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Anesth Analg 2004;99:689-693 © 2004 International Anesthesia Research Society doi: 10.1213/01.ANE.0000130023.48259.FB
William J. Greeley Section Editor |
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Abstract |
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Bacterial colonization is regarded as a causative factor for septic complications of caudal catheters in children. To determine whether tunneling caudal catheters reduces the bacterial colonization rate effectively, we evaluated 506 children being treated with tunneled or untunneled caudal or untunneled lumbar epidural catheters. Four-hundred-nine children completed the study. After aseptic removal, the catheters were cultured and sent for microbiological assessment. We found a bacterial colonization rate of 29% in untunneled caudal catheters, 11% in tunneled caudal catheters, and 9% in untunneled lumbar catheters. No severe infectious complications were reported. There was no correlation between catheter retention time and bacterial colonization except for the first 24 h, during which no bacterial colonization was detected. The overall colonization rate remained constant at approximately 13%. We found a positive correlation between bacterial colonization and redness at the catheter entry site. We conclude that tunneled caudal epidural catheters can be used in children for postoperative analgesia without an increased risk of epidural infection.
IMPLICATIONS: We investigated the rates of bacterial colonization of tunneled and untunneled caudal epidural catheters and lumbar epidural catheters in children. Tunneled caudal catheters had no more colonization than lumbar-inserted catheters, whereas untunneled caudal catheters showed significantly more colonization.
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Introduction |
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Continuous epidural analgesia is used increasingly for postoperative analgesia in children after painful procedures (1,2). Major advantages are the long-lasting, profound analgesia; the opioid-sparing effect (3); and possible improvement of postoperative gastrointestinal function (4). In young children, epidural catheters have to be placed under sedation or general anesthesia, which may delay the immediate detection of potential neurologic damage caused by the needle or the catheter. Caudal access to the epidural space provides a feasible alternative to the thoracic or lumbar routes: the anatomical landmarks are easy to identify, and the technique is simple and usually successful (5). Furthermore, the puncture site is a safe distance from neural structures, decreasing the likelihood of direct nerve damage or damage of the dura mater (6).
Caudal catheters are not widely used because some authors assume that possible fecal contamination and bacterial colonization of the insertion site leads to an increased risk of ascending infection to the epidural space (5). There are just two prospective studies comparing the colonization and infection rates of caudal epidural catheters with those of lumbar epidural catheters (7,8). The authors reported that the colonization rate of caudal catheters was significantly more rapid than that of lumbar epidural catheters. They concluded that effective measures must be taken to prevent caudal catheters from being soiled and contaminated. A suitable technique could be subcutaneous tunneling of the catheter. We have conducted a prospective trial to answer the following questions: are caudal catheters more frequently colonized than lumbar catheters, and if so, can subcutaneous tunneling reduce the colonization rate of caudal catheters?
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Methods |
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From October 1991 to February 1999, all patients with epidural catheters at Hanover Children’s Hospital and at Olgahospital, Stuttgart, were evaluated. Approval of the ethics committee and informed consent of the parents were obtained. The skin-cleaning procedure (three times with povidone-iodine solution), the technique of access to the epidural space, draping, and patient follow-up were performed according to protocol in both hospitals. We documented which access to the epidural space was chosen, the type of catheter, and the type and dose of local anesthetic used. All complications regarding the technique were also documented. Specifically, all clinical and laboratory signs of infection were recorded and evaluated.
Most catheters were placed under general anesthesia for postoperative pain control. In some adolescents, the catheters were placed under sedation only. The catheter sets used at Hanover Children’s Hospital were the Epidural-Minipack-System® manufactured by Portex, and those used at Olgahospital were the Contiplex-Set® from Braun. Epidural flat filters of the same size (0.2 µm) were used with the Portex and B. Braun sets.
In older children (median age, 9.8 yr), the lumbar route was chosen preferentially, whereas the caudal route was mainly used in children less than 1 yr old. For ethical reasons, we stopped using untunneled caudal catheters in 1994 because early results showed significantly more colonization in this group. The caudal catheters were either inserted percutaneously into the caudal hiatus (untunneled catheter) or tunneled away from the puncture site. Before puncture, we made a stab incision of 2 mm with a lancet. Tunneling was performed subcutaneously with a 20-gauge IV cannula in a cranial direction. This procedure is atraumatic and causes less tissue injury than a surgical incision.
