Plasma and amniotic fluid concentrations of fibronectin during normal pregnancy.

To ascertain the influence of pregnancy on plasma concentrations of fibronectin, we quantified plasma concentrations of fibronectin in 22 normal, pregnant women during the first, second, and third trimesters; at the time of delivery; and at six weeks and eight months postpartum, using a rapid, immunoturbidimetric procedure. Mean plasma concentrations of fibronectin rose significantly throughout pregnancy, and were significantly greater than umbilical cord plasma concentrations. Maternal plasma concentrations of fibronectin at six weeks postpartum were similar to those observed at the time of delivery, but returned to concentrations observed in nonpregnant women by eight months postpartum. No significant differences between concentrations of fibronectin in amniotic fluid obtained during the second and third trimesters of pregnancy were observed. Six-week postpartum values appeared to depend upon the type of infant feeding as values rose in bottle feeding but fell in breast-feeding mothers.

The first four years of the Uniformed Services University of the Health Sciences Graduate School of Nursing.

The Graduate School of Nursing (GSN) was established at the Uniformed Services University of the Health Sciences in 1993 to prepare advanced practice nurses, namely family nurse practitioners (FNPs) and nurse anesthetists (CRNAs), for the uniformed services. A study of needs for nurses in the uniformed services in these specialties indicated that by the year 2000 there would be a need requiring a total enrollment in educational programs of 268 CRNAs and 100 FNPs over a 5-year period. Offering the master of science in nursing degree, the GSN has enrolled 61 students in its two programs, and by the end of the 1997 academic year, it will have graduated 19 FNPs and 19 CRNAs. The GSN was authorized by the Department of Defense, Office of Health Affairs, in February 1996. Federal nursing chiefs serve as advisors to the GSN. The GSN received full accreditation from the Council on Accreditation of Nurse Anesthesia Educational Programs in 1994 and from the National League for Nursing in December 1996. All students who have graduated have successfully passed their certification examinations. Supplementing other educational resources, the GSN is helping to meet the educational needs of the uniformed nursing services by introducing pilot programs specifically designed to meet these needs.

The prevalence of visible and/or occult blood on anesthesia and monitoring equipment.

The Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control and Prevention (CDC) have attempted to stop the spread of blood-borne pathogens by issuing several recommendations and regulations. However, unless healthcare workers comply with these standards, they are not effective. In the anesthesia care environment, the anesthetist is responsible for ensuring that the equipment is clean, and disinfected, before use. We studied the prevalence of visible and occult blood on 6 types of anesthesia and monitoring equipment identified as ready for use in 28 operating suites, in 2 facilities. The sample consisted of 336 observations of the 6 types of equipment. The equipment was inspected for visible blood and then tested for occult blood using a 3-stage phenolphthalein test. Of the 336 observations, 110 (32.7%), were positive for occult blood with only 6 showing visible blood. The presence of blood on this equipment may be in direct violation of the OSHA Blood-borne Pathogen Standard and the infection control guidelines of the American Association of Nurse Anesthetists. Furthermore, the presence of blood on this equipment may increase the risk for nosocomial and occupational exposure to viral and bacterial pathogens. Recommendations were made to decrease the risks from this contamination by redesigning equipment, increasing the use of disposable equipment, and ensuring compliance with effective infection control practices.

Incidence of visible and occult blood on laryngoscope blades and handles.

Anesthesia providers must take appropriate precautions to reduce the potential for transmission of infectious agents to the patients under their care. The devastating spread of human immunodeficiency virus (HIV) and hepatitis B virus (HBV) over the past decade has resulted in the development of specific guidelines for the cleaning, disinfection, sterilization, and handling of medical equipment and instruments. Contamination of laryngoscope blades and handles with visible and occult blood frequently occurs during routine airway management. Several studies suggest procedures for cleaning, disinfection, sterilization, or handling of laryngoscope blades and handles are ineffective, or there may be poor compliance with the established protocols. The purpose of this study was to determine the incidence of visible and occult blood on laryngoscope blades and handles that were identified as ready for patient use. Sixty-five laryngoscope blades and handles identified as ready for patient use were observed for visible blood and tested for occult blood. A modified version of the three-stage phenolphthalein blood indicator test was employed to determine the presence of occult blood. None of the blades or handles observed had visible blood. Of the 65 blades tested for occult blood, 13 (20%) tested positive. Of the 65 handles tested for occult blood, 26 (40%) tested positive. More afternoon blades and handles tested positive for occult blood than morning blades and handles (P < 0.01). The extent to which contaminated anesthesia equipment plays in nosocomial infection is difficult to determine. The presence of blood is an indicator of potential cross-infection, since biological fluids, such as blood and saliva, are known to transmit infectious diseases. This study confirms that more rigorous decontamination protocols must be instituted to ensure complete removal of blood prior to sterilization, since laryngoscope blades and handles have irregular surfaces with repositories for infectious material.

