Management of a surgical patient with a label of penicillin allergy: narrative review and consensus recommendations.

Unsubstantiated penicillin-allergy labels are common in surgical patients, and can lead to significant harm through avoidance of best first-line prophylaxis of surgical site infections and increased infection with resistant bacterial strains. Up to 98% of penicillin-allergy labels are incorrect when tested. Because of the scarcity of trained allergists in all healthcare systems, only a minority of surgical patients have the opportunity to undergo testing and de-labelling before surgery. Testing pathways can be modified and shortened in selected patients. A variety of healthcare professionals can, with appropriate training and in collaboration with allergists, provide testing for selected patients. We review how patients might be assessed, the appropriate testing strategies that can be used, and the minimum standards of safe testing.

Consensus clinical scoring for suspected perioperative immediate hypersensitivity reactions.

BACKGROUND: Grading schemes for severity of suspected allergic reactions have been applied to the perioperative setting, but there is no scoring system that estimates the likelihood that the reaction is an immediate hypersensitivity reaction. Such a score would be useful in evaluating current and proposed tests for the diagnosis of suspected perioperative immediate hypersensitivity reactions and culprit agents. METHODS: We conducted a Delphi consensus process involving a panel of 25 international multidisciplinary experts in suspected perioperative allergy. Items were ranked according to appropriateness (on a scale of 1-9) and consensus, which informed development of a clinical scoring system. The scoring system was assessed by comparing scores generated for a series of clinical scenarios against ratings of panel members. Supplementary scores for mast cell tryptase were generated. RESULTS: Two rounds of the Delphi process achieved stopping criteria for all statements. From an initial 60 statements, 43 were rated appropriate (median score 7 or more) and met agreement criteria (disagreement index <0.5); these were used in the clinical scoring system. The rating of clinical scenarios supported the validity of the scoring system. Although there was variability in the interpretation of changes in mast cell tryptase by the panel, we were able to include supplementary scores for mast cell tryptase. CONCLUSION: We used a robust consensus development process to devise a clinical scoring system for suspected perioperative immediate hypersensitivity reactions. This will enable objectivity and uniformity in the assessment of the sensitivity of diagnostic tests.

Determination of the oxygen dissociation curve and P50 of whole blood. An evaluation of the Hem-O-Scan and instrumentation of laboratory systems.

The Travenol Hem-O-Scan and the Instrumentation Laboratory (IL) system for determination of the oxygen dissociation curve and P50 values have been evaluated. Using the Hem-O-Scan, an oxygen dissociation curve and P50 value may be obtained on 2 microliter of blood in 40 min, though the pH is not measured. In the IL system, approximately 3 ml of blood is required to establish four points on the oxygen dissociation curve in 80 min, and pH data are available. Both systems give reproducible results for P50, giving standard deviations of 0.786 mm Hg for the Hem-O-Scan and 0.949 mm Hg for the IL system, compared with 1.740 mm Hg for the manual system. Good agreement was found between the manual method and Hem-O-Scan (t = 0.363, degrees of freedom = 19, 0.8 greater than P greater than 0.7; r = 0.892, P less than 0.001). There was also satisfactory agreement between the IL system and the Hem-O-Scan (t = 0.370, degrees of freedom = 20, 0.8 greater than P greater than 0.7; r = 0.760, P less than 0.001). P50 values obtained by the manual and by both automated technics agree well with published values.

The in vitro effect of adenine on pyruvate kinase-deficient red cells.

In pyruvate kinase (PK)-deficient blood with high levels of reticulocytes, the degree of haemolysis after incubation at 37 degrees C for 48 h was halved by the inclusion of adenine in the medium. the decrease in haemolysis was associated with a higher ATP level but was not related to the pH of the incubation mixture. The incorporation of adenine into nucleotides studied over a 3 h period was similar in normal and PK-deficient blood. The observed increase in cellular ATP was equivalent to that shown by radioactive measurements to have been synthesized from added adenine. Inhibition of mitochondrial oxidative phosphorylation in the reticulocytes of the PK-deficient blood by KCN reduced the amount of adenine taken up by the cells by a factor of 3 and altered the pattern of incorporation into the nucleotides. Only 25% of the adenine which entered the blood cells was converted into ATP compared with 85% in the absence of cyanide. Despite the synthesis of small amounts of ATP from labelled adenine, the overall ATP content fell to less than 50% of its original level. It is suggested that incubation with adenine increased the ATP level in the reticulocytes by virtue of mitochondrial oxidative phosphorylation thereby reducing the haemolysis of these cells.

Temperature trends in total hip arthroplasty: a retrospective study.

The purpose of this study was to define the temporal trend in body temperature of patients during the first 5 days after total hip arthroplasty (THA). The medical records of 98 consecutive THAs were reviewed, 88 clinically uncomplicated cases were included. The average maximum temperature reached during the study period was 38.08 degrees C, a 3.7% (P< or =.01) increase from the preoperative base line of 36.64 degrees C. In this study, 62.5% of patients reached a temperature > or =38.0 degrees C; 19.3% > or = 38.5 degrees C; and 3.4% > or = 39.0 degrees C. No patients had a preoperative temperature of > or =38 degrees C recorded. On the first postoperative day, 39 patients had a temperature > or =38 degrees C. The number of febrile patients progressively decreased until by the fifth postoperative day, only 5 patients had a temperature > or =38 degrees C recorded.