A very rare, but important, risk factor in placement of epidural catheters is skin reactions to the antiseptic solution, adhesive tape, or the catheter itself. We describe a case of a severe inflammatory cutaneous reaction after continuous epidural analgesia used after an abdominal perineal resection. We highlight the importance of making the proper diagnosis and initiating timely therapy.
IMPLICATIONS: Cutaneous reactions to epidural catheter placement are rare, and usually related to the antiseptic solutions. Proper assessment and treatment is the key to avoiding serious complications.
From the *Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut; †SUNY Downstate Medical Center, Department of Dermatology, Brooklyn, New York.
Accepted for publication October 16, 2007.
Address correspondence and reprint requests to Dr. Raymond Sinatra, Department of Anesthesiology, Yale University School of Medicine, TMP-3, 333 Cedar St., New Haven, CT 06520-8051. Address e-mail to Raymond.Sinatra@yale.edu.
A very rare, but important, risk factor in placement of epidural catheters is skin reactions to the antiseptic solution, adhesive tape, or the catheter itself.1 In an attempt to avoid this complication, standard practice at our institution, includes a thorough cleaning of residual antiseptic solution with normal saline after placement of the epidural catheter, use of hypoallergenic nylon catheters and skin dressings (Tegaderm™; 3M Health Care, St. Paul, MN; NDC 8333-1626-05). Recently, we had a patient develop a severe inflammatory cutaneous reaction after placement of a 19-gauge open tip nylon epidural catheter (Perifix™; B. Braun Medical Inc., Bethlehem, PA; Product Code CESK REF 555963). The time course of development and the severity of this rare complication had never been seen by our Pain Management Service, although a similar report was described in 1993, when six nearly identical cases were seen in an 8-wk period at the same institution.2
A 59-yr-old man was admitted for an abdominal perineal resection for rectal carcinoma. The patient had a medical history significant for coronary artery disease status-post coronary artery bypass graft, hypertension, and colon cancer treated with chemotherapy. His medications included aspirin 81 mg, fluoxetine 20 mg, lansoprazole 30 mg, potassium chloride, spironolactone 25 mg, enalapril 2.5 mg, metoprolol succinate 50 mg, furosemide 40 mg, multiple vitamins, atorvastatin 10 mg, and ferrous sulfate. He had no known drug allergies. Before induction of anesthesia, an epidural catheter was placed in the T12–L1 interspace for postsurgical pain management. As per standard practice, the area was prepared with 10% povidone-iodine solution. The region was draped and excess solution dried off with sterile gauze. After catheter placement, the drape was removed, and the back was cleaned with normal saline solution to remove all iodine staining. The catheter was secured to the back using Tegaderm dressings. The patient received an epidural induction dose of 10 mL of bupivacaine 2.5 mg/mL and hydromorphone 1 mg and was treated intraoperatively with continuous infusion containing hydromorphone 10 μg/mL + bupivacaine 0.3125 mg/mL at a rate of 6 mL/h.
The patient recovered in the surgical intensive care unit and was followed by the Pain Management Service. His pain was well controlled with patient-controlled epidural analgesia at a continuous rate of 12 mL/h and a bolus dose of 3 mL every 6 min. The epidural site was checked daily with no signs of tenderness, erythema, or infection. After 48 h, the patient was transferred to the surgical recovery unit and the epidural analgesia was discontinued the following morning (approximately 72 h after insertion). On removal of catheter and Tegaderm dressings, the skin on the back was noted to be intact, not tender, and nonerythematous.
Twenty-four hours after removal of the catheter, a rash was noticed on the patient’s back, and the Pain Management Resident was called. On inspection, there was a thin 5-mm wide, nonulcerated, beefy red, and slightly raised curvilinear plaque that appeared to follow the course of the epidural catheter on the lumbar back. The surrounding skin was intact, and no other skin manifestations were noted. The area was slightly tender to touch but nonpruritic. A recommendation of hydrocortisone cream to be topically applied was recommended by our team.
The primary team also consulted Plastic Surgery team who initially felt that the lesion was a pressure sore and recommended bacitracin, a polypeptide antibiotic obtained from a strain of a bacterium (Bacillus subtilis) and used as a topical ointment in the treatment of certain bacterial infections, and xeroform dressing, 3% bismuth tribromophenate in a petrolatum blend on fine mesh gauze, to be applied to the area. After 24 h, the redness had spread to incorporate most of the area under the bacitracin and xeroform dressing with the initial skin changes being even more prominent than before.
