An epidural abscess due to resistant Staphylococcus aureus following epidural catheterisation

Abstract

SummaryFailed spinal anaesthesia for left total hip arthroplasty was followed postoperatively by dense motor paralysis and sensory deficit in the right leg. The patient had received a dose of subcutaneous heparin 1 h before the spinal anaesthetic was attempted. She died of pulmonary embolism on the ninth postoperative day. At autopsy extensive haematomyelia was found in relation to the needle track. Case reportAn overweight woman of 66 years (height 163 cm weight 87 kg) presented for a left Charnley total hip replacement. She had a history of deep vein thrombosis some 10 years previously, apart from which and notwithstanding her weight, she had remained in good general health. Her only medication was fenbufen for arthritis, which she had not taken for 1 week prior to the operation and co-codamol as required for pain. The patient was frankly advised of the danger of hip surgery but was keen to proceed because her arthritis was severely disabling and her pain constant. She had been waiting for surgery for some months and had been able to lose 8 kg in weight.Pre-operative laboratory investigations showed a haemoglobin of 12.9 g.dl ÿ 1 and platelets of 170 000 × 10 9 .l ÿ 1 . The patient's clotting function was not investigated.Despite the practical difficulties caused by her weight, regional analgesia was chosen. Premedication was with midazolam 5 mg intramuscularly and low-dose heparin was prescribed (5000 i.u. calcium heparin subcutaneously twice daily) the first dose being given 1 h pre-operatively.Spinal anaesthesia was attempted in the left lateral position with a 26G needle. It was extremely difficult to palpate the bony landmarks of the back but the subarachnoid space was located at the first attempt in what was believed to be the L 3-4 interspace and free flow of cerebrospinal fluid was observed. On injection of the local anaesthetic the patient complained of intense pain, described as sharp and stabbing in nature, down the left leg. The subarachnoid injection was abandoned and the needle withdrawn. A total of 0.3 ml of heavy bupivacaine 0.5% in 12% dextrose had been injected. The situation was discussed with the patient who was now pain free and it was decided to proceed with general anaesthesia. This was induced with thiopentone 250 mg and controlled ventilation with nitrous oxide, oxygen 30% and isoflurane 0.5% was facilitated with vecuronium. A total of 12 mg of morphine was administered during surgery. The operation was uneventful and the systolic blood pressure remained in the range 110-140 mmHg throughout. The duration of surgery was 90 min.The patient complained of moderate pain at the operative site and was given a further 5 mg of morphine intravenously in the recovery unit. Her immediate postoperative progress was otherwise unremarkable. The following morning when the patient awoke she complained that her right leg was numb and weak. Neurological examination confirmed this and neurological and neurosurgical opinions were sought. ᮊ 1997 Blackwell Science LtdOn physical examination a right-sided u...

A Prospective Evaluation of Anesthesia for Posterior Lumbar Spine Fusion: The Effectiveness of Preoperative Epidural Anesthesia With Morphine

“…6 -11 It is described that intensive combination of regional anesthesia, such as epidural anesthesia, spinal anesthesia, and nerve blocks, with other procedures and agents of general anesthesia will prevent the patients from suffering the abnormal and intractable pain in the early postoperative period. Contrary to limb surgery, 12,13 preoperative regional anesthesia like epidural block has not been generally accepted in the field of spinal surgery except for postoperative pain management 14 -19 because of its risk of infection, epidural bleeding for the operating site, 20,21 and difficulty of neurologic evaluation immediately after surgery.…”

Epidural abscess: Case report and literature review

“…There has been one further recent case report. 8 The actual complication rate for postepidural anesthetic is unknown. A retrospective audit in obstetric epidural practice indicates a frequency of 1:505,000.…”

Methicillin-resistant Staphylococcus aureus infections

“…Recently reported manifestations of MRSA infection include epidural MRSA abscesses 1) complicating the use of an epidural catheter [55], and 2) after hematogenous spread from a surgical site infection in the lower leg [56]. Another patient developed MRSA meningitis after electrical spinal cord stimulation for chronic neuropathic pain due to diabetes [57].…”