Downs JB, Chapman RL. Treatment of bronchopleu- ral fistula .... Ann Intern Med 1973; 79:867-887. 6. Peter G, Lloyd-Still JD, Lovejoy FH Jr. Local infection.
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High frequency, positive-pressure jet ventilation in bilateral bronchopleural fistula. Crit Care Med 1982; 10:119-121. 3. Zimmerman JE, Dunbar BS, Klingenmaier CH. Management of subcutaneous emphysema, pneumomediastinum and pneumothorax during respiratory therapy. Crit Care Med 1975; 3:69-73. 4. National Heart and Lung Institute, Division of Lung Diseases: Manual of Operation for Extracorporeal Support for Respiratory Insufficiency. Bethesda, Md, National Institute of Health, 1974. 5. Downs JB, Chapman RL. Treatment of bronchopleural fistula during continuous positive pressure ventilation. Chest 1976; 69:363-365. 6. Phillips YY, Lonigan RM, Joyner LR. A simple technique for managing a bronchopleural fistula while maintaining positive-pressure ventilation. Crit Care Med 1979; 7: 351-353. 7. Gallagher TJ, Smith RA, Kirby RR, Civetta JM. Intermittent inspiratory chest tube occlusion to limit bronchopleural cutaneous air leaks. Crit Care Med 1976; 4:328-332. 8. Ratliff JL, Hill JD, Tucker H, Fallat R. Endobronchial control of bronchopleural fistula. Chest 1977; 71:98-99.
9. Dennison PH, Lester ER. An anesthetic technique for the repair of bronchopleural fistula. Br J Anaesth 1961; 33:655-659. 10. Francis JG, Smith KG. An anesthetic technique for the repair of bronchopleural fistula. Br J Anaesth 1962; 34: 81 7-821. 11. Sjostrand U. High frequency, positive-pressure ventilation (HFPPV): A review. Crit Care Med 1980; 80:345-363. 12. Carlon GC, Kahn RC, Howland WS, et al. Clinical experience with high frequency jet ventilation. Crit Care Med 1981; 9:1-6. 13. Klain M, Smith RB. High frequency percutaneous transtracheal jet ventilation. Crit Care Med 1977; 5:280-287. 14. Butler WJ, Bohn DJ, Bryan AC, Froese AB. Ventilation by high frequency oscillation in humans. Anesth Analg (Cleve) 1980; 59:577-583. 15. Bohn DJ, Miyasaka K, Marchak BE, et al. Ventilation by high frequency oscillation. J Appl Physiol 1980; 48: 710-716. 16. Klain M, Smith RB, Babinski M. High frequency ventilation-An alternative to IMV? Crit Care Med 1978; 6:95-96.
HAEMOPHILUS INFLUENZAE SEPTIC THROMBOPHLEBITIS FOLLOWING USE OF A "SCALP.VEIN" NEEDLE Vincent 1. Ahonkhai, MD, Yasmin Bhasin, MD, Senih M. Fikrig, MD, Joseph Fitzgerald, MD, and Robert Cafone, PA Brooklyn, New York
Indolent Haemophilus influenzae type B septic thrombophlebitis developed in a 14-year-old boy two weeks after completing a course of intravenous antibiotics administered via a "scalp-vein" needle for an unrelated infection. Presumably, the primary disease (common variable immunodeficiency) contributed to the simultaneous occurrence of this unFrom the Departments of Pediatrics and Surgery, SUNYDownstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York. Requests for reprints should be addressed to Dr. Vincent I. Ahonkhai, Merck Sharp and Dohme Research Laboratories, West Point, PA 19486.
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common complication of scalp-vein needle use, with an unusual pathogen. Septic thrombophlebitis is usually associated with prolonged use of intravenous (IV) polyethylene catheter devices or with dermal infections in close proximity to an IV site. I The condition is less frequently reported in children than in adults, possibly because IV catheters are used more often in the latter population. The authors recently treated an adolescent male with Haemophilus influenzae septic thrombophlebitis, apparently unrelated to the aforementioned factors, but following
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the use of an IV "scalp-vein" steel needle. This case is presented because neither a report of septic thrombophlebitis caused by this organism nor the association of septicemia with scalp-vein needle in a pediatric patient could be found in the literature.