A dermatology consultant was then called who, on examination, concluded that the lesion was a contact dermatitis (CD) and felt the bacitracin had exacerbated the initial skin lesion. The dermatologist recommended stopping the xeroform dressing and bacitracin and applying topical hydrocortisone cream, which was started 48 h after initial discovery of the rash. The patient’s lesion was successfully treated with the application of the corticosteroid cream for 3 wk.
The use of indwelling epidural catheters for anesthesia and pain management is a common practice in contemporary anesthesiology. Cutaneous reactions to the antiseptic preparation, adhesive drapes, the catheter, and material used to secure the catheter can occur and have been described.1,3 These complications include reactions to the antiseptic, which generally involve the entire area of the back that was contacted by iodine-containing solutions. The irritant properties mimic an allergic response, including erythema, induration, and vesiculation.4,5 Reactions to adhesive tape often demonstrate precise dermatographia, with redness, pruritus, and blistering isolated to areas of skin to which the tape had been secured.3,6 Because of these known reactions, it is our policy to thoroughly clean the back after catheter placement with saline-soaked sponges to ensure that the povidone-iodine solution is completely removed. Once the area is dry, the catheter is secured using Tegaderm dressings, which are latex-free and reported to be hypoallergenic.
The fact that this was an isolated event at our institution makes a defect in catheter manufacture an unlikely cause of the inflammatory reaction. The manufacturer was contacted and had no previous reports of such an occurrence or any other allergic responses to the Perifix catheters, which are made of an inert biocompatible material, polyamide nylon.
In reviewing the literature, skin manifestations occurring solely along the path of the epidural catheter have been described in three instances. The first, reported by the Acute Pain Service at the University of Washington, described cutaneous inflammatory reactions to nylon epidural catheters in six patients over a period of 6–8 wk.2 The other two reports attributed the well delineated skin lesions to pressure sores caused by patients lying on the catheter. In one case, the epidural had been in place 2 days and, on removal of the dressing, two paramedianly displaced curvilinear Grade 2 pressure sores along the line of the epidural catheter approximately 6 cm each in length were noticed.7 In the second case, the epidural catheter was removed on the third postoperative day to reveal a linear pressure sore along the midline of the patient’s back, with a ruptured blister in the thoracic region.8 What makes the present case unusual is that the lesion was not present at the time of catheter removal, but instead appeared hours later, making a pressure sore an unlikely cause.
We have come to suspect that the present reaction may have been the result of several factors, including residual traces of iodine, extreme patient sensitivity, and pressure of the catheter on the skin. Despite thorough cleaning, it is possible that remnants of the povidone-iodine solution were left on the back, and that trace amounts under the catheter sensitized the skin to a greater degree than surrounding areas of the back. This hypothesis is consistent with the early manifestation of the lesion, which faithfully tracked the course of the catheter, including a pigtail loop that was used to help secure it to the patient’s back. Also consistent with this dual mechanism of sensitization is the observation that the catheter taped to skin outside the area of povidone-iodine wash was not as affected (Fig. 1).
What remains unclear is whether the reaction represented CD with delayed appearance, allergic dermatitis, or a combination of both. CD is the skin’s inflammatory response to either an irritant or allergen. Irritant CD results from the direct injury to the skin, whereas allergic CD is a cell-mediated type IV, delayed hypersensitivity reaction, and previous sensitization is needed for the reaction to occur. In either case, treatment involves removing the offending agent, and topical, and sometimes oral, steroids may be needed, depending on the severity and extensiveness of the reaction.
This case also illustrates the importance of proper diagnosis and initiation of timely and correct therapy. Misdiagnosis of the patient’s lesion as a pressure sore or catheter-related infection, followed by the application of bacitracin, a well known contact allergen,9 exacerbated the skin reaction to the point that it became a major concern to the patient and his caregivers. Early manifestations of the exacerbation of the inflammatory process can be seen in Figure 1, which was taken 12 h after application of the xeroform dressing with bacitracin. The rectangular shape of the xeroform dressing is delineated.
In conclusion, we report of unusual case of an inflammatory cutaneous reaction to epidural catheter placement. Although the offending agent is still unclear, one step that our institution is taking is changing to an alcohol-based antiseptic solution, chlorhexidine, because chlorhexidine which has been shown to be better for prevention of catheter-related infection.10 A possible secondary benefit, although unproven, is that removing a known allergen may decrease the occurence of this rare dermatological complication. We emphasize that, although this is a very rare complication of epidural catheters, appropriate diagnosis of dermatitis, regardless of the offending agent, and proper treatment with a topical corticosteroid are important for recovery.
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