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ANALGESIA

Acute Neck Cellulitis and Mediastinitis Complicating a Continuous Interscalene Block

Xavier Capdevila, MD, PhD^*, Samir Jaber, MD, PhD, Pertti Pesonen, MD, Alain Borgeat, MD, and Jean-Jacques Eledjam, MD

From the Department of Anesthesiology and Critical Care Medicine, *Lapeyronie University Hospital, St Eloi University Hospital, Montpellier, France; Department of Anesthesiology, Clinique Jean Causse, Le Colombier, France; and Department of Anesthesiology, Orthopedic University Clinic Zurich/Balgrist, Switzerland.

Address correspondence and reprint requests to Xavier Capdevila, MD, PhD, Head of Department, Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Avenue du Doyen G Giraud, Montpellier, France. Address e-mail to x-capdevila{at}chu-montpellier.fr.

Abstract

We report a case of acute neck cellulitis and mediastinitis complicating a continuous interscalene brachial plexus block. A 61-yr-old man was scheduled for an elective arthroscopic right shoulder rotator cuff repair. A continuous interscalene block was done preoperatively and 20 mL of 0.5% bupivacaine and 20 mL of 2% mepivacaine were injected through the catheter. Postoperative analgesia was provided by a continuous infusion of bupivacaine, 0.25% at 5 mL/h for 39 h using a 240-mL elastomeric disposable pump. The day after surgery, the patient complained of neck pain. The analgesic block was not fully effective. He was discharged home. Three days later, the patient was readmitted with neck edema and erythema, fever and fatigue. Neck ultrasonography and computed tomographic scan revealed an abscess of the interscalene and sternocleidomastiod muscles and cellulitis, as well as acute mediastinitis. Two blood cultures and surgical samples were positive for Staphylococcus aureus. The infection was treated with surgery, the site was surgically debrided, and a 2-mo course of vancomycin, imipenem, and oxacilline. The technique of drawing local anesthetic from the bottle and filling the elastomeric pump was the most likely cause of infection. This case emphasizes the importance of strict aseptic conditions during puncture, catheter insertion, and management of the local anesthetic infusate.

Continuous interscalene brachial plexus block is widely used for anesthesia and postoperative analgesia after shoulder surgery.1–3 The risk of infection during continuous peripheral nerve block is low.1,3 Wound or muscle abscesses have been reported after femoral,3,4 axillary,5,6 and interscalene blocks.1 We report a case of acute neck cellulitis and mediastinitis complicating continuous interscalene brachial plexus block.

CASE REPORT

A 61-yr-old man, ASA physical status 2, was scheduled for an elective arthroscopic right shoulder rotator cuff repair. His medical history was unremarkable except for hypercholesterolemia (no diabetes or steroid intake). Before induction of general anesthesia with propofol, fentanyl, and isoflurane, an interscalene catheter was placed aseptically in a preinduction room. The skin was disinfected with 10% povidone iodine and draped sterilely. The anesthesiologist wore a cap, a facemask, and sterile gloves. Continuous interscalene blockade was performed following the landmarks of Winnie et al.7 An insulated short-beveled needle with an 18-gauge cannula (Contiplex®; B Braun, Melsungen, Germany) was inserted until deltoid muscle contraction was observed at 0.5 mA, 100 µs, and 1 Hz. A 20-gauge catheter was advanced 4 cm. After a negative aspiration test, 20 mL of 0.5% bupivacaine and 20 mL of 2% mepivacaine were injected through the catheter. Then the catheter was secured with a transparent adhesive dressing (Opsite®, Smith and Nephew, Paris, France). Cefamandole, 750 mg, was injected during surgery. Surgery lasted 70 min and postoperative analgesia was provided by a continuous infusion of bupivacaine, 0.25% at 5 mL/h using a 240-mL elastomeric disposable pump (Easypump®, B Braun, Melsungen, Germany). Pump filling was performed by a nurse anesthetist. She needed six 20-mL bottles of bupivacaine, 0.5%, and 120 mL of saline. She wore a hat and a surgical mask but she did not wear sterile gloves during the procedure. The infusion of 0.25% bupivacaine lasted 39 h. Pain Visual Analog Scale values were noted every 8 h. The day after surgery, the patient complained of neck pain and received 20 mg of nalbuphine twice daily. The analgesic block was not fully effective for the patient. Pain VAS value was noted at 45 mm, on a scale ranging from 0 to 100 mm, despite the use of IV nalbuphine. The next day the catheter was removed in the surgical ward and the nurse noted local neck pain, induration, and erythema. The surgeon consulted the patient and prescribed frozen dressings and pristinamycine. The patient was discharged home. Three days later, the patient was readmitted with neck edema, progression of the erythema, fever, and fatigue. His temperature was 39.8°C, heart rate 120 bpm, arterial blood pressure 120/80 mm Hg, and respiratory rate 21 bpm. Laboratory findings showed an elevated C-reactive protein (250 mg/L) and leukocyte count (27 x 10⁹/L). Neck ultrasonography and computed tomographic scan revealed sternocleidomastoid and interscalene muscles abscess and cellulitis (Fig. 1) as well as acute mediastinitis (Fig. 2). Surgical drainage of the neck and mediastinum was performed. Two blood cultures and surgical samples were positive for Staphylococcus aureus. His hospital stay lasted 3 wk and was complicated by a pulmonary embolism secondary to a right axillary vein thrombosis and a C8-T1 neuropathy. The infection was treated with a 2-mo course of antibiotics (vancomycin, imipenem, and oxacilline), after which a final computed tomographic scan showed no sign of cellulitis and mediastinitis. His neuropathy resolved within 4 mo.

