Vol 2 | Issue 1 | January-June 2021 | Page 05-12 | Rammurthy Kulkarni, Amjad Maniar, Neha Singh, Vrushali Ponde, Kapil Gupta, Mohammad Azam Danish, Ritesh Roy, Archana Areti
Authors: Rammurthy Kulkarni , Amjad Maniar , Neha Singh , Vrushali Ponde , Kapil Gupta , Mohammad Azam Danish , Ritesh Roy , Archana Areti 
 Department of Anaesthesia, Axon Anaesthesia Associates, Bengaluru, Karnataka, India.
 Department of Anaesthesia, AIIMS, Bhubhaneshwar, Odisha, India.
 Director Child Anaesthesia Services, Mumbai, Maharashtra, India.
 Department of Anaesthesia, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi, India.
 Department of Anaesthesia, B. M. Jain Hospital, Bengaluru, Karnataka, India.
 Associate Clinical Director and HOD, Care Hospitals, Bhubaneshwar, Odisha, India.
 Department of Anaesthesia, Mahatma Gandhi Medical College Research Institute Puducherry, India.
Address of Correspondence
Dr. Vrushali Ponde, Director Child Anaesthesia Services, Mumbai, Maharashtra, India.
The frequency of infection following peripheral nerve block (PNB) is not very clear. The major reason for the paucity of literature is under-reporting of infectious complications. Though rare, the infectious complications associated with peripheral nerve blocks can be devastating and occasionally fatal.1 One case of necrotising fasciitis following an axillary approach to brachial plexus blockade for carpal tunnel release has been reported where the PNB was directly attributed to the infection. With the increase in the number of peripheral nerve block procedures being performed (both single injection and continuous techniques), it is expected that the infectious complication rate may also increase.
There is no uniform consensus amongst anaesthesiologists across the globe regarding the appropriate sterile technique that should be practised during the administration of regional anaesthesia. In a UK and Ireland based survey of obstetric anaesthesiologists, only half of the responders wore a face mask for both neuraxial (spinal and epidural) techniques. One-third of those who did not wear a mask believed that the mask actually increased the risk of infection.2 It can be easily assumed that a similar attitude is present while performing PNBs.
The aseptic chain starts right from hand washing and ends after the block needle has been taken out from the patient’s body (in a single injection technique) or till the perineural catheter is completely removed (in a continuous technique). Any breach in this chain may increase the chances of introducing infection.
1. Nseir S, Pronnier P, Soubrier S, Onimus T, Saulnier F, Mathieu D, Duroche A. Fatal streptococcal necrotizing fasciitis as a complication of axillary brachial plexus block. Br J Anaesth 2004; 92: 427-9.
2. Panikkar KK, Yentis SM. Wearing of masks for obstetric regional anaesthesia. Anaesthesia. 1996; 51: 398-400.
3. Hebl JR. The Importance and Implications of Aseptic Techniques During Regional Anesthesia. Reg Anesth Pain Med. 2006; 31(4):311-323.
4. Sellors JE, Cyna AM, Simmons SW. Aseptic precautions for inserting an epidural catheter: A survey of obstetric anaesthetists. Anaesthesia. 2002; 57:593-596.
5. Hartley JC, Mackay AD, Scott GM. Wrist watches must be removed before washing hands.BMJ. 1999; 318 (30): 328.
6. Jumaa PA. Hand hygiene: simple and complex. International Journal of Infectious Diseases.2005; 9: 3-14.
7. Mulroy MF, Weller RS, MD, Liguori GA. A Checklist for Performing Regional Nerve Blocks. Reg Anesth Pain Med. 2014; 39 (3): 195-199.
8. World Health Organization. WHO guidelines on hand hygiene in health care, 2009. Available from: http://whqlibdoc.who.int/publications/2009/ 9789241597906_eng.pdf. Accessed September 19, 2012.
