Clinical and laboratory observation

Meningitis associated with serial lumbar punctures and post-hemorrhagic hydrocephalus†

Induction of labor may be indicated to minimize maternal and fetal risks. The rate of induction is likely to increase as recent evidence supports elective induction at 39 weeks gestation. We review methods of induction and then analgesic options as they relate to indications and methods to induce labor. We specifically focus on parturients at high risk for anesthetic complications including those requiring anticoagulation, and those with cardiac disease, obesity, chorioamnionitis, prior spinal instrumentation, elevated intracranial pressure, known or anticipated difficult airway, thrombocytopenia, and preeclampsia. Guidelines regarding timing of anticoagulation dosing with neuraxial anesthetic techniques have been defined through consensus statements. Early epidural placement may be beneficial in patients with cardiac disease, obesity, anticipated difficult airway, and HELLP syndrome. Questions remain regarding how early is too early for epidural placement, what options are safest for patients with bacteremia, and what pain relief should be offered to those unable to tolerate cervical exams in early labor.

Germinal matrix hemorrhage–intraventricular hemorrhage (GMH-IVH) is the most common variety of neonatal intracranial hemorrhage and is characteristic of the premature infant. This form of brain injury affects around 25% of all very low birthweight (<1500 g) premature infants, resulting in an increased risk for neurodevelopmental disability. Its occurrence can lead to impact on subsequent brain development because of destruction of the immature germinal cerebral region resulting in loss of progenitor cells, acceleration of white matter injury via pressure and oxidative stress, and direct parenchymal injury. Finally, hydrocephalus can complicate IVH, resulting in a further increased risk of neurodevelopmental disability. In this chapter, the neuropathology, pathogenesis, clinical features, diagnosis, prognosis, and management of IVH, and its complications will be reviewed. The prominent position of this lesion in neonatal medicine has been accompanied by a large increase in work from several disciplines. This chapter attempts to integrate this information in a meaningful way without oversimplifying a clearly complex problem.

La pratique de l’anesthésie locorégionale chez des patients septiques ou à risque de l’être, pose différents problèmes en fonction du contexte. La réalisation d’un bloc périphérique est possible chez un patient devant être opéré d’une complication infectieuse distale. En raison d’une réduction possible de l’efficacité, l’utilisation d’adjuvants (clonidine) est recommandée). Les colonisations bactériennes des cathéters périphériques sont fréquentes mais les complications septiques sont rares. La rachianesthésie est susceptible de se compliquer de méningites par défaut d’asepsie. Le risque d’inoculation du LCR fait sursoir par précaution à la pratique d’une rachianesthésie chez un patient fébrile. Le risque septique lié à l’anesthésie péridurale est la survenue d’un abcès péridural. Dans le péripartum, il est possible d’effectuer une péridurale chez une patiente fébrile. Dans un contexte septique, la pratique d’un blood-patch après brèche de la dure-mère pourrait avantageusement être remplacée par un patch réalisé avec une solution colloïde.

Regional anaesthesia in septic patients or patients at risk, is a matter of concern. Patients with panaris or local sepsis may benefit of peripheral blocs for anaesthesia. Since efficacy may be reduced, the use of adjuvants (clonidine) could be recommended. Bacterial colonization of perineural catheters is common but the occurrence of local abscess is rare. Spinal anesthesia is prone to be complicated by bacterial meningitis, especially in case of violation of aseptic technique. In septic patients, the risk of CSF contamination prevents from using spinal anaesthesia. Epidural anaesthesia may be complicated by epidural abscess. In obstetrical practice, the use of epidural is not prohibited in a febrile parturient. In a patients suffering from infectious disease and post-dural puncture headache, the use of colloïd solution could be substituted to blood-patch.

Although individual cases have been reported in the literature, serious infections of the central nervous system (CNS) such as arachnoiditis, meningitis, and abscess following spinal or epidural anesthesia are rare. However, recent epidemiologic series from Europe suggest that the frequency of infectious complications associated with neuraxial techniques may be increasing. Importantly, while meningitis and epidural abscess are both complications of neuraxial block, the risk factors and causative organisms are disparate. For example, staphylococcus is the organism most commonly associated epidural abscess; often these infections occurred in patients with impaired immunity. Conversely, meningitis follows dural puncture, and is typically caused by alpha-hemolytic streptococci, with the source of the organism the nasopharynx of the proceduralist. In order to reduce the risk of serious infection following neuraxial blockade, the clinician must be knowledgeable in the pathogenesis of CNS infections, patient selection, and use of meticulous aseptic technique. Finally, since delay in the diagnosis may result in morbidity and even death, it is crucial to be aware of the presenting signs and symptoms of meningitis and epidural abscess.