Comment on ‘Time to re-evaluate the routine use of sterile gowns in neuraxial anaesthesia’

The technique of epidural anaesthesia delivered through a catheter during surgery became popular in the late 1970s following a series of fatalities after single shot epidural injections in the United States of America.^1,2 However, epidural catheters also enabled prolonged postoperative pain relief and became commonplace during the 1980s, especially in northern Europe. Unsurprisingly, complications following epidural catheterisation also increased, ranging from accidental removal of the catheter to delayed infection and central nervous system complications. Because of the relative rarity of severe complications, specific preventive measures were difficult to identify. Most anaesthesia societies and healthcare institutions have established guidelines and protocols to reduce the risk of severe complications. ³

Good postoperative pain relief has been the focus of thousands of publications. The authors of a recent paper ³ suggest it may no longer be required for anaesthetists to observe maximal surgical sterile precautions including a gown for most neuraxial procedures. The arguments for lessening the requirements of maximal sterility included the absence of evidence for sterile gowns and the anticipated benefits to the world environment if this precaution were omitted. I would like to caution against the suggestion although, admittedly, the risk of severe complications after neuraxial anaesthesia remains low.

In 1999, with other colleagues, I published a prospective, one-year national survey of the incidence of spinal epidural abscess (SEA) following epidural anaesthesia in Denmark. ⁴ The survey was prompted by personal observations at our national referral centre of both a disappointingly high incidence of epidural abscess after epidural anaesthesia and a (perceived) rather relaxed attitude towards sterile precautions during administration of epidural anaesthesia. At that time and in most Scandinavian anaesthesia departments, guidelines and recommendations prescribed the use of handwash and disinfection, sterile gloves, surgical face mask, cap, surgical drapes and disinfection of the site before a neuraxial anaesthesia procedure. Few anaesthesia departments mandated the use of a surgical gown in the 1980s to 1990s.

The main finding of our study was an incidence of SEA of 1:1930 epidurals (0.05%) overall, but with zero incidence of SEA in patients with an epidural catheter in situ for 2 days or less. The results may have influenced the use of long-term epidural catheterisation, and both local and national recommendations for maximal sterile precautions for the insertion of neuraxial catheters. Since then, there seems to have been limited interest for studies in this area, although a large Japanese registry analysis was published in 2021. ⁵

Recommendations for a procedure intended to prevent a rare occurrence often rest on a low class of evidence. As for neuraxial anaesthesia, it is important to differentiate between the precautions required for single shot spinal/subarachnoid injections and those required for insertion of an epidural catheter. In the event of a postoperative epidural infection, questions are bound to be asked if maximal precautions were not taken to prevent it.

Recent reviews of anaesthesia techniques and equipment base some of their recommendations for change on concern for the global environment. ⁶ A recent media release from the Australian and New Zealand College of Anaesthetists also encourages patients to consider the world climate when they decide their own healthcare (Carbon footprint of nitrous oxide (‘laughing gas’) should be explained to patients, anaesthetists say. ANZCA media release 30 May 2022, www.anzca.edu.au). Although such concerns may be commendable, it may not be a prudent course for anaesthetists to support the notion that environmental considerations be given priority in the medical management of the patient. Even if we are now aware of environmental side effects of some anaesthesia components, it may be wise to continue to provide what we know to be optimal care for the patient. The decision to exclude the use of desflurane or nitrous oxide, or a sterile gown for insertion of an epidural catheter, in the name of amelioration of a climate crisis ⁶ relies mostly on theoretical rationale and extrapolation rather than by scientific evidence. The more balanced and thoughtful publications in the field of anaesthesia and climate science ⁷ suggest that anaesthetists consider their opportunities to reduce the ‘carbon footprint’ of their practice while maintaining the most suitable and safe anaesthesia techniques.