CLINICAL PEARL The Guidelines for the International Surviving Sepsis Campaign call for administration of high-dose IV antibiotics within 1 hour of admission for anyone with suspected sepsis.
C. Anesthetic management
If delivery becomes necessary, neuraxial anesthetic techniques may not be a viable choice due to aberrant hemodynamic, respiratory, and coagulation parameters. When administering general anesthesia, it is important to choose induction agents which support the cardiovascular system, such as etomidate or ketamine. These agents will not prolong the time from induction to delivery, avoiding further compromise to the fetus. In addition, if a severe intraabdominal infection is suspected, it may be prudent to avoid succinylcholine because it may cause hyperkalemia in this setting.117 Rocuronium may be preferred for rapid sequence induction due to its rapid onset of action. Up to 40% of pregnant patients with septic shock may need to undergo surgery.109
V.Neuraxial anesthesia for the febrile parturient
Neuraxial anesthesia is generally preferred to general anesthesia in obstetrics, with reduced mortality and serious morbidity compared to general anesthesia. If general anesthesia is required for seriously infected patients, the risk of hemodynamic instability, airway compromise, and electrolyte abnormalities (discussed earlier) should be considered. Neuraxial anesthesia in febrile patients poses additional considerations.
A. Risk
There is some concern about causing infection while performing neuraxial anesthetic techniques in febrile parturients. However, in most cases, these techniques are safe when performed after administration of appropriate antimicrobial agents. In a classic paper by Carp and Bailey,118 treatment with a single dose of gentamicin before dural puncture in rats with E. coli bacteremia appeared to eliminate the risk of infection; however, it is unclear if this applies to the febrile obstetric population. Most spinal or epidural infections appear to be related to surgical procedures, hematogenous spread of infectious agents, prolonged catheterization, compromised immune status, and/or a lapse in sterile technique, but many cases are spontaneous in origin. The overall incidence of epidural abscess formation in parturients receiving neuraxial anesthesia is unknown, largely due to the rarity of occurrence and lack of centralized reporting. However, two large prospectively collected audits, one in the United Kingdom119 and one in the United States120 calculated the risk between approximately 1:60,000 and 1:300,000, albeit with very wide confidence intervals given the rarity of the outcome. The most common pathogens associated with spinal or epidural abscesses are S. aureus (50%), various streptococci (15%), and gram-negative rods (15% to 20%).121 Organisms cultured from anesthesiologists’ nasopharynx or skin have been implicated in some case reports.
B. IV antibiotics
It is reasonable to require administration of appropriate IV antibiotics before placement of a neuraxial anesthetic in a febrile parturient who appears ill and possibly bacteremic.122 However, the dose and timing of such treatment is currently unknown. In addition, there are no current guidelines surrounding maximum temperature, white blood cell counts, or other clinical signs, which one would clearly contraindicate neuraxial anesthesia. In a woman with florid sepsis, cardiovascular, respiratory, and hematologic concerns may preclude the use of neuraxial anesthesia, but the risks and benefits of alternatives must be assessed and weighed individually.
C. Aseptic technique
11 The ideal aseptic technique for regional anesthesia is controversial (see Chapter 10). There have been questions about the use of maximal aseptic precautions that are similar to those used during central venous access placement. Handwashing; jewelry removal; and use of sterile gloves (to supplement handwashing and not as a substitute), fresh mask, and cap have been shown to reduce the incidence of microbial contamination of the work area but not directly to reduce nosocomial infection. The ASRA consensus statement80 and ASA Task Force report122 acknowledge the importance of these precautions.
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