Background Massive exchange-transfusion of 42-day-old red blood cells (RBCs) in a canine model of S. aureus pneumonia resulted in in vivo hemolysis with increases in cell-free hemoglobin (CFH), transferrin bound iron (TBI), non-transferrin bound iron (NTBI), and mortality. We have previously shown that washing 42-day-old RBCs before transfusion significantly decreased NTBI levels and mortality, but washing 7-day-old RBCs increased mortality and CFH levels. We now report the results of altering volume, washing, and age of RBCs. Study Design and Methods Two-year-old purpose-bred infected beagles were transfused with increasing volumes (5-10, 20-40, or 60-80 mL/kg) of either 42- or 7-day-old RBCs (n=36) or 80 mL/kg of either unwashed or washed RBCs with increasing storage age (14, 21, 28, or 35 days) (n=40). Results All volumes transfused (5-80 mL/kg) of 42-day-old RBCs, resulted in alike (i.e., not significantly different) increases in TBI during transfusion as well as in CFH, lung injury, and mortality rates after transfusion. Transfusion of 80 mL/kg of RBCs stored for 14, 21, 28 and 35 days resulted in increased CFH and NTBI in between levels found at 7 and 42 days of storage. However, washing RBCs of intermediate ages (14-35 days) does not alter NTBI and CFH levels or mortality rates. Conclusions Preclinical data suggest that any volume of 42-day-old blood potentially increases risks during established infection. In contrast, even massive volumes of 7-day-old blood result in minimal CFH and NTBI levels and risks. In contrast to the extremes of storage, washing blood stored for intermediate ages does not alter risks of transfusion or NTBI and CFH clearance.

In 15 anesthetized apneic, oxygenated rabbits we simultaneously measured pleural liquid and interstitial extrapleural parietal pressures by using catheters and/or cannulas and micropipettes connected to a servonull system. With the animal in lateral posture, at an average recording height of 4.4 +/- 0.9 (SD) cm from the most dependent part of the cavity, the extrapleural catheter and the pleural cannula yielded -2.5 +/- 0.6 and -5.5 +/- 0.2 cmH2O; the corresponding values for micropipette readings in the two compartments were -2.4 +/- 0.6 and -5.4 +/- 0.4 cmH2O, respectively (not significantly different from those measured with catheters and cannulas). In the supine animal, interstitial extrapleural catheter pressure data obtained at recording heights ranging from 15 to 80% of pleural cavity lay on the identity line when plotted vs. the micropipette pressure values simultaneously gathered from the same tissues. We conclude that 1) micropipettes and catheters-cannulas yield similar results when recording from the same compartment and 2) the hydraulic pressure in the parietal extrapleural interstitium is less negative than that in the pleural space.

Treatment of acute pain in chronic disease requires the physician to choose from an arsenal of pain management techniques tailored to the individual patient. Celiac plexus block and neurolysis are commonly employed for the management of chronic abdominal pain, especially in debilitating conditions such as cancer or chronic pancreatitis. The procedure is safe, well tolerated, and produces few complications. We present a case of pulmonary embolism following a celiac plexus block and neurolysis procedure. Further study is required to determine if celiac plexus ablation, alone or in combination with other risk factors, may contribute to increased risk for pulmonary embolism in patients seeking treatment for chronic upper abdominal pain conditions. W e present the fi rst known reported case of pulmonary embolism following a celiac plexus block and neurolysis procedure in the outpatient pain clinic setting. CASE PRESENTATIONA 23-year-old woman received a celiac plexus block with lidocaine and bupivacaine, followed by an ablation with 98% dehydrated alcohol diluted with Omnipaque 180 at the L1 level for pain related to chronic pancreatitis. Th e procedure was performed at an off -site pain management clinic. Within 20 minutes of beginning the procedure, the patient experienced a rapid onset of persistent, severe (10/10) right lateral chest pain with radiation to the center of her chest and below her right breast to the epigastric region, accompanied by dyspnea, palpitations, nausea, and vomiting.She arrived at our emergency department (ED) within 30 minutes of symptom onset. Similar pain had not occurred in the past. Apart from her chronic abdominal pain, she denied any fever, chills, wheezing, hemoptysis, extremity swelling or pain, traumatic injury, diarrhea, constipation, or diaphoresis. Th e patient had driven 4 to 5 hours to the off -site pain clinic on the day of presentation. Although she had no recent surgeries, she indicated she had multiple hospitalizations, often for days to weeks at a time, for treatment of chronic pancreatitis. Medications included hydrocodone-acetaminophen (5/325 mg) and etonogestrel, which was implanted 3 weeks before the day of admission. She denied any tobacco, alcohol, or drug use. No family members had venous thrombosis, blood clotting disorders, or vasculitis conditions. Upon arrival at the ED, her blood pressure was 130/100 mm Hg; heart rate, 116 beats/minute; respirations, 18 breaths/minute; pulse oximetry, 98%; and temperature 99.7°F (37.6°C). She was mildly distressed, alert, oriented (×3), and cooperative. Physical exam disclosed only splinting with chest wall breathing movement. An abdominal exam revealed only mild, chronic, epigastric tenderness to palpation. Upper and lower extremities appeared normal with good pulses. Th e neurologic exam was normal. A 12-lead electrocardiogram in the ED demonstrated sinus tachycardia at a rate of 104 beats/minute, a S1QT3 pattern, and additional inverted T waves in V2 to V5 with normal ST segments and normal axis. A chest radiograph showed...

Background A female patient known to have schizoaffective disorder self‐presented to an emergency department in a state of acute agitation and paranoia shortly after a 35‐day inpatient stay at a psychiatric facility. Case report The patient exhibited no signs or complaints of dyspnea or hypoxia, but later collapsed and became hypoxic after sleeping comfortably with sedation for 12 h in the psychiatric unit. She was intubated and a computed tomography angiogram revealed bilateral lobar pulmonary emboli and right heart strain. Conclusion Psychiatric hospitalizations, medications, diagnoses and relevant sequelae increase venous thromboembolism risk more than many realize.

Infusion dead space is the internal volume of a catheter and tubing through which a fluid must pass before reaching a patient's intravenous space. It is a factor in time to delivery for intravenous administration and can be significant, depending on the volume and rate of infusion. A 10-kg infant was simulated, receiving an epinephrine infusion with a concentration of 20 mcg/mL at a rate of 0.1 mcg/kg/min, which equals 3 mL/h. Commonly used pediatric intravenous equipment was selected. The tubing was flushed with a dyed solution. The setup was connected to 24-and 22-gauge catheters, with and without extension tubing. Each configuration was tested by allowing the intravenous solution to drip onto chromatography paper until color could be seen. The time from the start of the infusion to the visualization of dye was recorded 10 times for each configuration. The average time was 88 seconds for a 24-gauge catheter and 439 seconds with extension tubing added. For the 22-gauge catheter, the average time was 98 seconds and 431 seconds with extension tubing. Though often considered inconsequential, infusion dead space can cause significant delays in drug administration, especially in small patients and with slow, concentrated infusions. When appropriate, clinicians should consider bolus administration of critical medication before starting an infusion.