Obstetric epidural catheter-related infections at a major teaching hospital

ORIGINALARTICLE

Obstetricepiduralcatheter-relatedinfectionsatamajor

teachinghospital:aretrospectivecaseseries

L.K.Green,M.J.Paech

DepartmentofAnaesthesiaandPainMedicine,KingEdwardMemorialHospitalforWomen,Perth,WesternAustralia,

Australia

ABSTRACTBackground:Clinicallyovertinfectionsoftheepiduralcatheterskinentrysiteoccurinapproximately1-5%ofpatientsafterafewdaysofcatheterizationbutseriouscomplicationssuchasdeeptissueinfectionorepiduralabscessappearrareintheobstetricpop-ulation.Inrecentyears,sporadicreportsandsmallseriessuggestthattheincidencemaybehigherthanpreviouslyestimated.Methods:Aretrospectivechartreviewwasconductedtoidentifyepiduralcatheter-relatedinfectionsoccurringbetweenJanuary2002andDecember2005inatertiaryreferralmaternityhospitaldeliveringbetween4000and6000womenperannum.CaseswereidentifiedusingInternationalStatisticalClassificationofDiseasescoding.Results:Intotal9482women(52.8%)whodeliveredhadanepiduralcatheterinserted.Therewere258caseswiththerelevantcodeidentifiedand49(0.52%,95%CI0.37-0.66%)hadepiduralcatheter-relatedinfection.Fourwomenhaddeeptissueinfection(inci-dence0.04%,95%CI0.01-0.11%;rate1in4741),representedbyparaspinousandepiduralabscessformation(incidenceofboth0.02%,95%CI0-0.08%;rate1in2371).Threeofthecasesaredescribed.Conclusions:Seriousepiduralcatheter-relatedinfectioninobstetricpatientsisrare,butourincidenceofseriousdeeptissueinfec-tionwasattheupperextremeoffiguresquotedinotherstudies.CrownCopyright󰀂c2009PublishedbyElsevierLtd.Allrightsreserved.

Keywords:Obstetric;Epidural;Abscess;Infection

Introduction

Epiduralabscessanddeeptissueinfectionafterepidural

catheterinsertionarerarebutseriouscomplications,

andmayrequiresurgicalinterventionandlong-term

antibiotictherapyandleadtopermanentdysfunction

orpersistingpain.Spontaneousepiduralinfectionswith-

outepiduralpunctureorepiduralcatheterizationarere-

portedatarateof2per10000hospitaladmissionsper

year.1Thereportedincidenceofepiduralabscessinthe

obstetricpopulationvarieswidely,rangingfrom0.2to

48per100000obstetricepiduralprocedures.2–7

Aretrospectiveanalysisofprospectivelycollected

dataaboutcomplicationsofobstetricepiduralanalgesia

andanaesthesia,conductedatourinstitutionbetween

July1989andAugust1994andinvolving10995cases,

foundnocasesofsuperficialorseriousdeeptissueinfec-

tionorabscessformation.8However,anumberofcases

wereknowntohaveoccurredinourhospitalduringthe

pastdecade,andtherehasbeenanincreasingnumberofcasereportsofepidural-relatedinfectioninrecent

years.9

Thisretrospectivestudywasdesignedtoestimatethe

incidenceandnatureofepiduralcatheter-relatedinfec-

tionsinalargematernityhospitalinAustralia.We

foundfourcasesofseriousinfectioninobstetric

patients,allofwhomhadanepiduralcatheterinserted

underfullasepticconditions,includingtheoperator

wearingacap,mask,gownandsterilegloves,afterre-

peatedskinapplicationof0.5%chlorhexidinein70%

alcoholandafterapplicationofatransparentdressing.

Methods

Weconductedaretrospectivechartreviewofepidural

complicationsthatoccurredbetweenJanuary2002and

December2005inourinstitution,KingEdwardMemo-

rialHospitalforWomen.Thetotalnumberofbirths,

electivecaesareansectionsandobstetricepiduraltech-

niquesperformedduringthisperiodwasobtainedfrom

thehospitalperinataldatabase(‘Stork’).Thehospital

hasatertiaryreferralmaternityunitservicingalocal

metropolitanpopulationofapproximately1.5million

andaruralpopulationwithintheentirestateof

WesternAcceptedJune2009Correspondenceto:DrLloydGreen,DepartmentofAnaesthesiaandPainMedicine,KingEdwardMemorialHospitalforWomen,374BagotRd,Subiaco,WesternAustralia6008,Australia.E-mailaddress:Lloyd.Green@health.wa.gov.auInternationalJournalofObstetricAnesthesia(2010)19,38–430959-289X/$-seefrontmatterCrownCopyright󰀂c2009PublishedbyElsevierLtd.Allrightsreserved.doi:

10.1016/j.ijoa.2009.06.001

www.obstetanesthesia.comAustralia(sizeapproximately2.5millionsquarekilome-

tres)ofapproximately500000.

Patientswithcomplicationswereidentifiedusingthe

InternationalStatisticalClassificationofDiseases

(ICD)code089.5.AccordingtotheInternationalStatis-

ticalClassificationofDiseasesandRelatedHealthProb-

lems,10thRevision,AustralianModification(ICD-10-

AM),producedbytheNationalCentreforClassifica-

tioninHealth(NCCH),code089.5isusedtoidentify

patientswhohavehadcomplicationsofspinalandepi-

duralanaesthesiaduringthepuerperium.Thiscodealso

identifiesthosewomenre-admittedtohospitalwithan

epiduralcomplication.

Ineachcasedatacollectedfromthemedicalrecord

includedpatientdemographicsandcharacteristics,the

reasonforinsertionoftheepiduralcatheter,thedura-

tionofepiduralcatheterization,potentialriskfactors

forinfection,andthesignsand/orsymptomsindicative

ofinfection.Epiduralcatheterrelatedinfectionwas

diagnosedinitiallyonclinicalgroundsandusuallyin-