PRACTICE PARAMETER Practice Advisory for the Prevention, Diagnosis, and Management of Infectious Complications Associated with Neuraxial Techniques (ANESTHESIOLOGY 2017; XXX:00-00) An Updated Report by the American Society of Anesthesiologists Task Force on Infectious Complications Associated with Neuraxial Techniques and the American Society of Regional Anesthesia and Pain Medicine* RACTICE advisories are systematically developed Methodology reports that are intended to assist decision-making P Definition of Infectious Complications Associated with in areas of patient care. Advisories provide a synthesis of Neuraxial Techniques scientific literature and analysis of expert opinion, clini- For this Advisory, infectious complications are defined cal feasibility data, open forum commentary, and consen- as serious infections associated with the use of neuraxial sus surveys. Practice advisories developed by the American techniques. Neuraxial techniques include, but are not Society of Anesthesiologists (ASA) are not intended as standards, guidelines, or absolute requirements, and their limited to, epidural, spinal, or combined spinal-epidural use cannot guarantee any specific outcome. They may be administration of anesthetics, analgesics, or steroids; lum- adopted, modified, or rejected according to clinical needs bar puncture/spinal tap; epidural blood patch; epidural and constraints, and they are not intended to replace local lysis of adhesions; intrathecal chemotherapy; epidural or institutional policies. spinal injection of contrast agents for imaging; lumbar/ Practice advisories summarize the state of the literature spinal drainage catheters; or spinal cord stimulation trials. and report opinions obtained from expert consultants and Infectious complications include, but are not limited to, ASA members. They are not supported by scientific literature epidural, spinal, or subdural abscess; paravertebral, para- to the same degree as standards or guidelines because of the spinous, or psoas abscess; meningitis; encephalitis; sepsis; lack of sufficient numbers of adequately controlled studies. bacteremia; viremia; fungemia; osteomyelitis; or discitis. Practice advisories are subject to periodic revision as war- Although colonization of the catheter is not considered an ranted by the evolution of medical knowledge, technology, infection, it may be considered a precursor to infection, and and practice. is reported as an outcome in this Advisory. This document updates the “Practice Advisory for the Prevention, Diagnosis, and Management of Infectious Purpose of the Advisory Complications Associated with Neuraxial Techniques by The purposes of this updated Advisory are to reduce the risk of the ASA Task Force on Infectious Complications Associ- infectious complications associated with neuraxial techniques ated with Neuraxial Techniques,” adopted by ASA in 2009 by identifying or describing: (1) patients who are at increased and published in 2010.† risk of infectious complications, (2) techniques for reducing This article is featured in “This Month in Anesthesiology,” page 1A. Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org). A complete bibliography used to develop this updated advisory, arranged alphabetically by author, is available as Supplemental Digital Content 1, http://links.lww.com/ALN/B368. Submitted for publication October 26, 2016. Accepted for publication October 26, 2016. Approved by the ASA House of Delegates on October 26, 2016. *Updated by the American Society of Anesthesiologists Committee on Standards and Practice Parameters: Jeffrey L. Apfelbaum, M.D. (Committee Chair), Chicago, Illinois; Terese T. Horlocker, M.D. (Task Force Chair), Rochester, Minnesota; Madhulika Agarkar, M.P.H., Scha- umburg, Illinois; Richard T. Connis, Ph.D., Woodinville, Washington; James R. Hebl, M.D., Rochester, Minnesota; David G. Nickinovich, Ph.D., Bellevue, Washington; Craig M. Palmer, M.D., Tucson, Arizona; James P. Rathmell, M.D., Boston, Massachusetts; Richard W. Rosenquist, M.D., Cleveland, Ohio; and Christopher L. Wu, M.D., Clarksville, Maryland. †American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques: Practice advi- sory for the prevention, diagnosis, and management of infectious complications associated with neuraxial techniques: A report by the American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques. ANESTHESIOLOGY 2010; 112:530–45 Copyright © 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2017; 126:585–601 Anesthesiology, V 126 • No 4 585 April 2017 Copyright © 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Downloaded From: http://anesthesiology.pubs.asahq.org/pdfaccess.ashx?url=/data/journals/jasa/936109/<zdoi;10.1097/ALN.0000000000001521> by ASA, Vicki Tedeschi on 06/26/2017 Practice Advisory infectious risk, and (3) interventions to improve outcomes the Advisory. Seventh, all available information was used after infectious complications. to build consensus within the Task Force to formulate the final document. A summary of recommendations is found Focus in appendix 1. This updated Advisory focuses on patients receiving neur- axial techniques. The practice settings include inpatient Availability and Strength of Evidence (e.g., operating rooms, intensive care units, postopera- Preparation of this update used the same methodologi- tive surgical floors, labor and delivery settings, or hospital cal process as was used in the original Advisory to obtain wards) and ambulatory facilities such as pain clinics. new scientific evidence. Opinion-based evidence obtained This updated Advisory does not address patients with from the original Advisory is reported in this update. The implantable drug or chronic indwelling neuraxial analge- protocol for reporting each source of evidence is described sic delivery systems or injection techniques outside of the below. neuraxis (e.g., peripheral nerve blocks or joint and bursal Scientific Evidence. Scientific evidence used in the devel- injections). opment of this updated Advisory is based on cumulative Application findings from literature published in peer-reviewed jour- nals. Literature citations are obtained from health care data- This updated Advisory is intended for use by anesthesiolo- bases, direct Internet searches, Task Force members, liaisons gists and other physicians and health care providers per- with other organizations, and manual searches of references forming neuraxial techniques. The Advisory may also serve located in reviewed articles. as a resource for other health care providers involved in the Findings from the aggregated literature are reported management of patients who have undergone neuraxial in the text of the updated Advisory by evidence category, procedures. level, and direction. Evidence categories refer specifically Task Force Members and Consultants to the strength and quality of the research design of the studies. Category A evidence represents results obtained In 2015, the ASA Committee on Standards and Practice from randomized controlled trials (RCTs) and Category Parameters requested that scientific evidence for this Advi- B evidence represents observational results obtained from sory be updated. The update consists of an evaluation of lit- erature that includes new studies obtained after publication nonrandomized study designs or RCTs without pertinent of the original Advisory. comparison groups. When available, Category A evidence The original Advisory was developed by an ASA-appointed is given precedence over Category B evidence for any Task Force of 10 members, including anesthesiologists in both particular outcome. These evidence categories are further private and academic practice from various geographic areas of divided into evidence levels. Evidence levels refer specifi- the United States and two consulting methodologists from the cally to the strength and quality of the summarized study ASA Committee on Standards and Practice Parameters. findings (i.e., statistical findings, type of data, and the The Task Force developed the original Advisory by means number of studies). In this document, only the highest of a seven-step process. First, they reached consensus on the level of evidence is included in the summary report for criteria for evidence. Second, a systematic review and evalu- each intervention-outcome pair, including a directional ation was performed on original published research studies designation of benefit, harm, or equivocality for each from peer-reviewed journals relevant to infectious complica- outcome. tions associated with neuraxial techniques. Third, a panel of Category A. RCTs report comparative findings between expert consultants was asked to participate in opinion sur- clinical interventions for specified outcomes. Statistically veys on the effectiveness of various strategies for prevention, significant (P < 0.01) outcomes are designated as either diagnosis, and management of infectious complications beneficial (B) or harmful (H) for the patient; statistically associated with neuraxial techniques, and to review