9. Sahni N, Biswal M, Gandhi K, Yaddanapudi S. Quantification of hand hygiene compliance in anesthesia providers at a tertiary care center in northern India. American Journal of Infection Control. 2015; 43(10): 1134-1136.
10. Munoz-Price LS, Bowdle A, Johnston BL, Bearman G, Camins BC, Dellinger EP, et al. Infection prevention in the operating room anesthesia work area. Infection Control & Hospital Epidemiology. 2019. 1–17.
11. Capdevila X, Bringuier S, Borgeat A. Infectious risk of continuous peripheral nerve blocks. Anesthesiology.2009; 110 (1): 182-188.
12. Lee JJ, Parry H. Bacterial meningitis following spinal anaesthesia for Caesarean section. British Journal of Anaesthesia. 1991; 66: 383-386.
13. Schneeberger PM, Janssen M, Voss A. Alpha-hemolytic streptococci: A major pathogen of iatrogenic meningitis following lumbar puncture. Case reports and a review of the literature. Infection. 1996; 24:29-33.
14. Moen V. Meningitis is a rare complication of spinal anesthesia. Good hygiene and face masks are simple preventive measures. Lakartidningen. 1998; 95(7):628, 631-2, 635.
15. Wildsmith JA. Regional anaesthesia requires attention to detail. Br J Anaesth. 1991; 67:224-225.
16. Philips BJ, Fergusson S, Armstrong P, Anderson FM, Wildsmith JA. Surgical face masks are effective in reducing bacterial contamination caused by dispersal from the upper airway. Br J Anaesth. 1992; 69(4): 407-8.
17. Rope T, Thunga S, Plaat F. Should unmasked anaesthetists be given benefit of the doubt? Anaesthesia. 2008; 63: 1372–1386.
18. Schweizer RT. Mask wiggling as a potential cause of wound contamination. Lancet 1976; 2:1129-1130.
19. Orr NW. Is a mask necessary in the operating theatre? Ann R Coll Surg Engl. 1981; 63: 390.
20. Black SR, Weinstein RA. The Case for Face Masks—Zorro or Zero? Clinical Infectious Diseases. 2000; 31:522–3.
21. Skinner MW, Sutton BA. Do Anaesthetists Need to Wear Surgical Masks in the Operating Theatre? A Literature Review with Evidence Based Recommendations. Anaesth Intensive Care. 2001; 29: 331-338.
22. Gharabawy R, Abd-Elsayed A, Elsharkawy H, Farag E, Cummings K, Eid G et al. The Cleveland Clinic Experience with Supraclavicular and Popliteal Ambulatory Nerve Catheters. Scientific World Journal.2014. Article ID 572507, 9pages.
23. Borgeat A, Blumenthal S, Lambert M, Theodorou P, Vienne P. The Feasibility and Complications of the Continuous Popliteal Nerve Block: A 1001- Case Survey. Anesth Analg. 2006; 103:229–33.
24. Compère V, Rey N, Baert O, Ouennich A, Fourdrinier V, Roussignol X, Beccari R, Dureuil B. Major complications after 400 continuous popliteal sciatic nerve blocks for post-operative analgesia. Acta Anaesthesiol Scand. 2009; 53: 339–345.
25. Neuburger M, Breitbarth J, Reisig F, Lang D, Büttner J. Complications and adverse events in continuous peripheral regional anesthesia. Results of investigations on 3,491 catheters. Anaesthesist. 2006; 55:33–40.
26. Neuburger M, Büttner J , Blumenthal S, Breitbarth J, Borgeat A. Inflammation and infection complications of 2285 perineural catheters: a prospective study Acta Anaesthesiol Scand. 2007; 51:108–114.
27. Capdevila X, Bringuier S, Borgeat A. Infectious risk of continuous peripheral nerve blocks. Anesthesiology. 2009; 110(1):182-188.
28. Reisig1 F, Neuburger M, Zausig YA, Graf BM, Büttner J. Successful infection control in regional anesthesia procedures. Observational survey after introduction of the DGAI hygiene recommendations. Anaesthesist. 2013; 62:105–112.