To protect the catheter during the procedure, the Tuohy needle was left in place until the 20-gauge cannula had been inserted (Fig. 1). We then removed the Tuohy needle and pushed the catheter through the 20-gauge cannula. In case of tunneled catheters, the puncture site was covered with a Steri-Strip.
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The catheter entry site was draped with a sterile transparent adhesive film, Tegaderm® (3M), which permitted inspection without dressing removal. The edges of the dressing were secured with tape. The integrity of the catheter and dressing was evaluated at least once a day. The dressing was changed under sterile conditions if it was damaged or if there was blood underneath. The bacterial filters were changed every 72 h.
The catheters were removed when epidural analgesia was no longer required and when intestinal motility had returned. Fever of unknown origin, redness at the insertion site, purulent discharge, or inadvertent disconnection led to early removal of the epidural catheter. Before removal of the catheter, the entry site was disinfected 3 times with 70% alcohol or povidone-iodine solution, and the antiseptic was allowed to dry. Two centimeters of the catheter tip was cultured and sent for microbiological assessment.
Treatment groups were as follows: untunneled lumbar catheter, tunneled caudal catheter, and untunneled caudal catheter. They were matched from all children who expected a long-term painful treatment during the defined investigation time. Because of the higher risk of lumbar catheters causing puncture under general anesthesia, young children (<6 yr) preferably received a tunneled or untunneled caudal catheter, as previously described. For ethical reasons, we stopped using untunneled caudal catheters in 1994. Since then, all caudal catheters have been tunneled. Older children (often >6 yr), who require less frequent surgical treatment or anesthesia for performing puncture, received a lumbar catheter.
We did not change the investigation protocol during the study period. The 
2 test was used for statistical analysis.
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Results |
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From October 1991 to February 1999, 506 children were included into the study: 168 children were treated at Hanover Children’s Hospital and 338 at Olgahospital in Stuttgart. There were no statistical differences in the results between hospitals. The age of the patients ranged from 1 day to 19 yr. There were 175 children younger than 1 yr old. The weight range was 1–80 kg.
Catheters remained in place for a median of 73 h (range, 1.5–352 h). In most cases, antibiotic prophylaxis or therapy was performed with a single dose of cefuroxime. A few children received antibiotic therapy with cefuroxime or cefotaxime three times a day. Children with caudal tunneled catheters were less often treated with antibiotics (63% tunneled caudal catheters versus 97% untunneled caudal catheters and 91% untunneled lumbar catheters) because of the types of surgery.
Some of our patients underwent orthopedic surgery of the lower extremities—for example, surgery for clubfoot. This surgery was usually performed in infants. However, some types of operations are often performed in older children. Because of the age of the children, the types of operation differed between children with caudal catheters and children with lumbar catheters, but there was no difference concerning the type of surgical treatment between the groups with tunneled and untunneled caudal catheters.
Four-hundred-nine (81%) catheters were cultured and sent for bacteriologic examination. Ninety-seven catheters could not be examined because of inadvertent dislodgement, incidental contamination on removal of the catheter, or patient transfer to another hospital before the catheter was removed. Three-hundred-sixty (88%) catheters were sterile. The untunneled caudal catheters exhibited a 3-times-more-frequent colonization rate compared with the other groups (Table 1). There was a significant difference (P < 0.01) in colonization between the untunneled caudal catheters and the lumbar or caudal tunneled catheters. In most cases, we found typical dermal microorganisms (Table 2).
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None of children with colonized catheters showed clinical or laboratory signs of a catheter-related infection. The colonization rate was significantly influenced by the age of the patients (P < 0.001); 61% of the colonized catheters were found in infants, 29% in children between 1 and 5 yr, and 11% in children older than 5 yr. We have not found any correlation between catheter retention times and bacterial colonization except for the first 24 h, in which no bacterial colonization was detected. The colonization rate remained constant at approximately 13% (Table 3).
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We found a significant correlation between redness at the catheter entry site and bacterial colonization. Colonization was detected in 29% of cases with redness at the catheter entry site, whereas only 11% of normal (nonred) catheter entry sites were colonized (P < 0.01).
