Prevention, Diagnosis, and Management of Infectious Complications Associated with Neuraxial Techniques

Before performing neuraxial techniques, conduct a history and physical examination relevant to the procedure and review relevant laboratory studies in order to identify patients who may be at risk of infectious complications.

Consider alternatives to neuraxial techniques for patients at high risk.

When neuraxial techniques are selected in a known or suspected bacteremic patient, consider administering preprocedure antibiotic therapy.

Select neuraxial technique on a case-by-case basis, including a consideration of the evolving medical status of the patient.

Avoid lumbar puncture in the patient with a known epidural abscess.

Use aseptic techniques during preparation of equipment (e.g., ultrasound) and the placement of neuraxial needles and catheters, including:

• Removal of jewelry (e.g., rings and watches)

• Hand washing

• Wearing of caps

• Wearing of masks covering both mouth and nose

  • Consider changing masks before each new case.

• Use of sterile gloves

• Sterile draping of the patient

Use individual packets of antiseptics for skin preparation.

Use an antiseptic solution (e.g., chlorhexidine with alcohol) for skin preparation, allowing for adequate drying time.

Use sterile occlusive dressings at the catheter insertion site.

Bacterial filters may be considered during extended continuous epidural infusion.

Limit the disconnection and reconnection of neuraxial delivery systems in order to minimize the risk of infectious complications.

Consider removing unwitnessed accidentally disconnected catheters.

Catheters should not remain in situ longer than clinically necessary.

Perform daily evaluation of patients with indwelling catheters for early signs and symptoms (e.g., fever, backache, headache, erythema, and tenderness at the insertion site) of infectious complications throughout their stay in the facility.

To minimize the impact of an infectious complication, promptly attend to signs or symptoms.

If an infection is suspected:

• Remove an in situ catheter and consider culturing the catheter tip.

• Order appropriate blood tests.

• Obtain appropriate cultures.

• If an abscess is suspected or neurologic dysfunction is present, perform imaging studies and promptly obtain consultation with other appropriate specialties.

Administer appropriate antibiotic therapy at the earliest sign or symptom of a serious neuraxial infection.

Consider consultation with a physician with expertise in the diagnosis and treatment of infectious diseases.

If an abscess is present, obtain surgical consultation to determine whether percutaneous drainage of the abscess or surgery (e.g., laminectomy) is warranted.