|Year : 2015 | Volume
| Issue : 4 | Page : 515-516
Meningitis following neuraxial blocks: A possibility always
Department of Anaesthesiology, Deen Dayal Upadhyay Hospital, New Delhi, India
|Date of Web Publication||14-Jul-2015|
153, New Ashiana Apartments, Plot - 10, Sector-6, Dwarka, New Delhi - 110 075
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Goswami U. Meningitis following neuraxial blocks: A possibility always. Med J DY Patil Univ 2015;8:515-6
Neuraxial blocks that include spinal and epidural anesthesia are very common anesthetic techniques that are used right from small peripheral health set ups to tertiary care hospitals. A huge variety of surgeries are being done with neuraxial blocks, and these are also being used as a modality of pain relief in various scenarios including labor. These blocks are however not without complications. Meningitis following spinal anesthesia (SA) is one of them. High morbidity and mortality are features of meningitis following SA but presently incidence is very low. Burke et al. in an editorial stated that as long as drug solutions and equipment manufactured to modern standards are used with sound aseptic techniques, the incidence of complications should be very low and the occasional case of meningitis is likely to be coincidental. However, every case should prompt a thorough consideration of all possible etiological factors including equipments and techniques. When there is no obvious bacterial infection, the possibilities of viral infection, chemical contamination and drug-induced contamination should be investigated.  Precautions are therefore of utmost importance - more so in developing countries like India, where SA is often considered a very minor procedure without giving adequate weightage to asepsis and antisepsis in peripheral hospitals and nursing homes. Many a time, lack of resources also makes compromises imperative. Instances are not uncommon when proper operation theater clothes, caps and masks are not used. In June 2007, the Healthcare Infection-Control Practices Advisory Committee (HICPAC) recommended for the first time that surgical masks be worn by spinal procedure operators to prevent infections associated with these procedures. HICPAC made the recommendation in response to several reports of meningitis following myelography procedures from where it was deduced wearing a mask might have prevented the infections. The findings underscore the need to follow established infection-control recommendations during spinal procedures, including the use of a mask and adherence to aseptic technique.  As underscored by the Center for Disease Control and Prevention, Streptococcus salivarius other viridans group streptococci are the most frequent causes of bacterial meningitis following spinal procedures such as anesthesia, accounting for up to 60% of cases. The majority of cases of S. salivarius meningitis (39 of 58 cases, 67%) were associated with iatrogenic causes, usually following epidural anesthesia or spinal myelography. Literature review identified 65 such iatrogenic meningitis cases.  Possible causes of spinal arachnoiditis include infections, blood in cerebrospinal fluid due to hemorrhage, intervertebral disk herniation, spinal surgery, SA, intraspinal steroid injection, myelography dye injection, and idiopathic. Methylprednisolone acetate has been reported to cause arachnoiditis. Intraspinal injections may be made intrathecally or epidurally, and reported cases of arachnoiditis have mostly followed an intrathecal injection. However, arachnoid villi subtend the subarachnoid, subdural, and epidural spaces, and thus, inflammation caused by an epidural injection can spread. The other danger associated with epidural injections is that the epidural space is entered 'blindly' during injection that may further lead to the development of arachnoiditis following epidural injection. The delayed occurrence of spinal arachnoiditis as late as 6-7 months is rare but not unprecedented.  Various additive drugs are nowadays used while administering SA. The drugs used must be considered as single use vials even if they are multi-dose ones. For example, when Fentanyl is used once only, the rest should be discarded. Lidocaine and bupivacaine should be used once only (if must be used more than once, the cap must be sterilized with betadine). A bacteriostatic filter should be used with all epidural catheters. Any narcotic infusion should be changed every 24 h.  This sort of simple aseptic measures, if followed as a protocol in all hospitals, can minimize the chances of meningitis following neuraxial blocks. A change in the mindset of everyone is required to avoid even the sporadic cases that occur. And cases do occur as reported sporadically. Even though the incidence of Post Dural Puncture Headache cases has also come down due to use of finer and better needles, they too occur now and then. This may act like a confounding factor in diagnosing meningitis as the cause of postspinal headache in the postoperative period. Proper vigilance and follow-up of every patient is, therefore, imperative as the scope of using neuraxial blocks expands from establishing anesthesia to other uses like facilitating pain relief for labor and cancer pain in a vast number of patients.
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