British Journal of Anaesthesia 1994; 73: 548-549

Post-sacral extradural catheter abscess in a child

E. R. EMMANUEL

Summary

A 4-yr-old child with hypospadias had a 20-gaugesacral extradural catheter inserted for perioperativeanalgesia. The catheter was removed 29 h afteroperation. Ten days after operation a skin pustulewas noted at the catheter site. The pustule dis-charged, recurred, discharged and then recurredover the next 36-48 h. The abscess and tract werethen explored under general anaesthesia: curettagewas performed and some fatty material sent forculture. No growth occurred from the specimen.Antibiotics were given and resolution followedwithout further problem. (Br. J. Anaesth. 1994; 73:548-549)

Key wordsAnaesthetic techniques, extradural. Anaesthesia, paediatric.Complications, abscess.

Children should be kept as pain free and comfortableas possible after operation. The methods useddepend on the surgical site and procedure. A methodfor perineal operations is the use of intermittent orbolus doses of local anaesthetic or local anaestheticwith opioid via a sacral extradural catheter. A casereport of a 3.5-yr-old boy is presented where a smalldeep subcutaneous abscess occurred after the use ofsuch a catheter.

Case report

A 3.5-yr-old, 15.6-kg boy, who suffered fromoccasional mild attacks of asthma which requiredsalbutamol inhaler treatment, was admitted forcoronal hypospadias repair (a Mathieu repair). Afterfasting and administration of oral premedication,anaesthesia was induced with an inhalation tech-nique, a vein was cannulated and the trachea wasintubated. The patient was then placed in the leftlateral position with his thighs and knees flexed, andprepared for insertion of a sacral extradural catheter.The operator's hands were washed and gloved andthe patient's sacral area washed three times with asolution of 0.5 % chlorhexidine gluconate in 70 %spirit, and draped. The sacral hiatus was identifieddigitally and a sterile 18-gauge cannula with a centralneedle inserted through the skin and sacral-coccygeal ligaments into the sacral extradural space,which was identified by the "loss of resistance " test.The cannula was advanced 1-2 cm over the needleand the needle withdrawn: a 20-gauge catheter was

then passed into the space for a distance ofapproximately 3 cm and the cannula withdrawn overthe catheter. A single-use Portex extradural bacterio-logical filter was attached to the end of the catheterand the catheter secured in place with a sterileadhesive transparent dressing. The catheter itselfwas then directed cephalad and secured to thepatient's skin with adhesive tape: 0.35 % bupivacaine7.5 ml was then injected down the catheter.

The patient was placed in the supine position andgeneral anaesthesia was maintained. The operativetime was 2 h and recovery from anaesthesia wasuneventful. After operation, an extradural "top up"with 0.35 % bupivacaine 7.5 ml was carried out 6.5 hlater. At the same time oral temazepam 5 mg wasgiven to allay anxiety. Oral morphine (Oramorph)4 mg was required 24 h after operation. The sacralextradural catheter was removed 29 h after operationand 32 h after operation oral paracetamol suspension120 mg was needed. This was given occasionally onthe second and third days after operation also. Thepatient's postoperative course was satisfactory untilday 10 when a small pustule was noted at theextradural catheter site: some hours later it drainedspontaneously but by the following day it was thenseen to have recurred. On day 12 a small scab wasseen with a slightly fluctuant area around it.Magnesium sulphate dressings were applied locallyand flucloxacillin 125 mg orally commenced. Thechild's general condition was good.

On day 14, after fasting and oral premedication,the very small abscess was incised and drained underinhalation general anaesthesia. The inflammatorymass was curetted and less than 1 ml of pus wasfound: this was sent for culture but no micro-organisms were grown.

Treatment with flucloxacillin was continued for afurther 12 days after drainage of the abscess, whichhealed completely. However, he developed amacular-papular erythematous rash 24 days afterhypospadias repair (12 days after commencement ofantibiotics). The antibiotics were stopped and therash resolved with the help of a 1-day course of oralchlopheniramine maleate 1 mg three times daily.

The child had recovered completely when dis-charged home on day 25 after operation.

E. R. EMMANUEL, MB, BS, MRCS, LRCP, FANZCA, Welsh Bums,Plastic, Reconstructive and MaxiUo-Facial Surgery Unit, StLawrence Hospital, St Lawrence Road, Chepstow, GwentNP6 5YX. Accepted for publication: March 10, 1994.

Present address: North East Thames Plastic and Burns SurgeryUnit, St Andrew's Hospital, BiUericay, Essex CM12 0BH.

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Post-sacral extradural catheter abscess 549

DiscussionThe first publication on sacral catheterizationappears to have been in 1988 [1] when it was used toeffect thoracic anaesthesia. Thus the technique isrelatively new and any complications are of interest.

