Infectious Complications in Pediatric Regional Anesthesia

By Carole Lin, MD and Ban Chi-Ho Tsui, MD
Lucile Packard Children’s Hospital at Stanford
Stanford, California

The importance of regional techniques for pain management in pediatric anesthesia practice has continued to grow. However, practitioners must ensure that they are vigilant and aware of the potential harm associated with regional techniques. Although infectious complications in pediatric regional anesthesia are rare, infection can lead to serious morbidity and mortality. The consequences of an infection for neuraxial blocks include meningitis and epidural abscess; these events can have profound long-term effects for a child. Peripheral regional techniques can also present with infections that result in critical complications, prolonged acute and chronic pain and increased costs of hospitalization. Pediatric anesthesiologists must continue to be proactive with preventative measures.

Infection as a reported complication in pediatric regional anesthesia is exceedingly rare. The Pediatric Regional Anesthesia Network (PRAN) is a multi-institutional database consisting of a consortium of institutions in the United States where pediatric regional anesthetics are frequently performed. Incidence of infection is tracked for both neuraxial and peripheral regional techniques. The PRAN database provides the most current and specific data pediatric regional technique complications. In 2015, Walder et al.1 reported that no infections occurred in over 6000 neuraxial single shot blocks and 32 cases of local inflammation or infection were reported in over 2900 neuraxial catheter blocks. All cases resolved without deep infections, abscess, meningitis or other long-term sequelae and only three cases required antibiotics. A 2018 PRAN report specifically looking at peripheral catheters reported 12 insertion site infections were reported in over 2000 peripheral nerve catheters. Again, all reported infections were superficial and resolved without serious deep infections, abscesses, sepsis or other serious consequences.2

The most recent report from Walker B et al. found that the incidence of cutaneous infections was 0.5% ( 53:10,000, 95% CI 43 to 64:10,000) with only one reported epidural abscess (0.76:10,000, 95% CI 0-8:10,000).2 The strength of the PRAN database is in its ability to capture an event with a low incidence of occurrence. However, the PRAN database islimited by its reliance on self-reporting. The consensus thus far is that although infectious complications in pediatric regional anesthesia techniques are an infrequent, even rare event, it is still a concern to be aware of.

The exact cause of regional infectious complications is often unclear. Nonetheless, infectious sources can generally be categorized into intrinsic or extrinsic risks.

Intrinsic conditions are risks associated with the comorbidities of the patient. Patients who are particularly at risk for infectious complications are those who are in an immunocompromised state. This includes conditions such as chemotherapy, trauma, sepsis, or induced immunosuppression secondary to transplantation. Hematogenous spread of bacteria is possible from remote or adjacent site infections such as abscesses, cellulitis, osteomyelitis or pneumonia. The colonization of known indwelling devices such as central lines or PICC lines may also seed regional catheters. It is important to conduct a thorough physical exam and review a patient’s history and laboratory information before performing a regional technique to identify patients at risk for infectious complications. While there is little available research and data on regional anesthesia in patients who are at a higher risk for infection due to these intrinsic factors such as bacteremia, recommendations exist advising practitioners to consider alternatives to neuraxial techniques3. If a neuraxial technique is selected for a patient with known bacteremia, pre-procedure antibiotic treatment should be maintained. The consensus statement from the ASA (American Society of Anesthesiology) strongly advises practitioners to avoid lumbar puncture in patients with epidural abscesses.3 The placement of regional catheters in these vulnerable patients is also at a high risk for infection as an indwelling foreign body may become a potential source of bacterial colonization.

Extrinsic sources of infection result from contamination from bacterial skin flora through the needle puncture site, inadvertent breakage of aseptic technique during regional procedure, and contamination from hub sites when drugs are dosed. Other possible contamination risks are related to drug delivery: contaminated syringes and tainted local anesthetic solutions. Anesthesiologists are positioned to impact the incidence of infections from extrinsic sources with the conscientious adherence to hand hygiene, surgical masks, procedure site preparation, aseptic technique, sterile local anesthetic preparation, and ultrasound equipment sterilization.