Fatal blood transfusion reactions. An analysis.

This analysis of fatal blood transfusion reactions includes statistics from the Bureau of Biologics provided through the Freedom of Information Act. The study of 126 reported transfusion fatalities occurring between 1976 and 1980 showed that the staff certifying compatibility and the personnel administering the blood have an approximately equal share of the problems. Resolution of blood bag labeling errors through automation leaves patient identification as a major obstacle to those certifying compatibility and the transfusionists. The patient identification wrist band is excellent. However, professional staff do not always utilize this information, relying on memory. In addition, professional staff do not always collate adequately the information on the blood transfusion request form, the blood bag label, and the wrist band of the patient to be transfused. Electronic collation is discussed as a means to identify discrepancies prior to transfusion. The special problem of staff dealing with a time-limited, life-threatening emergency is described and six critical areas related to the problem of fatal transfusion reactions are suggested for further analysis.

Delayed hemolytic episodes due to anti-M.

We observed three cases in which anti-M, undetectable in pretransfusion serum, was responsible for accelerated hemolysis of crossmatch-compatible red blood cells 5 to 15 days after transfusion. In each case, the direct antiglobulin test, which had been negative on pretransfusion testing, was weakly positive on the posttransfusion sample. Anti-M was identified in both the serum and eluate from the posttransfusion sample in two cases. In the third, anti-M could be identified only in the posttransfusion serum. Hemolysis was mild, and was not clinically suspected in any of these three patients until blood was requested for further transfusion. In one of the cases, the antibody was undetectable within a few weeks after the hemolytic episode. Destruction of transfused red blood cells by newly synthesized alloantibodies, particularly those of the Kidd system, is a familiar phenomenon to blood bankers. It is apparent from these studies that anti-M also can behave in this fashion.

The use of frozen intravenous crystalloid solutions as the refrigerant for shipping blood.

The authors studied whether cooled sterile intravenous crystalloid solutions could be used to refrigerate red cells during shipment. Six 1000-ml bags of 0.9 percent normal saline and lactated Ringers (RL) solutions were supercooled and tested separately at temperatures ranging from 1 to -78 degrees C, with either 5 or 30 units of packed red cells (PRBCs). The PRBCs were shipped in a standard military container that permitted separation of the supercooled solutions from the PRBCs. Cooling RL solutions to 6 degrees C and to -22 degrees C maintained acceptable storage temperatures of the PRBC for 36 and 50 hours, respectively, and did not cause visible damage to the units. No significant changes were observed in various biochemical measurements of the cells and plasma. Cooling the RL solution to -78 degrees C caused a significant (p less than 0.05) increase in plasma potassium concentration. The effectiveness of the crystalloid solutions in refrigerating blood varied with the ratio of the number of PRBCs to the volume of cooled solutions and with the ambient temperature surrounding the container. The results of this study suggest that cooled intravenous crystalloid solutions can be used as refrigerants for PRBCs during shipment.

Military blood banking: blood transfusion aboard a Naval hospital ship receiving multiple casualties in a combat zone, a controlled medical environment.

The materials, methods, and policies used in the Blood Transfusion Service aboard the USS Sanctuary (AH-17) during military operations off South Vietnam to transfuse multiple casualties are outlined. Materials and methods common to any blood bank were used with some modification to meet specific requirements. During the period 10 April 1967 to 1 May 1971, approximately 32,000 units of blood were recieved, and over 2,890 severely injured patients were transfused. The policies and techniques used enabled efficient and safe management of blood transfusion for these patients. These methods should be applicable in solving some of the problems which arises as a result of combat operations and civil disasters. A controlled medical environment is described.

Osmolality and oncotic pressure of volume expanding fluids for newborn administration.

Resuscitation of the newborn frequently requires rapid expansion of the circulating volume and correction of metabolic acidosis and hypoglycemia. solutions commonly used for resuscitation contain various concentrations of NaHCO3, glucose, electrolytes, and albumin. We have demonstrated the wide range of osmolalities of solutions frequently available in nurseries and delivery rooms and the resultant osmolalities caused by the addition of NaHCO3. We have also shown the in vitro concentration of albumin needed to equal full-term cord blood colloid osmotic pressure (COP).

Two additional examples of non-transfusion-stimulated anti-Kell.

We have recently encountered two additional examples of non-red cell-stimulated naturally occurring anti-Kelly antibodies in ther sera of two apparently healthy male blood donors. Neither of these donors was previously transfuse. Both antibodies were initially detected using a low ionic medium. Additionally, these two antibodies decreased in reactivity within a seven month period of time. Further documentation of these unusual cases may assist in the understanding of the Kell blood group system.