CASE REPORT A 14-year-old black male known to have common variable immunodeficiency (CVI) presented to the clinic in State University Hospital (SUH) with a swelling of the right upper limb for one week. The swelling was accompanied by local pain, tenderness, and slight limitation of movement. He had no fever or systemic symptoms. Three weeks previously he had been admitted to SUH for meningococcal septic arthritis of the left ankle. His treatment included a 14-day course of IV penicillin administered through scalp-vein needles inserted in multiple sites on his hands and forearms. He recovered slowly but completely, and was discharged home without significant phlebitis in his arms. At the end of one week he returned to the clinic. Examination on admission showed a welldeveloped 14-year-old boy who looked fairly comfortable, but with his right arm held in flexion at the elbow. His temperature was 36.6' C (98.2' F). His right arm, forearm, and hand were markedly swollen and moderately tender. There was a hemangioma-like engorgement on the right thumb and a cord-like induration was palpated along the anterior part of the right foream. It extended through the medial aspect of the arm into the axilla. His radial pulses were normal, and the rest of the physical examination revealed no other
abnormality. Laboratory studies included a white blood cell count of 6,300/mm3 with 39 percent neutrophils and 2 percent band forms. A blood culture grew H influenzae type B that produced beta lactamase, and was resistant to ampicillin but susceptible to chloramphenicol. Culture of the subcutaneous aspirate from the engorged right thumb showed no growth and roentgenogram of the right upper limb was normal. Thrombophlebitis of the right basilar and axillary veins was noted in Doppler studies. Immunologic data are summarized in Table 1. He was treated intravenously with chloramphenicol (2 g/day) and a heparin infusion for 14 days, as well
TABLE 1. IMMUNOLOGICAL DATA
Serum IgG-380 mg/dL; IgM-62 mg/dL; IgA-0 mg/dL Total B cells (polyvalent serum) IgG IgM IgA Total T cells Fc receptor with aggregate Ripley test la positive cells Mitogen response to PHA, Con-A
0.0% 0.0% 0.5% 0.5% 85.0% 7.0% 11.5% 3.0% Normal
as one dose of intramuscular gamma globulin, 0.7 mL/kg. Repeat blood cultures two days after starting antibiotic therapy showed no growth and Doppler studies after two weeks revealed complete resolution of thrombophlebitis, and the patient was discharged.
DISCUSSION Thrombophlebitis, an inflammatory condition of the vein sometimes followed by palpable thrombosis, is a common complication of intravenous infusions, resulting from physicochemical trauma to the endothelium. Its development has been associated with certain factors including increasing age, prolonged duration of infusion, obstruction to venous blood flow (as in ligation of the distal segment of a vein during cut down), acid pH of an infusion solution, anesthetic drugs, and other irritating agents.2-4 Septic thrombophlebitis, a condition in which the pathology mentioned above is complicated by bacterial infection, sometimes with bacteremia, is frequently a problem of intravenous plastic catheters, cannulas and, rarely, scalp-vein needles.; Although culture-positive catheter tips (not necessarily to be equated with infection) have been noted in 8.4 percent6 to 41.2 percent7 of pediatric patients, associated bacteremic infections have not been reported, to the authors' knowledge. In a series reported by Zinner et al,8 the seven patients in whom (bacteremic) septic thrombophlebitis was associated with IV scalp-vein needles were all
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adults. The disease in this study's patient accordingly represents an uncommon occurrence. Another unusual feature was the etiologic pathogen, which in this case was H influenzae. A review of the literature on the microbiology of septic thrombophlebitis or IV device microbial colonization shows that while many different organisms are incriminated, Staphylococcus and KlebsiellaEnterobacter are the most common.9 There is no mention of H influenzae in any of these reports. Since CVI produces a state of increased susceptibility to bacterial infections, it may not be surprising that this patient developed a bacterial infection. However, one would suspect that the pathogen in such an infection might be a common skin contaminant, with the potential of colonizing an IV site (and IV catheter, usually) and subsequently progressing to a focus of infection. While the patient's primary disease may explain some of these issues, to what extent it explains all of them is unclear. The infection in this patient was rather indolent, with perhaps a fairly good chance of being missed. A diligent and all-embracing approach
to management (sometimes including surgery) of such a case is always helpful. Literature Cited 1. Norden CW. Septic thrombophlebitis. In: Hoeprich P, ed. Infectious Diseases, ed 2. Hagerstown, Md: Harper & Row, 1977, pp 1012-1016. 2. Hastbacka J, Timmisto T, Elfving G, Tiitinen P. Infusion thrombophlebitis. A clinical study based on 1048 cases. Acta Anesthesiol Scand 1965; 10:9-30. 3. Enger E, Jacobsson B, Sorensen SF. Tissue toxicity of intravenous solutions. A phlebographic and experimental study. Acta Pediatr Scand 1976; 65:248-252. 4. Fonkalsrud EW. Postinfusion phlebitis in infants and children. How to avoid this complication. Clin Pediatr (Phila) 1969; 8:135-136. 5. Maki DG, Goldman DA, Frank SR. Infection control in intravenous therapy. Ann Intern Med 1973; 79:867-887. 6. Peter G, Lloyd-Still JD, Lovejoy FH Jr. Local infection and bacteremia from scalp-vein needles and polyethylene catheters in children. J Pediatr 1972; 80:78-83. 7. Lloyd-Still JD, Peter G, Lovejoy FH Jr. Infected "scalp-vein" needles. JAMA 1970; 213:1496-1497. 8. Zinner MJ, Zuidema GD, Lowery BD. Septic nonsuppurative thrombophlebitis. Arch Surg 1976; 111:122-125. 9. Moran JM, Rogar PA, Rowe Ml. A clinical and bacteriologic study of infections associated with venous cut downs. N EngI J Med 1965; 272:554-560.
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