Dramatic improvements in hand washing compliance by anesthesia practitioners have been made through education, access, workspace layout and culture. A survey of hand hygiene knowledge and perceptions among anesthesiologists still show deficits in recognizing opportunities for preventing transmissions from environmental bacterial reservoirs4. The removal of jewelry (rings and watches) as well as hand washing are recommended during equipment preparation and before placement of any regional techniques. Personal hand gels carried by anesthesiologists improved overall compliance of the an acute pain service from 34-63%.5 With increased hand hygiene, anesthesiologists decreased the amount of workspace contamination, reduced stopcock contamination, and decreased overall healthcare infections;6 these benefits extend to regional anesthesia infections. Hand washing with alcohol gel up to the elbows had the lowest incidence of colonization from the skin.7

Bacterial presence at the site of the regional technique is considered to be the most likely source of infection. Despite the cleansing and preparation of the skin with chemical agents, pathogenic bacteria can persist. An evaluation of 100 patients randomly assigned to chlorhexidine or provodine iodine skin preparation by Kobbuaban et al. revealed that chlorhexidine resulted in a greater decrease in positive skin cultures taken immediately after skin disinfection (10% chlorhexidine vs 35% provodone iodine).8 In a similar study, Kinirons et al. also found that chlorhexidine preparation reduced the risk of colonization of epidural catheters.9

The technique of single vs double application of chlorohexidine/ethanol was evaluated in 2011 showing no growth after application of either agent. A proper technique of single application chlorhexidine/ethanol sufficiently disinfected the skin prior to regional technique.10 Chlorhexidine/ethanol is the recommended antiseptic solution recommended before the placement of regional anesthesia. The practice of using chlorhexidine/ethanol cleansing is used off-label for pediatric patients less than two months old varies with institution. While dermatitis was noted, no systemic toxicity was reported.11

The importance of wearing a mask was highlighted in a systemic review of septic meningitis associated with neuraxial anesthesia. The agent streptococcus salivarious was the most common bacteria that caused spinal anesthesia meningitis and the lack of surgical mask usage was the most common risk factor.12 The current guidelines recommend surgical masks with complete coverage of the mouth and nose and to consider changing masks between cases.13

With the increasing utilization of ultrasound for the placement of neuraxial and peripheral  and regional blocks, awareness and education of the ultrasound probe as a possible vector for bacterial transmission is important.14 Guidelines exist for the preprocessing, cleaning and reuse of ultrasound equipment and probes.15 Non-compliance to decontamination protocols has been identified as high with many practitioners not using sterile ultrasound gel, not using sterile probe covers, or not aware of instances where the ultrasound probe was used but not correctly processed.16,17 The use of 0.5% accelerated hydrogen peroxide wipes for non-endocavity ultrasound probes still resulted in 25.9% bacterial contamination and growth.18 Isopropyl alcohol19 and newer ultraviolet sterilizer lamp are being explored for probe sterilization.20,21 The use of dedicated ultrasound covers and sterile ultrasound gel can help achieve an aseptic working field.22 A ten year retrospective review of 7476 single injection peripheral nerve blocks with low level disinfection technique of the probe and a sterile barrier dressing found no block related infections.23

The aseptic technique summary description for regional technique includes the removal of hand and wrist accessories, handwashing with an alcohol based antiseptic solution, the wearing of caps and masks (see above), use of sterile gloves, sterile draping, individual packaged antiseptics for skin preparation and use of an antiseptic solution (chlorhexidine with alcohol) for skin preparation.13,24 Chlorhexidine dressings have been shown in some studies to reduce the bacterial colonization at the tip and insertion sites of both epidural and peripheral catheters25 but there are also studies refuting the efficacy of chlorhexidine-impregnated patches.26 Sterile occlusive dressing should be used for catheter taping and bacterial filters may be considered for extended placements.

