Answering your questions: iodine disinfectant for infants, biohazard waste transport and stroke work-up. (Tips From the Clinical Experts).Iodine disinfectant for infants In the January 2002 MLO MLO Mycoplasma-like organism(s) "Tips from the clinical experts," p. 25, a question was asked in regard to site preparation for infant blood cultures. In the response, a statement was made that, "For patients who may be allergic to iodine compounds, chlorhexidine chlorhexidine /chlor·hex·i·dine/ (klor-heks´i-den) an antibacterial effective against a wide variety of gram-negative and gram-positive organisms; used also as the acetate ester, as a preservative for eyedrops, and as the gluconate or solutions have been shown to be exceptionally bactericidal bactericidal /bac·te·ri·ci·dal/ (bak-ter?i-si´d'l) destructive to bacteria. Bactericidal An agent that destroys bacteria (e.g. ." My questions are: 1. Is the chlorhexidine solution safe to use as a blood-culture prep for neonates/infants? 2. According to manufacturers, iodine has been noted as being highly absorbed and linked to hypothyroidism hypothyroidism: see thyroid gland. in the very young infant. Do you have any recommendations on using iodine on infants? 3. If these solutions are not recommended for premature and neonates, what site preparation would you recommend for blood cultures? A The Association for Women's Health, Obstetric and Neonatal Nurses and the National Association of Neonatal Nurses (AWHONN/NANN) has established a guideline on infant skin care based on a literature review published in the Journal of Obstetrical and Gynecological gynecological /gy·ne·co·log·i·cal/ (-kah-loj´i-k'l) gynecologic. Neonatal Nursing. (1,2) The literature review unearthed studies comparing chlorhexidine, isopropyl alcohol and povidone-iodine as skin disinfectants in adults and showed that chlorhexidine was the most effective skin disinfectant in reducing catheter-related infections. It also discovered research showing that alcohol-containing disinfectants cause the greatest amount of permanent tissue damage in study animals compared to povidone-iodine. Finally, the literature review found evidence that when povidone-iodine compounds are used for skin disinfection disinfection, n the process of destroying pathogenic organisms or rendering them inert. disinfection, full oral cavity, n a procedure used to reduce active periodontal disease, usually completed within a certain short time frame. , infants can demonstrate elevations in serum iodine levels, increased urinary excretion of iodine and potential systemic thyroid effects. No mention was made of the effects of chlorhexidine absorption. Keep in mind that this guideline has not yet worked itself into the phlebotomy Phlebotomy Definition Phlebotomy is the act of drawing or removing blood from the circulatory system through a cut (incision) or puncture in order to obtain a sample for analysis and diagnosis. literature or standards, but is worthy of consideration. A study of facilities that have implemented the guideline concludes that promoting an intact skin surface may reduce systemic infection in the vulnerable neonatal population. (3) Therefore, the guideline recommends chlorhexidine and povidone-iodine as skin decontaminants on neonates, but proposes that the solutions be removed with sterile saline solution or water (instead of alcohol preps) to prevent absorption. Some manufacturers of prep kits containing chlorhexidine, however, do not recommend using it on infants less than two months old, so be sure to follow the product literature accompanying any prep solution. Dennis Ernst, MT(ASCP ASCP American Society of Clinical Pathologists. ) Director The Center for Phlebotomy Education Inc. Ramsey. IN References (1.) Lund C, Kuller J, Lane A, Lott W, et al. Neonatal akin care: the scientific basis for practice. JOGNN JOGNN Journal of Obstetric, Gynecologic, and Neonatal Nursing . 1999;28(3):241-254. (2.) Alcohol Discouraged as Skin Prep on Infants. Phlebotomy Today 2002;3(1). www.phlebotomy.com/Newsl0201.htm. Accessed June 12, 2002. (3.) Lund C, Osborne J, Kuller J, Lane A, et al. Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. JOGNN. 2001;30(1):41-51. Biohazard bi·o·haz·ard n. 1. A biological agent, such as a virus or a condition that constitutes a threat to humans, especially in biological research or experimentation. 2. waste transport Q Our hospital puts specimen tubes and containers in bags (secondary containers) to transport them within the hospital. We currently use specimen bags with biohazard labels. Can labs put these specimen bags with biohazard labels into regulated waste if no contamination with blood or body fluids is visible? Do we even need to be using specimen bags with biohazard labels? I have been told that we could just use a standard Ziploctype bag for transporting specimens within the facility and that this could be a substantial cost savings to the hospital. Could this unmarked bag be discarded in the regular trash? A Many waste facilities audit incoming waste to be sure that bio-hazardous waste is not present. The presence of a biohazard labeled bag, even if clean and uncontaminated, would raise a red flag. Bags used to carry specimen containers do not need to have biohazard labels. As long as they remain clean and do not become contaminated with body fluids, they may be discarded in regular trash. This saves money, both in the lower cost of the bags and the reduction of regulated waste. In our hospital, we spend 28 cents a gallon to dispose of To determine the fate of; to exercise the power of control over; to fix the condition, application, employment, etc. of; to direct or assign for a use. See also: Dispose biohazardous waste, and approximately $75 a ton to dispose of regular trash! Daniel