Transfusion-related sepsis due to Serratia liquefaciens in the United States.

BACKGROUND: Severe, often fatal, transfusion reactions due to bacterial contamination of blood components continue to occur. Serratia liquefaciens, an unusual human pathogen, is a recently recognized potential cause of transfusion-related sepsis. CASE REPORTS: Five episodes of transfusion-related sepsis and endotoxic shock due to S. liquefaciens were reported to the CDC from July 1992 through January 1999. One episode has been described. The remaining four, all fatal, are described here: three associated with RBC transfusion and one associated with transfusion of platelets. In each instance, the source of contamination could not be found. The implicated units tended to be older (mean RBC age 28 days), and visual discoloration was noted in each RBC unit, although usually in retrospect. CONCLUSION: S. liquefaciens is an increasingly recognized cause of transfusion-related sepsis and is associated with a high mortality rate. S. liquefaciens can contaminate both RBCs and platelets, but the mechanism(s) of contamination remain unknown. Increased attention to pretransfusion visual inspection may avert the transfusion of some S. liquefaciens-contaminated RBC units. However, more sensitive rapid diagnostic tests are needed to further reduce the risk of transfusion-related sepsis and endotoxic shock.

D-Dimer formation during cardiac and noncardiac thoracic surgery.

UNLABELLED: The ability to make therapeutic decisions regarding excessive fibrinolysis in the perioperative period is limited by the lack of availability of a near site monitor of fibrinolysis. We investigated the use of a latex agglutination D-dimer assay to detect perioperative fibrinolysis in patients undergoing thoracic surgery with and without extracorporeal circulation. We studied 27 patients who underwent thoracic surgery requiring cardiopulmonary bypass (CPB; coronary artery bypass grafting, n = 12; valvular surgery, n = 15) and a cohort of 20 patients who underwent noncardiac thoracic surgical procedures not requiring CPB. The purpose of this investigation was to determine the relationship among alterations in the latex agglutination D-dimer assay, use of extracorporeal circulation, type of cardiac surgical procedure, and mediastinal and/or chest tube drainage (cardiac surgery only) in patients undergoing thoracic surgery. Perioperative D-dimer levels, measured by latex agglutination, had significant (P < or = 0.05) intragroup changes among patients undergoing cardiac surgery (requiring CPB) and the cohort of patients who underwent noncardiac thoracic surgery without CPB. Although intraoperative D-dimer levels were not increased in patients undergoing noncardiac thoracic surgery, postoperative levels were significantly (P < 0.05) increased (compared with preinduction). In cardiac surgery patients requiring CPB, intraoperative D-dimer formation was significantly (P < or = 0.05) increased but did not demonstrate any intragroup (coronary artery bypass grafting versus valvular surgery) differences. Finally, D-dimer levels were not associated with postoperative mediastinal and/or chest tube accumulative drainage measured at intervals up to 48 h postoperatively in patients undergoing cardiac surgery requiring CPB. Our study indicates that the latex agglutination D-dimer assay can detect excessive fibrinolysis perioperatively, and that extracorporeal circulation can significantly influence the pattern of D-dimer formation in patients undergoing thoracic surgery. IMPLICATIONS: We assessed the ability of a readily available D-dimer assay to detect excessive fibrinolysis in patients undergoing thoracic surgery with and without extracorporeal circulation. The findings demonstrate that the assay used in this investigation reflected variable amounts of fibrinolysis in patients undergoing both types of thoracic surgery.

Evaluation of laboratory coagulation and lytic parameters resulting from autologous whole blood transfusion during primary aortocoronary artery bypass grafting.

STUDY OBJECTIVE: To determine if autologous blood reinfusion influences overall hemostatic function following aortocoronary artery bypass graft (CABG) surgery, and if so, where the predominant area of this influence lies. DESIGN: Prospective, with control values on each patient. SETTING: Cardiac operating room of a major university-affiliated county hospital. PATIENTS: 20 patients undergoing elective CABG surgery. INTERVENTIONS: Following heparinization, and prior to cardiopulmonary bypass (CPB), venous blood (average 4.9 ml/kg) was removed via an indwelling internal jugular catheter into a preservative-free plastic transfer pack unit and stored without agitation at room temperature. This autologous whole blood was reinfused after systemic protamine reversal of heparin. Blood samples for analysis were drawn immediately before and 5 minutes after completion of the reinfusion. MEASUREMENTS AND MAIN RESULTS: Autologous blood reinfusion appears to be significantly related to increased hemoglobin, hematocrit, platelet count, fibrinogen, plasminogen, and antiplasmin levels. The prothrombin time and activated partial thromboplastin times decreased significantly, whereas activated clotting times and D-dimer levels were unchanged. Significant increases occurred in the following thromboelastography parameters: maximum amplitude, amplitude 60 minutes after the maximum amplitude, and whole blood clot lysis index. Reaction time and coagulation time were not statistically different from control values. CONCLUSIONS: Significant improvements in coagulation and lytic parameters occur following CPB after the infusion of autologous blood. These improvements in coagulation indices may be the result of the infused blood or hemoconcentration, which is also known to occur during this period. Additional control studies are needed to differentiate these effects.