Personal communication has revealed that an-aesthesia and postoperative pain relief via thelumbar, and particularly sacral, extradural catheterroutes, are carried out fairly commonly for lowerabdominal and limb surgery in other parts of theworld, for example Australasia, Canada and theUSA. The sacral approach is easier than the lumbarto perform because of anatomical considerations.Until about 1993 there were no published reportsfrom the UK of anaesthesia or postoperative painrelief via sacral extradural catheters in children.However, articles published in Canada [2] and fromtwo separate units in the UK [3, 4], together withmore recent publications from Australia (of workfirst presented in 1991), the USA [5] and Europe,now lend support to this method of pain relief inchildren.

The major infective complication of extraduralcatheterization reported to date is extradural abscess:informed opinion believes that the majority of theseabscesses are the result of blood-borne infection froma distant site [6, 7]. Contamination by injected fluid,infection from an adjacent area or from skin, andfrom the " extraduralist" are other sources ofinfection [8].

Only one case of minor infection, a subcutaneousabscess (which occurred during lumbar extraduralcatherization for 20 days for pain relief in malignantdisease in an adult) has been reported [9] to date.The first published report of an extradural abscesswas in 1974 [10]; since when 15 cases have beenreported [8] in adult patients who have had cathetersinserted for so-called short-term reasons (rangingfrom 13 days to 6 weeks). Since that publicationanother two or three cases have been reported. Aliterature search has not revealed any case reports inchildren and a review in press [5] of 1620 extraduralscarried out in patients less than 18 yr old (wherecaudal catheterization was carried out in 60 (3.7%)patients) revealed only one infection which occurredat the site of a thoracic extradural catheter in a 10-yr-old child requiring pain relief for disseminatedmalignant disease. The number of sacral extraduralcathenzations in children less than 5 yr of age in thisgroup of 60 was not stated.

The case reported here occurred in a series of 24sacral extradural catheterizations carried out during

general anaesthesia to provide analgesia duringanaesthesia and the postoperative period.

The cause of infection in our patient may havebeen related to the use of a cannula that did not havea central stilette. A sterile kit marketed for anotherinvasive procedure was used because a purpose-designed paediatric extradural catheterization kitwas not available in the hospital at the time. Theneedle central to the cannula did not have a centralstilette and it is possible that a tiny core of skin mayhave been deposited deeply in the tissues and causedthe abscess. No growth was obtained from the verysmall amount of pus obtained and consequently norelationship could be established with either theanaesthetist or the patient, but such aetiology cannotbe excluded.

Another possible source of infection of the sacralextradural site in small children is from faecalcontamination: this did not occur here and so farthere have been no reports of such an event. It isgenerally believed that infection of sacral cathetersites from accidental faecal and urinary soiling ismore likely to occur in infants than in older childrenor adults. However, according to practitioners of thistechnique in infants, infection did not occur whenaccidental contamination of the sealed sterile siteoccurred [Wolf AR, personal communication].

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JW. Thoracic epidural anesthesia via caudal route in infants.Anesthesiology 1988; 69: 265-269.

2. Rasch DK, Webster DE, Pollard TG, Gurkowski MR.Lumbar and thoracic epidural analgesia via the caudalapproach for post-operative relief in infants and children.Canadian Journal of Anaesthesia 1990; 37: 359-362.

3. Wolf AR, Hughes B. Pain relief for infants undergoingabdominal surgery: comparison of infusions of i.v. morphineand extradural bupivacaine. British Journal of Anaesthesia1993; 70: 10-16.

4. Peutrell JN, Hughes EG. Epidural anaesthesia through caudalcatheters for inguinal herniotomies in awake ex-prematurebabies. Anaesthesia 1993; 47: 128-131.

5. Berde CB, Strafford MA, Wilder RT. The risk of infectionfrom epidural analgesia in children: a review of 1620 cases.Anesthesia and Analgesia (in press).

6. Saady A. Epidural abscess complicating thoracic epiduralanalgesia. Anesthesiology 1976; 44: 265-269.

7. Crawford JS. Pathology in the epidural space. British Journalof Anaesthesia 1975; 47: 412-414.

8. Ngan Kee WD, Jones MR, Thomas P, Worth RJ. Extraduralabscess complicating extradural anaesthesia for Caesareansection. British Journal of Anaesthesia 1992; 69: 647-652.

9. Knitza R. Subkutaner absces ruch langzeitkatheter-periduralanaesthesie. Anaesthetist 1981; 30: 198-199.

10. Ferguson JF, Kirsch WM. Epidural empyema followingthoracic extradural block. Journal of Neurosurgery 1974; 41:762-764.

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