Perineural catheters; bowel preparation; watertight sealant for dural repair; family-centered surgical care

AORN Journal,  May, 2007  by George Allen

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Complications with perineural catheters

Acta Anaesthesiologica Scandinavica

January 2007

Continuous peripheral nerve blockade, also called perineural local anesthetic infusion, involves the percutaneous insertion of a catheter directly adjacent to the peripheral nerve(s) supplying a surgical site. Local anesthetic is then infused through the catheter providing site-specific analgesia. Perineural catheters (PNCs) have become the gold standard for postoperative analgesia after orthopedic surgery. Although a low rate of infection is associated with PNCs, when infections do occur they can have potentially deleterious consequences. There is a paucity of data, however, about local inflammation and infection associated with PNCs. The objective of this prospective study was to obtain a better evaluation of PNC-associated complications and to assess the incidence and severity of local inflammation and infection after the placement of PNCs at various anatomic sites. (1)

Between January 2002 and December 2003, all elective orthopedic and trauma patients who received PNCs at a hospital in Germany were assessed prospectively. Trauma patients were defined as those receiving a PNC within 36 hours after trauma to one or more limbs. Exclusion criteria were known allergy to local anesthetics, pre-existing nerve damage, and signs of infection at the puncture site.

The PNCs were placed by 36 anesthesiologists at different sites under aseptic conditions according to a standardized procedure that was routine at the institution. Both the nurse and the anesthesiologist involved in the placement of the PNC wore head coverings and face masks. All blocks were performed with the aid of a nerve stimulator, and the PNC was fixed to the skin with sutures or subcutaneous tunneling and skin tape. A micro-filter was connected between the PNC and the infusion line for continuous local anesthetic application.

All PNCs were checked daily by an anesthesiologist, and the puncture site was evaluated for signs of local inflammation or infection. The dressing was changed on the first postoperative day and on following days only when secretions or blood interfered with visualization of the PNC insertion site. The PNC was removed

* when it was no longer required for analgesia,

* if analgesia could not be satisfactorily achieved, or

* if there were any signs of infectious complications.

The catheter tips were sent for culture. Additionally, three days after the PNC was removed, the puncture point was checked for the occurrence of delayed inflammation or infection.

The outcome measures were the incidence and severity of infectious complications and catheter tip culture evaluation results. Local inflammation was defined as the presence of redness, swelling, or pain on pressure at the PNC insertion site. Infection was defined as the presence of purulent material at the PNC insertion site with or without the need for surgical intervention. All infectious complications were documented according to their severity, time course, and duration. Common statistical procedures, including means, t tests, and analysis of variance (ANOVA), were used to analyze the data.

Findings. Of the 2,285 PNCs evaluated during the study, 686 (30%) were in trauma patients. Overall, anesthesiologists placed

* 600 axillary catheters,

* 303 interscalene catheters,

* 92 infraclavicular catheters,

* 65 psoas compartment block catheters,

* 574 femoral catheters,

* 57 sciatic catheters with a transgluteal approach,

* 239 sciatic catheters with an anterior proximal approach,

* 255 popliteal catheters with a posterior approach, and

* 100 popliteal catheters with a lateral approach.

The incidence rates of local inflammation and infection were 4.2% and 3.2%, respectively. Surgical intervention was needed in 0.9% of the cases. In addition,

* extended duration of PNC placement was found to be a significant risk factor (P < .05);

* interscalene catheters were associated with an increased risk of infection (4.3%, P < .05); and

* anterior proximal sciatic catheters were associated with a lower risk of local inflammation (1.7%, P < .05) and infection (0.4%, P < .05).

Catheter tip cultures revealed Staphylococcus epidermidis (ie, 42%) and Staphylococcus aureus (ie, 58%).

Clinical implications. The results of this study revealed that in the orthopedic and trauma patient populations, infection resulting from PNCs was a rare occurrence, but the incidence increased with the duration of PNC placement. Perioperative nurses should ensure that aseptic technique is rigorously adhered to by all personnel involved in the placement of PNCs.

Efficacy of bowel preparation tablets

American Journal of Gastroenterology November 2006

The decreased incidence and mortality rates associated with colon cancer during the past few decades have been attributed to the early detection and removal of precancerous lesions by screening with colonoscopy. Colon cancer remains a leading cause of cancer death in North America, however, and screening rates remain low. Reasons for the low screening rates generally relate to patients' reluctance to undergo colonoscopy, tolerability of the bowel preparation method, and inadequacy of the bowel preparation.