In all 3 groups, perioperative antibiotic prophylaxis or therapy significantly reduced the rate of colonization (24 colonized catheters of 129 patients without antibiotic treatment versus 25 colonized catheters of 280 patients treated with antibiotics; P < 0.001). This was also true for the colonization rate and the retention times (P < 0.001 for all retention times) and for the rate of redness of catheter entry site. Thirty-seven percent of the children showed redness at the catheter entry site if they were not treated with antibiotics. Perioperative antibiotic prophylaxis reduced the redness at the catheter entry site to 9% (P < 0.001).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Bacterial colonization of caudal catheters in children occurs frequently (7–9). Whether ascending colonization plays a role in epidural abscess formation is not clear. Nevertheless, it seems wise to reduce the colonization rate of caudal catheters as much as possible. In our nonrandomized prospective clinical trial, we demonstrated that the colonization rate in untunneled caudal catheters was three times more than in lumbar epidural catheters (29% versus 9%). None of our patients developed signs of a catheter-associated systemic or severe local infection. Kost-Byerly et al. (8) also found, in a similar patient population, more frequent bacterial colonization of caudal epidural catheters (37%) compared with lumbar epidural catheters (25%). McNeely et al. (7) found a fivefold increased incidence of colonization in untunneled caudal compared with untunneled lumbar epidural catheters. Abouleish et al. (10) showed that, even in adults after a short time, cultures from the entry site of caudal catheters revealed more contamination than cultures from the entry site of lumbar epidural catheters.
Studies of infectious complications of long-term epidural catheters were performed by Du Pen et al. (11) and Rauck et al. (12). They reported an overall infection rate of 23.7% and 25%, respectively. Severe complications, such as epidural space infections, were found at a rate of 4.3% and 5.3%, respectively.
The conclusions to be drawn from our results are limited because the caudal epidural group differed significantly from the lumbar epidural group regarding age and weight. In the participating institutions, caudal access to the epidural space was preferred over lumbar access in neonates and infants for reasons discussed in the Introduction. Therefore, the caudal group patients were young, whereas the lumbar epidural group patients were older. We encountered more frequent bacterial colonization of the catheter in younger children compared with older children. We do not know which of the younger children in our study were toilet trained. This has been described previously by McNeely et al. (7) and Kost-Byerly et al. (8), who showed that the colonization rate of caudal catheters in children younger than three years was more than in older children. The incidence of redness of the insertion site did not differ significantly in their studies.
The prevalent germ we found in colonized caudal catheters was Staphylococcus epidermidis, and this is in accordance with the results of other investigators (7,8,13). We do not know whether the bacterial colonization reached the epidural space or whether the catheters were contaminated subcutaneously on removal by the deeper parts of the catheter entry site that may not have been sufficiently reached by antiseptics. We did not find a significant correlation between antibiotic therapy, predominantly with cefuroxime, and the bacterial colonization rate between groups.
All catheters that remained in place for <24 hours were sterile. In catheters used for more than 24 hours, the colonization rate was more or less constant and was not related to the application time. A positive correlation was found between redness of the catheter entry site and bacterial colonization. Redness of the entry site was noted in 14% of all catheters evaluated. The colonization rate in these patients was twice as much as in patients without local inflammatory signs (23% versus 10%). It remains unclear whether colonization started at the tip of the inserted catheter or was due to the catheter being pulled back through the red skin. Artificial contamination was prevented by careful disinfection of the skin and strictly sterile procedure of cutting and storing the tip of the catheter. Kost-Byerly et al. (8) and Lakshmi et al. (14) did not find a corresponding correlation in their study. For children with perioperative prophylaxis or therapy with antibiotics, we found significantly less colonization for the different retention times. Antibiotics also reduced the rate of redness at the catheter entry site. Because of the number of patients in the group with caudal untunneled and lumbar catheters was too small, we do not have results of the effect of antibiotic administration on redness of catheter entry or on colonization at different retention times in these groups.
