Abstract

NM-306

The Curious Case of the Contaminated Catheter: A Multidisciplinary Approach to Confirmed Epidural Disconnection and Contamination in an Infant

Petter J, Broussard A, Yates C
University of Oklahoma, Oklahoma City, Oklahoma, United states of america

Case Report
A 9-month-old previously healthy male presented with hydronephrosis due to right ureteropelvic junction obstruction. He underwent uncomplicated pyeloplasty and stent placement, for which a caudal epidural catheter was placed. One day postoperatively, the acute pain team was notified that the dressing had become soiled, requiring the nurse to replace it. This was unwitnessed by the acute pain service. Per protocol, the epidural infusion was suspended to ensure adequate pain control with oral medication before removal. Three hours later, satisfactory pain control without epidural analgesia was confirmed, and the acute pain service returned to remove the catheter. Examination revealed the dressing was once again soiled and separated from the skin with fecal material beneath the dressing. While removing the remaining dressing, it was discovered that the catheter had been cut four centimeters from the caudal insertion site, presumably during the initial dressing change that morning. Ten centimeters of catheter remained in the patient. The catheter was immediately removed, with a clean catheter tip noted. For concerns of fecal contamination of the catheter, Infectious Disease was consulted, other institutions’ acute pain services were queried, and a literature review was conducted. No definitive guidelines were found to aid in management of a contaminated catheter. On the recommendation of the Infectious Disease service, our patient remained inpatient and was given three doses of intravenous ceftriaxone. He was then discharged home in stable condition. Follow-up four weeks later revealed the patient was without any signs or symptoms of infection or weakness.
Discussion
This case highlights the management of potential complications associated with neuraxial anesthesia. Neuraxial catheter disconnection has been discussed in the literature. The American Society of Anesthesiologists practice advisory states that “the Task Force believes that, in order to avoid infectious complications, an unwitnessed accidently disconnected catheter should be removed.” Also, it has been shown that with short, witnessed disconnection times with limited intra-catheter fluid movement, re-sterilization is possible. However, the novel portion of this case concerns contamination coupled with disconnection. Guidelines concerning post-exposure antibiotic prophylaxis are nonexistent. Our approach to this situation was to utilize a multidisciplinary team, including Infectious Disease consultation. The lack of literature concerning management of a contaminated catheter emphasizes the importance of further study in order to create standardized guidelines for acute pain services.
References
1. Practice Advisory for the Prevention, Diagnosis, and Management of Infectious Complications Associated with Neuraxial Techniques: An Updated Report by the American Society of Anesthesiologists Task Force on Infectious Complications Associated with Neuraxial Techniques and the American Society of Regional Anesthesia and Pain Medicine*. Anesthesiology 2017;126(4):585-601.
2. Paul B. Langevin, MD, Nikolaus Gravenstein, MD, Sharon O. Langevin, Paul A. Gulig, PhD; Epidural Catheter Reconnection: Safe and Unsafe Practice. Anesthesiology1996;85(4):883-888.