BACTERIAL MENINGITIS FOLLOWING EPIDURAL BLOOD PATCH IN A PARTURIENT
Abstract Number: 214
Abstract Type: Case Report/Case Series
Epidural analgesia is the most effective technique of providing pain relief during labor.
Practitioners are aware of the most common complications occurring with epidural analgesia like maternal hypotension and postdural puncture headache. The purpose of this report is to reacquaint the clinician with the potential serious complications.
24 year old G1 P0 Parturient at 40 weeks was admitted in labor. She had no significant history. Patient requested epidural block for analgesia. During attempted CSE, an accidental dural puncture ensued. The catheter was inserted into the intrathecal space. An infusion of Bupivicaine 0.1 % with Fentanyl 2 mcg/ml was started at 2 ml/hr. Patient had adequate pain relief and delivered a healthy infant about four hours intrathecal catheter placement. Ten mls of sterile saline was injected into the intrcathecal catheter one hour after delivery and the catheter was removed 24 hours later. The parturient developed a postural headache with no other neurologic signs and symptoms. Over the next 24 hours, she received intravenous hydration, IV caffeine and analgesics with minimal relief of the headache. She opted for epidural blood patch. A few hours after the epidural blood patch, the parturient was symptoms free and was discharged home. Incidentally, her CBC from that morning was as follows: WBC 11.9, H/H 13.2/ 39.4, platelets 164.
Five days later, she was referred by her Obstetrician for episodes of severe frontal throbbing headache(9/10), worsening for the last several hours with mild nuchal rigidity. VSS: BP 112/62, HR 100, RR 14, Sat 98 % and temp of 102*. A lumbar puncture was performed and she was started on triple regimen of Vancomycin, Cefotaxime and Ampicillin. LP results were as follows: WBC 661 RBC 22 Neutrophils 90 Lymphocytes 10, Proteins 107. The gram stain was positive Cocci in chains. The culture grew Alpha Hemolytic Streptococcus in chains. Two days later, patient was symptom free and afebrile. She had a PICC line placed and was discharged with Cefotaxime every 24 hours for 2 weeks.
DISCUSSION: Neuraxial infection has been identified as the most common cause of neuraxial injury in obstetric cases in the ASA Closed-Claims database. Meningitis following epidural/spinal anesthesia is a rare complication. Recent survey shows that incidence from spinal and CSE is 1 in 39,000. Risk factors are: Dural puncture, labor, provider not wearing a mask, bacteremia, vaginal infection and immunocompromise?. ASRA Practice advisory council on Infection complications associated with Regional anesthesia says ”alcohol based Chlorhexidine solutions should be considered the antiseptic of choice” (2004). Meticulous technique, frequent observations, vigilance, early recognition of complications and prompt treatment are the key stones to minimize permanent neurologic sequelae.
REFERENCE: ASRA Practice Advisory on Infectious Complications in Regional Anesthesia