We thank Drs. McCabe and Christie for their letter, which describes adverse neuraxial outcomes from their own clinical practice,1published in an article almost simultaneously with our own report.2It is indeed reassuring to find that most of their conclusions are consistent with our experience, and overall we hope this will heighten awareness of the insidious problem of epidural space infections and help to avoid long-term adverse outcomes.
In their article, they describe three cases of meningitis as separate adverse outcomes after analgesic epidural infusions, all being diagnosed within 5 days of catheter removal. We did not report any discrete episodes of meningitis, and on searching our database specifically for the term, we have not discovered any such events. It would seem that meningitis per se after epidural analgesia is an uncommon event.
The reason for our change to alcoholic Betadine solution for skin preparation was because we found it difficult to see the light pink alcoholic chlorhexidine on the skin, to ensure full coverage of the area. The apparent increase in incidence of site infections subsequent to this is being monitored and will be reviewed at the end of this year. Clinical recommendations tend to favor alcoholic chlorhexidine skin preparation,3and if our trend is not simply an aberration, we will adopt a return to alcoholic chlorhexidine.
The second spinal hematoma was an intrathecal bleed in patient 3. An L2–L3 epidural was placed for analgesia after removal of a femoral nail and insertion of a hip screw. A “bloody tap” on the first pass complicated insertion of the epidural, which was resited and managed effectively for 2 days. The catheter was dislodged and subsequently removed after 1 h after 5,000 U dalteparin, and the patient subsequently developed neck stiffness and nausea. Magnetic resonance imaging of the spine revealed intrathecal blood from L1 to L3. The patient's symptoms resolved rapidly with no specific management.
We support the recommendations of Drs. McCabe and Christie for auditing these complications. As part of a statewide government initiative commissioned by the Victorian Quality Council, Department of Human Services (Melbourne, Victoria, Australia), we have developed a toolkit for measuring Acute Pain management outcomes.*Included in this is a pro forma that includes specific fields for recording adverse neuraxial outcomes after epidural analgesia as well as other adverse events such as respiratory depression necessitating naloxone treatment associated with systemic opioids. This is being implemented throughout the state of Victoria and is hoped to lead to a more accurate and balanced understanding of the incidence of all serious adverse outcomes relating to acute pain management.
Finally, the provision by Drs. McCabe and Christie of written advice at discharge to patients who have had an epidural is an initiative to be commended.
†St. Vincent's Hospital Melbourne, Victoria, Australia. firstname.lastname@example.org