Small volume vacuum phlebotomy tubes: a controlled before-and-after study of a patient blood management initiative in an Australian adult intensive care unit.

BACKGROUND: Patients admitted to intensive care units (ICUs) undergo multiple blood tests. Small volume vacuum phlebotomy tubes (SVTs) provide an important blood conservation measure. SVTs reduce summative blood loss and may reduce odds of transfusion. We aimed to determine whether low volume blood sampling using SVTs for routine diagnostic purposes translates to decreased fall in haemoglobin concentration, and examine downstream effects on anaemia and need for transfusion during ICU admission. STUDY DESIGN AND METHODS: A single-centre, controlled before-and-after study, evaluating a unit-wide changeover from conventional volume vacuum phlebotomy tubes (CVTs) to SVTs on April 2015. All ICU patients admitted for > 48 hours during the 12 months before and after the intervention were included in multivariate and univariate analysis. Groups were stratified into short admissions (2-7 days) and long admissions (> 7 days). RESULTS: A total of 318 patients were analysed. For short admissions, SVTs decreased fall in haemoglobin concentration (unstandardized coefficient, -6.7; P = 0.001) and episodes of severe anaemia (odds ratio, 0.37, P = 0.02). There were no changes to haemoglobin concentration in long admissions. No effects on need for transfusion were observed (short admissions, P = 0.05; long admissions, P = 0.11). SVTs reduced daily sampling volumes by 50% with no increase in laboratory error (short admissions, P = 0.61; long admissions, P = 0.98). A moderate correlation existed between blood draws and fall in haemoglobin concentration (short admissions, r = 0.5; long admissions, r = 0.32). CONCLUSION: SVTs reduce sampling volume without increasing laboratory error. Follow-on effects include reduced fall in haemoglobin concentration and severe anaemia. These correlations are absent in long admissions.

Bedside placement of an endobronchial valve to aid invasive ventilation and weaning from extracorporeal membrane oxygenation.

A bronchopleural fistula (BPF) is a life-threatening complication of cardiothoracic surgery and acute illness. There is no consensus on how best to treat a BPF. Recently, endobronchial one-way valves, designed for bronchoscopic lung volume reduction in emphysema, have been used to treat BPFs. We describe the use of an endobronchial oneway valve, placed at the bedside via flexible bronchoscopy, to treat a BPF in a patient with hypoxic respiratory failure, supported by extracorporeal membrane oxygenation (ECMO), secondary to pneumonia. We believe that this is the first published description of this technique being used in a patient needing ECMO support.

Late antibody-mediated rejection after heart transplantation following the development of de novo donor-specific human leukocyte antigen antibody.

BACKGROUND: Antibody-mediated rejection (AMR) is an important problem after heart transplantation. Most cases seem to occur in sensitized recipients with preformed donor-specific human leukocyte antigen antibody (DSA) early after transplantation. Few data exist on AMR in patients who form de novo DSA. We describe the clinical features and treatment outcome for late AMR secondary to de novo DSA. METHODS: This was a retrospective, observational cohort study. All heart transplant patients treated for symptomatic AMR secondary to de novo DSA between November 2005 and August 2011. RESULTS: Fifteen patients were treated for AMR giving an incidence of 3.1 cases per 1000 person years and a prevalence of 1.4%. All had evidence of heart failure on presentation and de novo DSA at diagnosis. There was a spectrum of histologic and immunohistochemical findings. Despite treatment with immunepheresis, intravenous immunoglobulin, and rituximab, and in some cases total lymph node irradiation (n=3) and bortezomib (n=2), clinical outcomes were poor. DSA antibody levels, measured using Labscreen single antigen kits, were reduced by a mean of 76% with a median of 77% and a range of 35% to 99%, but were not eliminated. Forty-six percent had persistent cardiac allograft dysfunction. Mean and median survival was 1.3 and 0.8 years after diagnosis of AMR. Only 40% were alive at the end of the study period. CONCLUSION: Late cardiac AMR caused by de novo DSA was an uncommon but serious problem. Despite treatment consistent with current best practice, 46% of patients developed persistent cardiac dysfunction and their medium-term survival was poor.

Concomitant pulmonary and hepatic toxicity secondary to nitrofurantoin: a case report.

BACKGROUND: Concomitant pulmonary and hepatic toxicity secondary to nitrofurantoin is a rare but serious complication of the use of Nitrofurantoin. CASE PRESENTATION: A 72 year old woman taking Nitrofurantoin for recurrent urinary sepsis presenting with breathlessness abdominal discomfort and abnormal liver function tests is described. Drug toxicity secondary to Nitrofurantoin was diagnosed. Cessation of the drug and a course of steroids markedly improved her condition. DISCUSSION: We review the drug reactions associated with Nitrofurantoin and suggest an alternative treatment strategy for recurrent urinary sepsis. CONCLUSION: Adverse drug reactions are an important cause of concomitant lung and liver toxicity and the mainstay of treatment is drug withdrawal.