Catheters are a concern for infection as indwelling foreign devices are ideal sites for bacterial growth and introduction. Aseptic technique should be maintained when accessing the catheter for drug boluses and the sterile catheter infusion system should be interrupted as little as possible with the same level of care as central line access. Scholle et al. found that after deliberate inoculation of epidural catheter end in a bacterial solution (staphylococcus epidermis), cutting the catheters 20mm from the contaminated end and disinfection by spray-wipe antiseptic completely prevented bacterial growth.27 Consideration of removal of unwitnessed or accidentally disconnected catheters due to the assumption of loss of sterility is reasonable in this situation.

The advantage of tunneling catheters is to reduce dislodgment and colonization of bacteria. More reports are being published on the practice of tunneling for both epidural and peripheral nerve catheters. The literature supports the use of tunneling epidurals for stability of catheter placement but not a clinically significant reduction in infection rates.28,29 While case series have reported decreased colonization and  infection rates in tunneling of caudal epidural catheters, these studies are limited in the size.30–32 Bacterial colonization in 402 tunneled perineural catheters indwelling for an average of 48 hours showed a colonization rate of 6.22% but no clinical infection was found in those patients.33 The technique of tunneling catheters, while not necessary, does help with stability and for catheters meant to persist longer than five days may help decrease infection complications.

The greatest risk for infections for both neuraxial and peripheral catheter technique is the length of time the catheters are inside the patient. From a large retrospective review of 1,620 pediatric epidural catheters, only one of the catheters placed greater than five days in an immunocompromised patient resulted in an epidural abscess requiring laminectomy for drainage.34 A large retrospective study evaluated the extent to which the infection risk for both epidural and peripheral catheters increase over time. Infection risk in catheter use increases over time but especially after four days, the authors concluded that both types of catheters should be removed as soon as practical.35

A large retrospective analysis of 40,362 patients showed that single dose antibiotic prophylaxis was associated with fewer peripheral and epidural catheter infections.36 The literature reports that infectious complications can still occur with the presence of prophylactic antibiotics. There are strong recommendations from the ASA 2017 guidelines to deliver pre-procedure antibiotics when a neuraxial technique is performed in a patient with known or suspected bacteremia.37

There should be a high-index of suspicion for infection and anesthesiologists should be checking daily for the physical manifestations of infection. Early signs of infection are fever, back pain, swelling, erythema, tenderness and exudate at the site. Blood tests such as white blood cell count, sedimentation rate, and C reactive protein should be ordered as well as cultures of the suspected sites of bacterial presence: blood, exudate from site, cerebral spinal fluid. Administration of appropriate antibiotic therapy in consultation with appropriate infectious expertise should begin as early as possible. Late signs of infection such as neck stiffness, photophobia, neurological abnormalities, hypotension or respiratory distress should trigger prompt and appropriate infectious disease consultation, removal of any regional catheter, and imaging: magnetic resonance imaging, computed tomography, or myelogram. Timely and early surgical consultation should be obtained in anticipation of surgical drainage.

All practices placing pediatric regional blocks and catheters should have a consistent practice for the follow-up of catheters for the duration of placement and even after the catheter has been removed. Infectious complications such as epidural abscesses have been reported days after catheter removal. Bacterial meningitis has been reported ten days after a spinal anesthesia in a patient.38 Because children may be discharged with indwelling catheters, deliberate follow-up for the duration of catheter use and removal should be done daily. Patient and parent education on infectious indications as well as information on how to contact anesthesiologists should be provided. Akerman supports the development of automated patient follow up systems.39 Technology such as automated follow-up and telemedicine may aid follow-up and surveillance for infectious complications for long term catheters.

Pediatric anesthesiologists must weigh the benefits of each regional technique against the risks of complications. Infectious complications are among the rare but most relevant of concerns. Healthcare- associated infections from regional blocks and catheters are continuous concerns as an important cause of suffering for patients and lead to increased healthcare cost. By and large, infection rates have been commonly utilized to gauge the overall quality of surgical care but as well as anesthesia care provided. Compliance with recommendations with the goal of preventing infectious complications in pediatric regional anesthesia should always be maintained as a priority. For this reason, a safe practice of aseptic technique must be carefully implemented and should be easily accomplished through education, culture, and technology.

References

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