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• W2076045944 abstract "Editor—We read with interest the case report of cerebrospinal fluid (CSF)-cutaneous fistula and pseudomonas meningitis complicating a thoracic epidural, by Abaza and Bogod.1Abaza KT Bogod DG. Cerebrospinal fluid‐cutaneous fistule and pseudomonas meningitis complicating thoracic epidural analgesia.Br J Anaesth. 2004; 92: 429-431Crossref PubMed Scopus (9) Google Scholar Two points of discussion have arisen. First, were there signs of systemic inflammation (e.g. high or low white blood cell count, high or low core temperature, tachypnoea, or tachycardia) present before epidural catheter insertion? The presence of such signs could represent systemic sepsis, which is a relative contraindication to epidural anaesthesia. The majority of anaesthetists questioned in a survey of practice in England would not place an epidural in a patient with culture negative sepsis.2Low JH. Survey of epidural analgesia management in general intensive care units in England.Acta Anaesthesiol Scand. 2002; 46: 799-805Crossref PubMed Scopus (25) Google Scholar We acknowledge that in this patient such signs might have been secondary to Crohn's disease alone, but think that the potential risk outweighed any potential benefit from the epidural, particularly as the patient was receiving immunosuppressant drugs. Second, an epidural catheter remaining in situ for 8 days is notably at odds with our own acute pain practice. In this department, most epidural catheters are removed on day 3, and all by day 5 (after correction of coagulopathy, if necessary). We appreciate that patient preference was a factor in the delayed removal in this case, but question whether the patient should have been offered a choice after 5 days had elapsed. Most literature concerning timing of epidural catheter removal relates to anticoagulation or infection. Immunocompromise has been identified as a risk factor for the development of an epidural abscess,3Wang LP Schmidt JF. Severe infections after epidural catheterisation.Ugeskr Laeger. 1998; 160: 3202-3206PubMed Google Scholar as has prolonged duration in situ.4Wang LP Haurberg J Schmidt JF. Long‐term outcome after neurosurgically treated spinal epidural abscess following epidural analgesia.Acta Anaesthesiol Scand. 2001; 45: 233-239Crossref PubMed Scopus (20) Google Scholar The incidence of a positive culture from epidural catheter tips steadily increases with duration with insertion,5Simpson RS Macintyre PE Shaw D Norton A McCann JR Tham EJ. Epidural catheter tip cultures: results of a 4‐year audit and implications for clinical practice.Reg Anesth. Pain Med. 2000; 25: 360-367PubMed Google Scholar although duration is not identified as a risk factor for infection in some studies.6Darchy B Forceville X Bavoux E Soriot F Domart Y. Clinical and bacteriologic survey of epidural analgesia in patients in the intensive care unit.Anesthesiology. 1996; 85: 988-998Crossref PubMed Scopus (91) Google Scholar In conclusion, we consider that the problem described was a complication of management of the epidural, rather than of epidural anaesthesia itself. D. A. Blacoe Editor—We thank Drs Blacoe, Ashworth and Ure for their interest in our report, and for the opportunity to respond to the points they have raised. With regard to our patient's preoperative condition, he was admitted to hospital 1 week before his operation under the care of the physicians with an exacerbation of Crohn's disease, having then been referred on to the surgical team 48 h before surgery. On the day of his operation, he had features of unresolving bowel obstruction (nausea, vomiting, abdominal pain, radiological evidence). He was clinically well rehydrated, apyrexial, heart rate 88/min, blood pressure 105/72 mm Hg, leukocyte count 9.1 cells mm−3. There was therefore no reason to suspect underlying sepsis. We agree with Blacoe and colleagues that neuraxial block should not be performed in patients with untreated bacteraemia; however, catheter placement remains controversial in patients with systemic infection that is responding to antibiotic therapy.7Horlocker TT. Complications of spinal and epidural anesthesia.Anesthesiol Clin North America. 2000; 18: 461-485Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar Early detection of epidural space infection (ESI) may sometimes be difficult as our report illustrates, with onset of symptoms and signs delayed for up to 60 days after catheter insertion being reported.5Simpson RS Macintyre PE Shaw D Norton A McCann JR Tham EJ. Epidural catheter tip cultures: results of a 4‐year audit and implications for clinical practice.Reg Anesth. Pain Med. 2000; 25: 360-367PubMed Google Scholar Our patient's condition was compounded by the occurrence of an unrecognized durocutaneous fistula, which exposed him to a higher risk of developing meningitis caused by breach of the dura.8Bouhemad B Dounas M Mercier FJ Benhamou D. Bacterial meningitis following combined spinal‐epidural analgesia for labour.Anaesthesia. 1998; 53: 292-295Crossref PubMed Scopus (68) Google Scholar We acknowledge that steroid therapy placed our patient in a higher risk category for ESI, but other risk factors identified also include diabetes, chronic renal failure, anorexia, chronic alcohol abuse, and cancer.9Kindler CH Seeberger MD Staender SE. Epidural abscess complicating epidural anesthesia and analgesia. An analysis of the literature.Acta Anaesthesiol Scand. 1998; 42: 614-620Crossref PubMed Scopus (163) Google Scholar Denying such a sizeable group of patients the potential benefits of epidural analgesia cannot be recommended, but a risk–benefit assessment should be undertaken in discussion with the patient. Provided the patient is fully informed of the risks involved, we believe they indeed should be given the choice of keeping epidurals in situ for longer than average if they so wish. Evidence from the literature, however, is inconclusive as to the timing of epidural catheter removal to prevent ESI after use for postoperative analgesia. A review by Ngan Kee and colleagues10Kee WD Jones MR Thomas P Worth RJ. Extradural abscess complicating extradural anaesthesia for Caesarean section.Br J Anaesth. 1992; 69: 647-652Crossref PubMed Scopus (105) Google Scholar showed that the majority of cases of catheter-associated epidural abscess involved cases where catheters were in place for 5 days or less, and concluded that a long duration of catheterization was not a risk factor. Another review confirmed that in 52% of cases catheters were in situ for 5 days or less, whereas only 24% were in place for >5 days.9Kindler CH Seeberger MD Staender SE. Epidural abscess complicating epidural anesthesia and analgesia. An analysis of the literature.Acta Anaesthesiol Scand. 1998; 42: 614-620Crossref PubMed Scopus (163) Google Scholar This led Breivik11Breivik H. Neurological complications in association with spinal and epidural analgesia—again.Acta Anaesthesiol Scand. 1998; 42: 609-613Crossref PubMed Scopus (47) Google Scholar to conclude that duration of epidural catheterization was not a decisive factor for developing an ESI. This lack of conclusive evidence is reflected in our hospital's Acute Pain Service guidelines for management of epidurals, where there is no specified time after which catheters must be removed. This may also reflect our surgical caseload, which includes thoracic and upper gastrointestinal surgery, where surgeons are actively supporting use of epidurals for longer periods postoperatively for their perceived benefits. Review of such guidelines after this unfortunate case has resulted in tightening of the procedures for insertion and follow-up of epidurals, as well as post-insertion infection control precautions to minimize infection risk. Nursing and trainee medical staff education should highlight the need for vigilance for early recognition of this rare but serious complication." @default.
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• W2076045944 title "Infective complications of thoracic epidural" @default.
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