There are case reports describing epidural abscess formation with continuous lumbar and caudal epidural analgesia (15,16) in children, even though the risk of an epidural infection is regarded to be small (8,9,17,18). In a review of 1620 pediatric cases, Strafford et al. (9) did not report any epidural infection. Broadman (19) reviewed approximately 3500 pediatric cases and found a similar result. Several techniques to reduce the bacterial colonization of epidural catheters have been investigated. Abouleish et al. (10) have evaluated the effectiveness of different techniques of skin disinfection. Spraying the skin with povidone-iodine and removing the excess of fluid after one minute is regarded as adequate. The Centers for Disease Control guidelines for prevention of intravascular catheter-related infections (20) recommend 2% chlorhexidine-based preparations, as well as tincture of iodine or 70% alcohol for skin disinfection. Other studies have evaluated special dressing techniques for epidural catheters, such as chlorhexidine dressing or barrier flaps (13,21). De Cicco et al. (22) studied the time-dependent efficacy of bacterial filters for epidural catheters and the influence of filter-changing frequency on bacterial contamination. Their data showed a significant positive relationship between the incidence of catheter tip colonization and the filter-changing frequency. They also found an unmodified antimicrobial function of Portex and Braun filters for at least 60 days. They concluded that it appears feasible to reduce the frequency of filter changing during long-term epidural catheterization.
Tunneling of percutaneous catheters is mainly used in the long-term treatment of chronically ill patients (23–25). We investigated whether subcutaneous tunneling in a cranial direction is effective in reducing bacterial colonization of caudal epidural catheters. By this technique, the catheter entry site is displaced to the lumbar region and out the diaper area. Our results indicate that a significant reduction of the colonization rate may be achieved by cranial tunneling (11% versus 29%), although in our study the risk of colonization in patients with tunneled caudal catheters could have been increased because of the smaller number of patients receiving antibiotics. The demographic data between the groups with tunneled and untunneled catheters were comparable. However, the number of patients with untunneled catheters was much smaller than the number of patients with tunneled catheters. A preliminary analysis confirmed our assumption that the colonization rate differs between techniques; therefore, the untunneled technique was abandoned by many of the participating anesthesiologists.
We conclude that tunneling of caudal catheters decreases the colonization rate to levels similar to those found in lumbar epidural catheters (10.5% versus 9.4%, respectively). We believe that this technique is a simple and effective way to use caudal epidural catheters in children. The results of our investigation indicate that tunneling of caudal catheters may decrease the risk of epidural infection.
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References |
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- Thies KC, Boos K, Buscher H, et al. Postoperative Schmerztherapie im Kindesalter. Dtsch Ärzteblatt 2000; 97: A2034–7.
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[Abstract/Free Full Text] - Steinbrook RA. Epidural anesthesia and gastrointestinal motility. Anesth Analg 1998; 86: 837–44.[Web of Science][Medline]
- Busoni P. Katheter-Kaudalanästhesie. In: Saint-Maurice C, Schulte Steinberg O, eds. Regionalanästhesie bei Kindern. Stuttgart: Gustav Fischer, 1992: 88–97.
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- McNeely JK, Trentadue NC, Rusy LM, Farber NE. Culture of bacteria from lumbar and caudal epidural catheters used for postoperative analgesia in children. Reg Anesth 1997; 22: 428–31.[Web of Science][Medline]
- Kost-Byerly S, Tobin JR, Greenberg RS, et al. Bacterial colonization and infection rate of continuous epidural catheters in children. Anesth Analg 1998; 86: 712–6.[Abstract]
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[Abstract/Free Full Text] - Flandin-Bléty C, Barrier G. Accidents following extradural analgesia in children: the result of a retrospective study. Paediatr Anaesth 1995; 5: 41–6.[Web of Science][Medline]
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[Abstract/Free Full Text] - Broadman LM. Pediatric regional anesthesia. Clin Anesth Updates 1992; 3: 1–14.
- O’Grady N, Alexander M, Dellinger P, et al. Guidelines for the prevention of intravascular catheter-related infections: Centers for Disease Control and Prevention. MMWR Recomm Rep 2002; 51: 1–29.[Medline]
- McClain BC, Redd SA. Barrier flaps for continuous caudal anesthesia in pediatric patients. Anesthesiology 1993; 79: 400–1.[Web of Science][Medline]
- De Cicco M, Matovic M, Castellani GT, et al. Time-dependent efficacy of bacterial filters and infection risk in long-term epidural catheterization. Anesthesiology 1995; 82: 765–71.[Web of Science][Medline]
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