View larger version (63K): [in this window] [in a new window]   Figure 1. Extensive cellulitis and edema (circled in white) of the sternocleidomastoid and interscalene muscles 3 days after removal of the catheter.

View larger version (64K): [in this window] [in a new window]   Figure 2. Extension of the abscess in the mediastinum with pneumomediastinum (white circle) and septic infiltration of mediastinal fat (arrow).

DISCUSSION

Continuous perineural catheter infection is an uncommon, but potentially serious complication after regional anesthesia. Several studies have reported bacterial colonization in 16.7%–57% of catheters after 48 h of peripheral nerve blockade,3,8,9 but only 3.0%–9.0% produced additional signs of local inflammation3,8 and 0.1%–0.9% of severe infection.1,3,10 For perineural interscalene catheters, colonized catheters were found in 11%–25%.3,8 Coagulase-negative staphylococcus was the bacterial species most commonly found for catheter colonization3,8 but S. aureus, as found in our patient, is the most common causative organism in the case of muscle or wound abscess.3,4,8,10 In our patient, neck cellulitis and abscess most likely resulted from catheter colonization or local anesthetic contamination with subsequent extension from the interscalene space to the mediastinum. This case emphasizes the importance of strict aseptic conditions during needle puncture, catheter insertion, and management, including handling of local anesthetic. The anesthesiologist wore a cap, a facemask, and sterile gloves but not a sterile gown. However, the wearing of gowns during the placement of nonpermanent catheters is not recommended.11,12 In retrospect, the infusion fluid and the catheter tip should have been sent for culture when the nurse on the surgical ward pulled the catheter and noted redness and swelling in the neck.

Skin disinfection before catheter placement is a key issue for preventing colonization and infectious complications. The American Society of Regional Anesthesia and Pain Medicine has recommended the routine use of alcohol-based chlorhexidine for skin disinfection prior to all neuraxial and peripheral regional techniques due to its rapid and prolonged effect, as well as its superior effectiveness against S. aureus.13 Povidone 10% iodine was used for skin preparation in our patient. Unfortunately, there was no record of the time allowed to dry the skin before regional anesthesia was administered.

Another potential source of infection is contaminated anesthetic solutions or syringes. This factor is important in our patient because six bottles of 0.5% bupivacaine and 120 mL of saline were necessary to fill the disposable pump. For this purpose, the nurse did not use a prefilled bag or pump and had to manipulate the infusion line each time, increasing the risk of bacterial contamination of the local anesthetic solution. The system was manipulated twice for dressing change but not for pump change. Hunt et al.14 demonstrated that multiple maneuvers or catheter disconnection should be avoided to limit the risk of contamination of the catheter or infused solution.15 Finally, the site of catheter insertion may be another risk factor. Recently, Neuburger et al.10 reported that the interscalene catheter was an independent risk factor for inflammation or infection.

This case report highlights the need to establish definite recommendations regarding use of perineural catheters and emphasizes the importance of adhering to strict principles of asepsis for technical procedures and for the management of the continuous infusion of local anesthetics. This case report stresses the importance of a continuous infusion of sterile or aseptically prepared solutions of local anesthetic with the pump filled in the pharmacy under a laminar flow hood.

Footnotes

Accepted for publication November 1, 2007.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Web of Science (2) Citing Articles via Google Scholar Google Scholar Articles by Capdevila, X. Articles by Eledjam, J.-J. Search for Related Content PubMed PubMed Citation Articles by Capdevila, X. Articles by Eledjam, J.-J. Related Collections Complications Regional Anesthesia