29. Aveline C, Hetet HL, Roux AL, Vautier P, Gautier JF, Fabrice Cognet et al. Perineural Ultrasound-Guided Catheter Bacterial Colonization: A Prospective Evaluation in 747 Cases. Reg Anesth Pain Med. 2011; 36: 579-584.
30. Bergman BD, Hebl JR, Kent J, Horlocker TT. Neurologic Complications of 405 Consecutive Continuous Axillary Catheters. Anesth Analg. 2003; 96:247–52.
31. Wiegel M, Gottschaldt U, Hennebach R, Hirschberg T, Reske A. Complications and Adverse Effects Associated with Continuous Peripheral Nerve Blocks in Orthopedic Patients. Anesth Analg. 2007; 104:1578–82.
32. Kinirons B, Mimoz O , Lafendi L, Naas T, Jean-François Meunier JF, Nordmann P. Chlorhexidine versus Povidone Iodine in Preventing Colonization of Continuous Epidural Catheters in Children. Anesthesiology. 2001; 94:239–44.
33. Culligan PJ, Kubik K, Miles Murphy M, Blackwell L, Snyder J. A randomized trial that compared povidone iodine and chlorhexidine as antiseptics for vaginal hysterectomy. American Journal of Obstetrics and Gynecology. 2005; 192: 422–5.
34. Darouiche RO, Wall MJ, Itani KMF, Otterson MF, Webb AL, Carrick MM et al. Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis. N Engl J Med. 2010; 362:18-26.
35. Krobbuaban B, Diregpoke S, Prasan S, Thanomsat M, Kumkeaw S. Alcohol-based chlorhexidine vs. povidone iodine in reducing skin colonization prior to regional anesthesia procedures. J Med Assoc Thai. 2011; 94(7): 807-12.
36. Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A, Liu Z. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database of Systematic Reviews. 2015, Issue 4.
37. Yoshii T, Hirai T, Yamada T, Sakai K, Ushio S, Egawa S et al. A Prospective Comparative Study in Skin Antiseptic Solutions for Posterior Spine Surgeries. Chlorhexidine-Gluconate Ethanol Versus Povidone-Iodine. Clin Spine Surg. 2018; 31(7): E353-E356.
38. Sakuragi T, Yanagisawa K, Dan K. Bactericidal activity of skin disinfectants on methicillin-resistant Staphylococcus aureus. Anesthesia and Analgesia 1995; 81: 555–8.
39. Killeen T, Kamat A, Walsh D, Parker A, A. Severe adhesive arachnoiditis resulting in progressive paraplegia following obstetric spinal anaesthesia: a case report and review. Anaesthesia. 2012; 67(12): 1386-94.
40. Bogod D. The sting in the tail: antiseptics and the neuraxis revisited. Anaesthesia. 2012; 67:1305–20.
41. Association of Anaesthetists of Great Britain & Ireland. Safety guideline: skin antisepsis for central neuraxial blockade. Anaesthesia (ePub ahead of print, 3 Sep 2014): doi: 10.1111/anae.12844.
42. De Cicco M, Matovic M, Castellani GT, Basaglia G, Santini G, Del Pup C, Fantin D, Testa V. Time-dependent efficacy of bacterial filters and infection risk in long-term epidural catheterization. Anesthesiology. 1995; 82: 765-771.
43. Saady A. Epidural abscess complicating thoracic epidural analgesia. Anesthesiology. 1976; 44:244-246.
44. Borum SE, McLeskey CH, Williamson JB, Harris FS, Knight AB. Epidural Abscess after Obstetric Epidural Analgesia. Anesthesiology. 1995; 82: 1523-1526.
45. Kaushal M, Narayan S, Aggarwal R, Kapil A, Deorari AK. In vitro use of Epidural Filters for Prevention of Bacterial Infection. INDIAN PEDIATRICS. 2004; 41(17): 1133-1137.
