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Residual sedation and brain stem death testing

We would like to present the case of a skin abscess which was obscured by the use of a Lockit (Smiths Medical, Hythe, UK) epidural catheter clamp. A patient undergoing major abdominal surgery had an epidural catheter inserted at T10 ⁄ 11 at the first attempt, using full aseptic precautions. It is our normal practice to maintain epidural analgesia for 5 days postoperatively in such cases. To ensure secure fixation, the epidural was secured with a sterile Lockit covered by a clear dressing, which was itself covered by another dressing with the central area removed so that the epidural site remained visible (Fig. 1). On the 5th postoperative day the epidural catheter was removed. At the site of insertion a 4 · 4 cm discharging superficial skin abscess and widespread erythema were noted. Intravenous antibiotics were commenced immediately. Neurological examination was unremarkable and an MRI scan showed no collection in the epidural or subdural space. After 5 days of intravenous antibiotic therapy the patient was discharged from hospital and there were no long-term sequelae. The procedure of epidural catheterisation carries the risk of bacterial colonisation, even when strict aseptic precautions are adhered to. Many causes of contamination have been identified [1–4]. It is known that the risk of infection is related to the length of time that the epidural remains in situ [5]. We believe that in these patients 5 days of use is justified to ensure adequate postoperative analgesia. As a result of this case we have reconsidered our method of securing epidural catheters. The method of fixation used precludes visual inspection of the epidural site without disruption of the dressing. Although not the classical presentation of an epidural abscess, any inflammation at the site of insertion should prompt immediate removal of the catheter. In this case the abscess was completely obscured by the Lockit clamp. Despite the secure fixation achieved by the use of such a device, we now question whether its value is diminished by the risk of delaying the recognition of the signs of a potentially devastating complication.