M. Baer, MD Professor Emeritus Department of Pathology Oregon Health and Science University Portland, OR Stroke work-up Q We are currently trying to update/standardize the order sets for stroke patients. Both the ASA Asa (ā`sə), in the Bible, king of Judah, son and successor of Abijah. He was a good king, zealous in his extirpation of idols. When Baasha of Israel took Ramah (a few miles N of Jerusalem), Asa bought the help of Benhadad of Damascus and and another reference cite ESRs as part of the standard blood work. Why wouldn't a GRIP be more appropriate? I have long been a fan of the use of GRIP (I'm an ancient med tech) and remember the classic paper that Dr. Nakamura published regarding use of CRP C-reactive protein (CRP) A protein present in blood serum in various abnormal states, like inflammation. Mentioned in: Pelvic Inflammatory Disease CRP, n.pr See C-reactive protein. as an indicator of inflammation instead of temp, ESR ESR - Eric S. Raymond or WBC WBC white blood cell; see leukocyte. WBC abbr. white blood cell WBC, n stands for white blood cell. -- and this was before the ultra-sensitive tests were available. A Both the erythrocyte sedimentation rate Erythrocyte Sedimentation Rate Definition The erythrocyte sedimentation rate (ESR), or sedimentation rate (sed rate), is a measure of the settling of red blood cells in a tube of blood during one hour. (ESR) and C-reactive protein (CRP) should be included in the standard work-up for stroke patients. Below are the studies which support the usefulness of ESR and CRP. * ESR and strokes: The ESR has been shown to be a risk factor for the development of strokes. (1,2,3) Also, the ESR is an independent predictor of short-term stroke outcome. (3) One of the popular ESR methods is the Westergren method, which has been reported to be marginally affected by age, race and blood storage. (4) * C-reactive protein in cardiovascular diseases: CRP is an acute-phase serum protein primarily produced in the liver and is a marker for acute inflammatory response. With the development of sensitive assays for CRP, (5) many studies have shown that CRP is an independent risk factor for coronary heart disease coronary heart disease: see coronary artery disease. coronary heart disease or ischemic heart disease Progressive reduction of blood supply to the heart muscle due to narrowing or blocking of a coronary artery (see atherosclerosis). , peripheral vascular disease Peripheral Vascular Disease Definition Peripheral vascular disease is a narrowing of blood vessels that restricts blood flow. It mostly occurs in the legs, but is sometimes seen in the arms. , atherosclerotic disease and stroke. (6,7,8) The high-sensitivity CRP assay has prognostic utility in patients with acute coronary heart disease and is a strong independent predicator Noun 1. predicator - an expression that predicates grammatical construction, construction, expression - a group of words that form a constituent of a sentence and are considered as a single unit; "I concluded from his awkward constructions that he was a foreigner" of future coronary events in apparently healthy persons. (7) * CRP and cerebrovascular diseases: Ford & Giles (9) have reported that CRP concentration may be a risk factor or marker for stroke in the U.S. population. Other investigators have shown that an elevated CRP is a marker of increased risk in ischemic stroke (10) and fatal strokes in elderly persons. (11,12) The increased levels of CRP were found to be associated with a poor outcome in patients with ischemic stroke. (13) Associated with elevated CRP levels in strokes, there has been reported an activation of the coagulation/fibrinolysis system (14) and elevated fibrinogen Fibrinogen The major clot-forming substrate in the blood plasma of vertebrates. Though fibrinogen represents a small fraction of plasma proteins (normal human plasma has a fibrinogen content of 2–4 mg/ml of a total of 70 mg protein/ml), its conversion levels. (13) In contrast to the above reports on the value of GRP GRP Group GRP Group (file name extension) GRP Glass Reinforced Plastic GRP Gastrin-Releasing Peptide (biology) GRP Gross Rating Point (advertising) determination in strokes, Canova, et al, (15) have studied 138 patients with cerebrovascular cer·e·bro·vas·cu·lar adj. Relating to the blood supply to the brain, particularly with reference to pathological changes. cerebrovascular pertaining to the blood vessels of the cerebrum or brain. events and concluded that CRP is not a useful marker to predict the outcome of an acute cerebrovascular event in hospital. Canova, et al, (15) stated there was no relationship between time intervals since onset of symptoms and GRIP measurement. They suggested that an acute cerebrovascular event has little influence on GRIP values. The studies by Canova and coworkers were done on patients admitted to the hospital for an acute cerebrovascular event and were prospectively studied. The Canova study (15) was not designed as the other studies which determined elevated GRP as a risk factor for ischemic strokes, (11,12,13) and for ischemic Ischemic An inadequate supply of blood to a part of the body, caused by partial or total blockage of an artery. Mentioned in: Antiangiogenic Therapy, Subarachnoid Hemorrhage, Ventricular Fibrillation ischemic and fatal strokes in elderly persons. (11,12) In strokes and cerebrovascular diseases, there are elevations of both CRP and ESR. Also, there is activation of the coagulation/fibrinolysis system and elevated fibrinogen levels. The ESR is influenced greatly by the levels of fibrinogen and the coagulation coagulation (kōăg'y  lā`shən), the collecting into a mass of minute particles of a solid dispersed throughout a liquid (a sol), usually followed by the precipitation or system.
