Thigh abscess as a complication of continuous popliteal sciatic nerve block

V. Compère1,*, C. Cornet1, V. Fourdrinier1, A. M. Maitre1, N. Mazirt2, N. Biga2 and B. Dureuil1

1 Department of Anesthetics and Intensive Care, Rouen University Hospital, France. 2 Department of Orthopedic Surgery, Rouen University Hospital, France

* Corresponding author. E-mail: vincentcompere{at}hotmail.com

Accepted for publication April 29, 2005.


    Abstract
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
We present a case report of severe localized infection after continuous popliteal sciatic nerve block. The report highlights the importance of meticulous asepsis and possibly limiting the duration of catheter use.

Keywords: anaesthetic techniques, regional, continuous ; complications, abscess


    Introduction
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Continuous popliteal sciatic nerve block is an established technique for surgery of the foot and ankle. This technique is useful as it facilitates early patient discharge after lower limb surgery.1 The main complications related to this technique are the occurrence of neurological injuries.2 We report a case of thigh abscess complicating a continuous popliteal nerve block.


    Case report
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
A male patient of 57 yr of age, ASA I, was admitted for foot surgery. Before anaesthesia, the patient was monitored using pulse oximeter, ECG and a non-invasive arterial pressure monitor. A popliteal catheter was inserted while maintaining full aseptic precautions; the anaesthetist ‘scrubbed up’ with aqueous chlorhexidine 4%, and wore a gown, cap, facemask and sterile gloves. The skin surface was prepared with alcoholic chlorexidine 0.5% and a sterile drape. Continuous popliteal nerve procedure was performed using the technique described by Vloka and colleagues.3 After local infiltration of the skin with lidocaine 1%, the catheter (Contiplex®D) was inserted under guidance of electrical stimulation (Stimultex® HNS 11) to identify sciatic nerve. The cannula was 55 mm in length with an internal diameter of 18 G. The catheter was placed at a depth of 2 cm and secured with a clear self-adhesive dressing. After a negative aspiration test, 20 ml of ropivacaine 0.2% was injected.

Postoperative analgesia was administered using a continuous popliteal infusion with ropivacaine 0.2% at an infusion rate of 7 ml h–1 (infusor Baxter® with a volume of 250 ml). The infusor had a bacterial filter included into the system and the number of bag changes was limited to three. Five days after surgery, the catheter was removed. The nurse observed an area of superficial inflammation at the site of catheter insertion; there was no fever or pain. Fifteen days after the catheter was removed, the patient complained of pain in the thigh with fever. He had an elevated leukocyte count and increased C-reactive protein. Ultrasonography revealed a thigh mass (Fig. 1) and the abscess was treated by surgery. Copious amounts of pus subsequently indicated methicillin-resistant Staphylococcus aureus. The infection was treated with a 1-month course of antibiotics (vancomycin) with complete recovery.



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Fig 1 Results of ultrasonography: the abscess is circled in white.

 

    Discussion
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
Severe infections after peripheral nerve blocks have been observed only rarely. To our knowledge, the only reported infectious sequelae of such techniques are psoas abscess complicating femoral nerve block4 and localized infection after prolonged use of axillary catheter.5 The site of catheter insertion should be considered as it influences the rate of bacterial colonization; the bacterial colonization rate of continuous femoral nerve catheters may be as high as 57%,6 which is related to contamination from faecal or urinary organisms.

In contrast, two studies have demonstrated that catheters inserted via the popliteal route are associated with a very low rate of bacterial colonization between 7.5% and 18.9%.7 8 This incidence is comparable with the low colonization rates observed for epidural or caudal catheters.9 Nevertheless, several case reports have described abscess formation after epidural catheterisation.10 11 Although S. aureus is the most common causative organism cultured from epidural4 10 11 or psoas abscess,4 it was not the most common organism isolated from peripheral analgesic catheters6 7 and it has been generally regarded as a pathogen of clinical significance. To our knowledge, this is the first case report to describe a severe infectious complication following a continuous popliteal nerve block. The abscess may have resulted from catheter colonization at the skin entry site and subsequently transmitted the infection from the skin to the thigh as previously suggested by Adam and co-workers for a psoas abscess complicating femoral nerve block.4 No risk factor for increased rate of infections such as diabetes mellitus or immunosuppression was present in this patient.

The duration of catheter use of 5 days in this case may also have played a role in the genesis of thigh abscess. In fact, this is the maximum duration which is reported in the literature.6 It is also possible that the longer the duration of catheter placement the greater the risk of high level of bacterial catheter colonization and consequently the risk of further infection as reported for central venous line catheters.12 However, no data are available to date regarding this type of a mechanism for peripheral catheters used for continuous analgesia.

In conclusion, serious complications may rarely occur during continuous popliteal sciatic nerve block for postoperative analgesia. This case emphasizes the importance of adhering to strict aseptic technique and possibly of limiting the duration of catheter use. The authors emphasize the importance of using techniques that minimize the risk of bacterial contamination during both catheter placement and management of the infusion.


    Acknowledgments
 
The authors are grateful to Richard Medeiros, Medical Editor of Rouen University Hospital, Rouen, France, for his valuable advice in editing the manuscript.


    References
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
1 White PF, Issioui T, Skrivanek GD, Early JS, Wakefield C. The use of a continuous popliteal sciatic nerve block after surgery involving the foot and ankle: does it improve the quality of recovery? Anesth Analg 2003; 97: 1303–9[Abstract/Free Full Text]

2 Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anaesthesia in France: The SOS Regional Anaesthesia Hotline Service. Anesthesiology 2002; 97: 1274–80[CrossRef][ISI][Medline]

3 Vloka JD, Hadzic A, Kitain E, et al. Anatomic considerations for sciatic nerve block in the popliteal fossa through the lateral approach. Reg Anesth 1996; 21: 414–8[ISI][Medline]

4 Adam F, Jaziri S, Chauvin M. Psoas abscess complicating femoral nerve block catheter. Anesthesiology 2003; 99: 230–1[CrossRef][ISI][Medline]

5 Bergman BD, Hebl JR, Kent J, Horlocker IT. Neurological complications of 405 consecutive continuous axillary catheters. Anesth Analg 2003; 96: 247–52[Abstract/Free Full Text]

6 Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral nerve block catheter for postoperative analgesia: bacterial colonization, infectious rate and adverse effects. Anesth Analg 2001; 93: 1045–9[Abstract/Free Full Text]

7 Bernard N PP, Branchereau S. Suivi multicentrique prospectif des effets adverses d'ordres infectieux sur 1416 blocs nerveux périphériques continus. Ann Fr Anesth Reanim 2002; 21: R076

8 Cuvillon P, Labourcey L, Veyrat E, et al. Analgésie postopératoire continue par cathéter polpité périphérique: innocuité-éfficacité. Ann Fr Anesth Reanim 1998; 17: 991

9 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[ISI][Medline]

10 Phillips JM, Stedeford JC, Hartsilver E, Roberts C. Epidural abscess complicating insertion of epidural catheters. Br J Anaesth 2002; 89: 778–82[Abstract/Free Full Text]

11 Yuste M, Canet J, Garcia M, Gil MA, Vidal F. An epidural abscess due to resistant Staphylococcus aureus following epidural catheterisation. Anaesthesia 1997; 52: 163–5[CrossRef][ISI][Medline]

12 Polderman KH, Girbes AR. Central venous catheter use. Part 2: infectious complications. Intensive Care Med 2002; 28: 18–28[CrossRef][ISI][Medline]





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