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

3. Severe Neurological Complications after Central Neuraxial Blockades in Sweden 1990 – 1999 Moen V et al. Anesthesiology 2004;101:815-817. EBCSESBContinuous SBTotal Spinal hematoma21(7/14)4(1/3)7(0/7)1(1/0)33(9/24) Cauda equina syndrome8(4/4)4(0/4)18(13/5)2(1/1) 32(18/14) Purulent meningitis5(1/4)1(0/1)20(14/6) 3(2/1) 29(17/12) Epidural abscess12(5/7)1(0/1) 13(5/8) Traumatic cord lesion8(3/5) 1(0/1)9(3/6) Cranial subdural hematoma3(1/2)2(2/0) 5(3/2) Paraparesis3(1/2)1(1/0) 4(2/2) Other2(0/2) 2(0/2) Total62(22/40)9(1/8)50(30/20) 6(4/2) 127(57/70) Complications According to Type of Central Neuraxial Blockade Permanent Neurological ComplicationFull RecoveryDamageNo InformationAll Spinal hematoma627–33 Cauda equina syndrome –32 –32 Purulent meningitis216229 Epidural abscess74213 Miscellaneous Traumatic cord lesion –9 –9 Cranial subdural hematoma41 –5 Paraparesis –4 –4 Other –2 –2 Total38854127 Neurological Complications Related to Outcome

4. 12345678910111213141516171819202122232425262728293031 0000000000000000000000 Número de anestesias peridural Tempo de cateterização (dias) Wang LP et al. Anesthesiology 1999;91:1928-1936. RISK OF INFECTION

5. Epidural abcess

6. DIFFERENTIAL DIAGNOSIS Epidural AbscessEpidural Hemorrage Age of patientAny age50% over 50 years Previous historyInfection *Anticoagulants Onset1 - 3 yearsSudden Generalized symptomsFever, malaise, back painSharp, transient back and leg pain Sensory involvementNone or paresthesiasVariable, late Motor involvement Flaccid paralysis, later spasticFlaccid paralysis Segmental reflexesExacerbated * - later obtundedAbolished MRI / CT / MyelogramSigns of extradural compressionSigns of extradural compression Cerebrospinal fluidIncreased cell countNormal Blood dataRise in sed rateAbn cogs * Infrequent findings

7. SOURCE OF INFECTION OrganismN (n*)%N (n*) %N (n )% CNS12 (7)42.99 (5)42.935 (10)40.2 Propionibacterium acnes932.1838.135 (6)40.2 Corynebacterium sp.1 (1) 3.614.810 (1)11.5 Micrococcus sp.27.100.000.0 Enterococcus sp.1 (1)3.61 (1)4.822.3 Staphilococcus aureus1 (1) 3.61 (1)4.81 (1)1.1 Acinetobacter baumanil1 (1) 3.61 (1)4.81 (1)1.1 Acinetobacter sp.13.600.01 (1)1.1 Peptostreptococcus spp00.000.022.3 Total #28 (11)21 (8)87 (20) Isolated Microorganisms from the Samples Epidural Catheter Tip SegmentSubcutaneous SegmentSkin S S Yuan HB et al. Anesthesiology 2008;108:130-137.

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

9. StudyTreatmentControlOR (random)WeightOR (random) or sub-categoryn/Nn/N95% CI% 95% CI 01 CNS infection by epidural catheters Mann 14 0 / 292 / 264.460.17 [ 0.01, 3.63 ] Subtotal (95% CI) 29 26 4.460.17 [ 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) Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis CATHETER DRESSING 0.010.1110100 Favors treatmentFavors control Ho KM et al. J Antimic Chemoth;58:281-287.

10. 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.

11. 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.