia via the caudal route. The set was evaluated in 91 children (age range: 1 day to 10 years). Cannulation of the caudal space was achieved in all patients, and catheterisation of the extradural space was successful in 96.7% of patients. Postoperative analgesia was satisfactory in 95% of children who had continuous extradural analgesia. There were no major complications or neurological sequelae associated with using the set. We found the Caudal Extradural Catheter Tray provides the necessary equipment to perform extradural anaesthesia and analgesia safely and successfully in children of a wide age range.

Risk factors for bacterial catheter colonization in regional anaesthesia

Background

Although several potential risk factors have been discussed, risk factors associated with bacterial colonization or even infection of catheters used for regional anaesthesia are not very well investigated.

Methods

In this prospective observational trial, 198 catheters at several anatomical sites where placed using a standardized technique. The site of insertion was then monitored daily for signs of infection (secretion at the insertion site, redness, swelling, or local pain). The catheters were removed when clinically indicated (no or moderate postoperative pain) or when signs of potential infection occurred. After sterile removal they were prospectively analyzed for colonization, defined as > 15 colony forming units.

Results

33 (16.7%) of all catheters were colonized, and 18 (9.1%) of these with additional signs of local inflammation. Two of these patients required antibiotic treatment due to superficial infections. Stepwise logistic regression analysis was used to identify factors associated with catheter colonization. Out of 26 potential factors, three came out as statistically significant. Catheter placement in the groin (odds-ratio and 95%-confidence interval: 3.4; 1.5–7.8), and repeated changing of the catheter dressing (odds-ratio: 2.1; 1.4–3.3 per removal) increased the risk for colonization, whereas systemic antibiotics administered postoperatively decreased it (odds ratio: 0.41; 0.12–1.0).

Conclusion

Colonization of peripheral and epidural nerve catheter can only in part be predicted at the time of catheter insertion since two out of three relevant variables that significantly influence the risk can only be recorded postoperatively. Catheter localisation in the groin, removal of the dressing and omission of postoperative antibiotics were associated with, but were not necessarily causal for bacterial colonization. These factors might help to identify patients who are at increased risk for catheter colonization.

Subcutaneous tunneling of caudal catheters reduces the rate of bacterial colonization to that of lumbar epidural catheters

Bacterial colonization is regarded as a causative factor for septic complications of caudal catheters in children. To determine whether tunneling caudal catheters reduces the bacterial colonization rate effectively, we evaluated 506 children being treated with tunneled or untunneled caudal or untunneled lumbar epidural catheters. Four-hundred-nine children completed the study. After aseptic removal, the catheters were cultured and sent for microbiological assessment. We found a bacterial colonization rate of 29% in untunneled caudal catheters, 11% in tunneled caudal catheters, and 9% in untunneled lumbar catheters. No severe infectious complications were reported. There was no correlation between catheter retention time and bacterial colonization except for the first 24 h, during which no bacterial colonization was detected. The overall colonization rate remained constant at approximately 13%. We found a positive correlation between bacterial colonization and redness at the catheter entry site. We conclude that tunneled caudal epidural catheters can be used in children for postoperative analgesia without an increased risk of epidural infection.

Epidural catheter colonization is not associated with infection

BACKGROUND

Epidural anesthesia is one of the most common types of regional anesthesia. Although retrospective reviews suggest that the incidence of infection from short-term epidural catheter use is exceedingly low in patients undergoing surgery, the correlation between epidural catheter cultures and infection has not been well defined. The purpose of this study was to determine the frequency of bacterial colonization of epidural catheters in adult patients undergoing surgery under epidural anesthesia, as well as the correlation between epidural catheter cultures and infection.

METHODS

A prospective nonrandomized study was conducted over a period of 28 months. The incidence of bacterial contamination after epidural catheterization and the correlation between epidural catheter cultures and infection was investigated for 245 adult ASA I, II patients undergoing surgery under lumbar epidural anesthesia. Catheters were removed when epidural analgesia was no longer required, or if clinical signs of infection or catheter malfunction were present. All epidural catheters were cultured upon withdrawal.