The suggestion of adding CRP assays to the order sets for stroke patients is an excellent one. In addition, the ESR is also helpful. Each of the assays for CRP and ESR may indicate that there is deviation from the "normal" physiological state of the patient, such as acute inflammation or a change in coagulation system. Robert M. Nakamura, MD Chairman Emeritus and Senior Consultant Department of Pathology Scripps Clinic La Jolla, CA References (1.) Adolfsson R, Svardudd K, Tibblin G. 1913 men study -- a longitudinal study of the development of stroke in a population. Scand J Soc Med Suppl. 1977;14:122-127. (2.) Gillum RF, Sempos CT. Erythrocyte sedimentation rate and stroke incidence in the NHANES NHANES National Health and Nutrition Examination Survey (US CDC) Epidemiologic Follow-up Study. Stroke. 1997 Apr; 28(4):873-874. Comment on: Stroke. 1996 Nov; 27(11): 999-2604. (3.) Chamorro A, Vila N, Ascaso C, Saiz A. Montalvo J, Alonso P. et al. Early prediction of stroke severity. Role of the erythrocyte sedimentation rate. Stroke 1995 Apr; 26(40): 573-576. (4.) Saadeh C. The erythrocyte sedimentation rate: old and new clinical applications. South Med J. 1996 Mar; 92(3): 220-225. (5.) Rifai N. Ridker PM. High-sensitivity C-reactive protein: a novel and promising marker of coronary heart disease. Clin Chem 2001 Mar; 47(3): 493-411. (6.) Albert MA. The role of C-reactive protein in cardiovascular disease risk. Curr Cardiol Rep. 2000 Jul: (24): 274-279. (7.) Albert MA, Ridker PM. The role of C-reactive protein in cardiovascular disease risk. Curr Cardiol Rep. 1999 Jul; 1(2): 99-104. (6.) Folsom AR, Pankow JS, Tracy RP, Arnett DK, Peacock JM, Hong Y, et al. The Investigators of the NHBLI Family Heart Study. Association of C-reactive protein with markers of prevalent atherosclerotic disease. Am J. Cardiol. 2001 Jul 15; 88(2): 112 117. (9.) Ford ES, Giles WH. Serum C-reactive protein and self-reported stroke: findings from the NHANES III Arterioscler Thromb Vesc Biol. 2000 Apr; 20_4):1052- 1056. (10.) Di Napoli M, Pupa F. Bocola V. C-reactive protein in ischemic stroke: an independent prognostic factor. Stroke 2601 Apr; 32(4): 917-924. (11.) Gussekloo J. Schaap MC. Frolich M, Blauw GJ, Westendorp RG. C-reactive protein is a strong hut nonspecific risk factor of fatal stroke in elderly persons. Arterioscler Thromb Vasc Biol 2000 Apr; 20(40):1047-1051. (12.) Rost NS, Wolf PA, Kase CS, Kelly-Hayes M, Silbershatz H, Massaro JM, et al. Plasma concentration of C-reactive protein and risk of ischemic stroke and transient ischemic attack Transient Ischemic Attack Definition A transient ischemic attack, or TIA, is often described as a mini-stroke. Unlike a stroke, however, the symptoms can disappear within a few minutes. : the Framingham study. Stroke 2001 Nov; 32 (11):2575-2579. (13.) Di Napoli M, Papa F. Bocola V. Prognostic influence of increased C-reactive protein and fibrinogen levels in ischemic stroke. Stroke 2001 Jan; 32(1): 133-136. (14.) Tohgi H, Konno S, Takahashi S, Koizumi O, Kondo R, Takahashi H. Activated coagulation/fibrinolysis system and platelet function in acute thrombotic stroke patients with increased C-reactive protein levels. Thromb Res 2000 Dec 1:100 (5):373-379. (15.) Canova CR, Courtin C, Reinhart WH. C-reactive protein (CRP) in cerebrovascular events. Atherosclerosis 1999 Nov 1: 147 (1):49-53. Daniel M. Baer is professor emeritus of laboratory medicine at Oregon Health and Science University in Portland, OR, and a member of MLO's editorial advisory board. |
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