Administration of high-dose aprotinin during nonprimary cardiovascular surgery: case reports and review of the literature.

The perioperative management of two patients undergoing complex "redo" cardiac surgical procedures are presented. The management of both patients included the prophylactic administration of aprotinin via a "compassionate use" protocol. Aprotinin, a serine protease inhibitor, has been shown to limit the exposure to blood and blood products in patients undergoing high-risk cardiac surgical procedures. In late December 1993, the Food and Drug Administration approved aprotinin for administration to cardiac surgical patients considered at high risk for post-cardiopulmonary bypass coagulopathies. Indications for the administration of aprotinin, as well as a brief review of the literature relating to the perioperative administration of aprotinin, are included.

Influence of ketorolac tromethamine on clot elastic strength in humans as assessed by thromboelastography.

STUDY OBJECTIVE: To evaluate the effect of ketorolac tromethamine on coagulation using thromboelastography (TEG). DESIGN: TEGs were performed in each patient before and after ketorolac administration. Each patient's predrug results were used as control measurements for comparison with the postdrug results. SETTING: Medical center surgical unit. PATIENTS: Twenty ASA physical status I and II patients undergoing minor elective surgery; 12 healthy volunteers. INTERVENTIONS: TEGs were performed in all subjects before and 60 minutes after the intramuscular (IM) administration of ketorolac tromethamine 60 mg. Ten surgical patients were studied in the intraoperative period, and 10 surgical patients were studied in the postoperative period. The 12 healthy volunteers did not undergo a surgical procedure. MEASUREMENTS AND MAIN RESULTS: Specific parameters assessed from the TEGs were reaction time (R time), coagulation time (RK time), clot formation rate (angle of deflection), and maximum clot strength (maximum amplitude of deflection). Ketorolac administration did not cause statistically significant changes in these parameters in any of the three groups studied. CONCLUSIONS: IM administration of ketorolac tromethamine 60 mg did not significantly alter the speed of formation or viscoelastic strength of clots as measured by TEG. These results provide additional support for prior clinical studies confirming the safety of ketorolac administration in the perioperative period.

Diagnosis, classification, and course of myelodysplastic syndromes.

The myelodysplastic syndromes are bone marrow stem cell disorders that result in disorderly and ineffective hematopoiesis. They are prognostically heterogenous. Approximately one third of cases evolve to acute myeloid leukemia. Many additional cases terminate in severe bone marrow failure. The French-American-British Working Group classification of the myelodysplastic syndromes defines morphologic and prognostic groups. Cytogenetic and in vitro cell culture characteristics are important prognostic indicators.

Isolation of the insoluble straight fibrils of Pick's disease.

This paper describes the isolation and partial purification of the straight fibrils that occur in the neurons of Pick's disease. Pick fibrils are highly insoluble in a variety of solvents. These fibrils were shown to be sodium dodecyl sulfate insoluble even in the presence of a reducing agent at elevated temperatures. This allowed the selective isolation of the fibrils using the SDS boiling procedure and sucrose gradient centrifugation that have been described for isolation of paired helical filaments of Alzheimer's disease. The isolated fibrils retained the native morphology seen in tissue sections, but some appeared to become unraveled to yield a paired helical appearance. These results indicate that the Pick fibrils have many chemical and structural characteristics in common with Alzheimer paired helical filaments, and suggest that these two diseases may be closely related.

Effects of a vitamin K-deficient diet and antibiotics in normal human volunteers.

Decreased concentrations of vitamin K-dependent plasma clotting factors are a well-documented response of vitamin K-deprived patients administered broad-spectrum antibiotics. It has recently been claimed that antibiotics containing a N-methylthiotetrazole (NMTT) side chain cause this response through a direct effect of NMTT on the vitamin K-dependent posttranslational carboxylation of these clotting factors. To further study these relationships, 11 groups of three volunteers were fed a synthetic vitamin K-free diet for 2 weeks. During the last 10 days of vitamin K restriction, seven of the volunteer groups received a therapeutic dose of antibiotics not containing NMTT: ampicillin, sulfamethoxazole-trimethoprim (Bactrim), cefoxitin, cefotaxime, ceftazidime, clindamycin, and piperacillin, and three groups received NMTT-containing antibiotics: moxalactam, cefamandole, and cefoperazone. Serum phylloquinone (vitamin K1) concentrations reflected dietary intake and fell from 1.4 +/- 0.9 ng/ml after 3 days of hospital diet to 0.4 +/- 0.3 ng/ml after 13 days of vitamin K-free diet. Median stool excretion of phylloquinone was 19 micrograms/day while subjects consumed the hospital diet, and fell to 3 micrograms/day by day 6 on vitamin K-free diet. Prothrombin times remained within the normal range throughout the study. Suppression of vitamin K-dependent clotting factor biosynthesis was evident by decreased factor VII levels in seven of the volunteers and by an increased concentration of des-gamma-carboxy (abnormal) prothrombin in 21 of the volunteers. The changes occurred in the control subjects and in subjects receiving all nine of the 10 antibiotics with no consistent pattern.(ABSTRACT TRUNCATED AT 250 WORDS)