RESULTS

Epidural catheters were kept in place for 2.3 +/- 0.2 days (range 0.1-12 days). Bacteriological analysis of the 245 epidural catheters yielded 28% positive cultures. The most prevalent microorganism was Staphylococcus epidermidis (58%). In obstetric operations a frequency of 32% positive cultures was observed. Neither central nervous system nor systemic infections occurred during the study. No correlations were found among the type of surgery, the type of antibiotic administration, the sex or age of the patients, the duration of catheter placement, the maximum body temperature, and the frequency of positive epidural catheter cultures. There was no correlation between epidural catheter colonization and infection.

CONCLUSION

The contamination of epidural catheters was found to be independent of the administered antimicrobial agents prior to surgery, the duration of catheter placement, and the presence of fever. Except for perioperative prophylaxis, therapeutic use of antibiotics for short-term epidural catheters is not recommended.

Skin disinfection before epidural catheterization: comparative study of povidone-iodine versus chlorhexidine ethanol

BACKGROUND

Chlorhexidine is better than povidone-iodine for skin preparation before intravascular device insertion or blood culture collection, but it is not known whether chlorhexidine is superior in reducing the colonization of continuous epidural catheters.

METHODS

Patients requiring an epidural catheter for postoperative analgesia were randomly assigned to receive skin preparation with 0.5% chlorhexidine ethanol (CE group) or 10% povidone-iodine (PI group) before catheter insertion. Using surgical aseptic techniques, catheters were inserted into either the lumbar or the thoracic epidural space. Gloves used at catheter insertion, swabs of insertion site skin and the catheter tip at catheter removal were qualitatively cultured.

RESULTS

Of 70 randomly assigned patients, 62 were evaluable. The clinical characteristics of the patients and the risk factors for infection were similar in the two groups. Catheters were kept in place for 49 +/- 7 h (mean +/- SD). Seven cultures from gloves yielded microorganisms. In 1 case, the leak test of gloves was positive. Fifteen cultures of catheter insertion sites yielded microorganisms: 7/28 (25%) in the PI group and 8/34 (24%) in the CE group. Six cultures of catheter tips yielded microorganisms: 3/28 (11%) in the PI group and 3/34 (9%) in the CE group. As for the incidence of isolation of bacteria, no difference was seen between the two groups. In none of these 62 cases was any inflammatory reaction seen in the skin locally at catheter removal.

CONCLUSIONS

The effect of 0.5% chlorhexidine ethanol is not different from that of 10% povidone-iodine in reducing catheter colonization associated with short-term epidural catheter placement.

The caudal catheter in neonates: where are the restrictions?

PURPOSE OF REVIEW

In neonates, epidural catheters inserted at the sacral hiatus can easily be advanced to a lumbar or thoracic level. These 'caudal catheters' are popular because they allow the neonate to benefit from epidural analgesia without the concerns of spinal cord injury potentially associated with primary thoracic placement in an asleep neonate. This review looks at use and benefits, and risks and complications of caudal epidural catheters in neonates.

RECENT FINDINGS

Restrictions of neonatal caudal catheters are related to risks associated with placement and advancement of the catheters, infectious risks of caudal catheters, and toxicity risks related to the higher free fraction and lower clearance of bupivacaine in neonates. Caudal catheters in neonates are popular, but evidence that they improve outcome is lacking.

SUMMARY

Epidural anesthesia and analgesia for neonates should be performed and managed by pediatric anesthesiologists. Potential risks and complications must be appreciated and all steps to maximize safety of the technique must be taken. In particular, close postoperative observation and pain service management are indispensable. Future research should investigate the risks of caudal and segmentally placed catheters in neonates, study the role of epidural analgesia in outcome improvement for neonates, and guide us to safer use of local anesthetics suitable for neonates with their pharmacologic immaturity.

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.