46. Morris W, Simon L, Tryfa M, Pelle-Lancien E, Masson F. Efficiency of antibacterial filters for epidural catheters in obstetrics: preliminary results. European Journal of Anaesthesiology. 2001; 18: 110.
47. Timsit JF, Bruneel F, Cheval C, Mamzer MF, Orgeas MG, Wolff M et al. Use of Tunneled Femoral Catheters To Prevent Catheter Related Infection. Ann Intern Med. 1999; 130: 729-735.
48. Kumar N, Chambers WA. Tunnelling epidural catheters: a worthwhile exercise? Anaesthesia. 2000; 55: 625–626.
49. Marhofer D, Marhofer P, Triffterer L, Leonhardt M, Weber M, Zeitlinger M. Dislocation rates of perineural catheters: a volunteer study. British Journal of Anaesthesia. 2003; 111 (5): 800–6.
50. BURSTAL R, WEGENER F, HAYES C, LANTRY G. Subcutaneous Tunnelling of Epidural Catheters for Postoperative Analgesia to Prevent Accidental Dislodgement: A Randomized Controlled Trial. Anaesth Intens Care 1998; 26: 147-151.
51. Bougher RJ, Corbett AR, Ramage DTO. The effect of tunnelling on epidural catheter migration. Anaesthesia. 1996; 51: 191-194.
52. Sellmann T, Bierfischer V, Schmitz A, Weiss M, Rabenalt S, MacKenzie C, et al. Tunneling and Suture of Thoracic Epidural Catheters Decrease the Incidence of Catheter Dislodgement. The Scientific World Journal Volume 2014, Article ID 610635, 9 pages.
53. Byrne KPA, Freeman VY. Force of removal for untunnelled, tunnelled and double-tunnelled peripheral nerve catheters. Anaesthesia. 2014; 69: 245–248.
54. Bomberg H, Kubulus C, Herberger S, Wagenpfeil S, Kessler P, Steinfeldt T, et al. Tunnelling of thoracic epidural catheters is associated with fewer catheter-related infections: a retrospective registry analysis. British Journal of Anaesthesia. 2016; 116 (4): 546–53.
55. Compe`re V, Legrand JF, Guitard PG, Azougagh K, Baert O, Ouennich A, et al. Bacterial Colonization After Tunneling in 402 Perineural Catheters: A Prospective Study. Anesth Analg 2009; 108: 1326–30.
56. MANN TJ, ORLIKOWSKI CE, GURRIN LC, KEIL AD. The Effect of the Biopatch, a Chlorhexidine Impregnated Dressing, on Bacterial Colonization of Epidural Catheter Exit Sites. Anaesth Intensive Care 2001; 29: 600-603.
57. Ho KM, Litton E. Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis. Journal of Antimicrobial Chemotherapy. 2006; 58: 281–287.
58. Kerwat K, Eberhart L, Kerwat M, Hörth D, Wulf H, Steinfeldt T, et al. Chlorhexidine Gluconate Dressings Reduce Bacterial Colonization Rates in Epidural and Peripheral Regional Catheters. BioMed Research International Volume 2015, Article ID 149785, 5 pages http://dx.doi.org/10.1155/2015/149785.
59. Schroeder KM, Jacobs RA, Guite C, Gassner K, Anderson B, Donnelly MJ. Use of a chlorhexidine-impregnated patch does not decrease the incidence of bacterial colonization of femoral nerve catheters: a randomized trial. Can J Anesth. 2012; 59: 950–957.
60. Bomberg H, Krotten D, Kubulus C, Wagenpfeil S, Kessler P, Steinfeldt T, et al. Single-dose Antibiotic Prophylaxis in Regional Anesthesia. Anesthesiology 2016; 125:505-15.
|How to Cite this Article: Kulkarni R, Maniar A, Singh N, Ponde V, Gupta K, Danish MA, Roy R, Areti A | Sterility Protocols During Regional Anaesthesia: An AORA Initiative | International Journal of Regional Anaesthesia | January-June 2021; 2(1): 05-12.