Rapid infusion of additive red blood cells: alternative techniques for massive hemorrhage.

Additive red blood cells (RBCs) have replaced packed RBCs for treatment of massive hemorrhage in many medical centers. Modifications in transfusion apparatus and RBC viscosity were tested for their ability to provide rapid flow of additive RBCs. Infusions through standard transfusion tubing and three types of large-bore transfusion tubing were compared using three large-bore catheters, two infusion pressures, and additive RBCs of three different viscosities. More than 13 minutes were required to infuse 1 unit 4 C RBCs using current accepted practice (16-gauge catheter, standard tubing, gravity flow). The most rapid technique resulted in an infusion time of 20 +/- 1 seconds for 22 C blood. The addition of pressure infusion, large-bore tubing, or an 8F catheter to a transfusion system reduced infusion times up to 74%, 82%, and 85%, respectively. The combination of all three techniques resulted in a maximum improvement of 96%. Saline predilution and warming did not consistently provide clinically important differences in infusion time but may be important for avoidance of hypothermia. Spectrophotometric measurement of free hemoglobin demonstrated no clinically significant hemolysis secondary to rapid infusion. Clinical management should address potential hypocalcemia and coagulopathy. We conclude that large-bore tubing, pressure infusion, and an 8F catheter can provide important decreases in infusion time of additive RBCs without evidence of significant hemolysis.

Initial management of hand injuries in the emergency patient.

Failure to develop a proper routine for complete examination and documentation of the injured hand may result in the inability to make the proper diagnosis. Less than optimal treatment may result. Ultimately, the end result is unnecessary functional loss and, frequently, medical-legal difficulties. Initial emergency department management of acute hand is reviewed: recognition of surgical emergencies, proper initial treatment of tendon and nerve injuries, splinting, and record keeping are emphasized.

Local anesthetics.

Local anesthetics are remarkably useful agents that enhance patient comfort and improve patient compliance. Their use, however, requires an understanding of their action, proper dosages, potential risks, and treatment of reactions. We have presented the history, pharmacokinetics, action, risks of using, and ways in which agents are used to treat the most common agents, with notes on the special aspects of each agent. With the increased awareness that these are, indeed, not benign substances, we hope that serious reactions can be avoided by prophylactic measures and proper treatment in the early stages of toxicity.

Measurement of lactate in ascitic fluid: an aid in the diagnosis of peritonitis with particular relevance to spontaneous bacterial peritonitis of the cirrhotic.

Lactate concentrations were measured in the ascitic fluid of patients using the Monotest Lactate Kit, an inexpensive, reliable bedside test that gives results within 15 min. The values were significantly higher in 24 patients with proven bacterial peritonitis, eight of them with spontaneous bacterial peritonitis, than in 53 patients with uninfected ascites of various other etiologies. In only two patients from the latter group, both with hepatic carcinoma and peritoneal metastases, were the values in the range found in bacterial peritonitis. Lactate determination was at least as sensitive as measurement of WBC levels for diagnosing peritonitis. Serial determinations in two patients with peritonitis showed declining values as the disease responded to treatment. The test has particular relevance for patients with spontaneous bacterial peritonitis, because this disease, which is potentially life-threatening although frequently asymptomatic, requires immediate treatment, yet currently depends on time-consuming culture procedures for diagnosis.