Letters to the Editor
Chlorhexidine mediated access site ulceration Sir, A 45‑year‑old female presented to our institution with an acute myocardial infarction. She required venoarterial extracorporeal membrane oxygenation (ECMO) and mechanical ventilation (for acute respiratory failure/ pulmonary edema). Her hospital course was further complicated by sepsis, acute renal failure, and amputation of her right lower extremity secondary to a vascular insult that resulted from ECMO cannula placement. She had no known allergies. Here we report a rare case of serious skin ulceration secondary to a chemical burn produced by the antiseptic chlorhexidine (CHL) at the placement site of a central venous catheter. The patient required central venous cannulation for fluids, inotropic/vasopressor support, monitoring, and renal dialysis. Her right and left internal jugular veins were accessed. Both catheters were removed and replaced in the same locations 1 week later when a fever occurred. Three days later, a necrotic ulcer was discovered at the hub of the right‑sided internal jugular vein catheter [Figure 1]. Due to concerns for infection, the catheter was removed. The patient’s access site had been treated with CHL at the time of each line placement and the dressing changed as per the intensive care unit protocol. The catheter tip was sent for culture, along with a small tissue sample from the ulcer. CHL use was discontinued because of a high index of suspicion regarding its etiology as the offending agent. Both cultures were reported as negative. Within 48 h the affected access site demonstrated substantial healing [Figure 2]. CHL is a synthetic bisguanide that is a low cost, highly efficacious microbiocide commonly used in surgical fields. It can cause hypersensitivity reactions with resultant ulceration, and is an allergen that can cause anaphylaxis. [1] CHL’s bactericidal capacity is unquestioned.[2] However, its ability to cause deleterious cytopathic effects on human cells in the laboratory is also well‑documented.[3] Recent literature indicates that the type of chemical injury that occurred in our patient is underrecognized, especially in the very young, the critically ill, and the immunosuppressed.[4] Whenever patients have dressings applied, whether they are CHL impregnated or simply a sterile dressing placed over an area of skin where a CHL scrub has 184
Figure 1: Chlorhexidine ulcer
Figure 2: Healing ulcer
been performed, there should be vigilant monitoring of the site. Prabhav S Patil, Aly D Branstiter, Ravi S Tripathi, Thomas J Papadimos
Department of Anaesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
Address for correspondence: Dr. Thomas J Papadimos, Department of Anaesthesiology, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Room N417C, Doan Hall Columbus, OH 43210, USA. E‑mail: [email protected]
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 2 | Apr-Jun 2014
Letters to the Editor
REFERENCES 1. 2. 3. 4.
Calogiuri GF, Di Leo E, Trautman A, Nettis E, Ferrannini A, Vacca A. Chlorhexidine hypersensitivity: A critical and updated review. J Allergy Ther 2013;4:4. Hodge D, Puntis JW. Diagnosis, prevention, and management of catheter related bloodstream infection during long term parenteral nutrition. Arch Dis Child Fetal Neonatal Ed 2002;87:F21‑4. Goldschmidt P, Cogen R, Taubman S. Cytopathic effects of chlorhexidine on human cells. J Periodontol 1977;48:212‑5. Weitz NA, Lauren CT, Weiser JA, LeBoeuf NR, Grossman ME, Biagas K, et al. Chlorhexidinegluconate‑impregnated central access
catheter dressings as a cause of erosive dermatitis: A report of 7 cases. JAMA Dermatol 2013;149:195‑9. Access this article online Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.134188
Paying medical bills at Kiosks in China: Is it a viable model for the USA? Sir, On a recent visit to the new FirstAffiliatedHospital, Wenzhou Medical College, Zhejiang, China, we were not only impressed by its bed capacity (3,250 beds) and equipment, but also by its innovative way to collect fees and provide services. Many of our conversations throughout our visit to the medical center were in regard to reimbursement. [1,2] Much to our surprise what we thought were ATM machines were, in fact, fee payment transaction systems (FPTS). Throughout the hospital there are 64 FPTS machines [Figure 1]. These devices have multiple screens that direct payments to the proper area/code for services rendered. These machines take cash, credit cards, national hospital cards, and private insurance cards. They are used for many services. Deposits are made prior to the provision of clinical/medical, surgical, or laboratory services. The FPTS is also used for downloading medication prescriptions. Prescriptions from the “essential” list are free; a listing of government sponsored generic drugs. If a medication is imported there must be prepayment for it. Also, if the patient chooses, he/she may select the drugs for which they can afford to pay,
Figure 1: Fee payment transaction system, First Affiliated Hospital, Wenzhou, Zhejiang, China
that is, if the patient’s physician has written for drugs from the imported medications list. The FPTS also prints laboratory results and is used for clinic registration and same day surgeries. All medical insurance cards sanctioned by the government can be used. Certain services require higher levels of insurance, such as cardiac surgery. In other words, a copayment is needed. The government encourages use of local medical services before receiving care from a provincial capital (usually a larger hospital/medical center). As a patient seeks care at a larger facility, a higher a percentage of the patient’s bill will be borne by the individual. The Chinese national medical card requires no password for its use. This could present a problem if lost, but officials deny they have privacy violations to any significant degree. If the insurance card is lost, the patient can get another by presenting a driver’s license or an identity card at the nearest hospital. If for some reason they do not have a health insurance card they must go the emergency department for care. In this era of electronic media use in American medicine, there may be an opportunity in personnel savings if these types of transaction systems were in place. It would be interesting to explore the possibility. While the FPTS may be perceived to work better for the clinic system, it is within the near term realm of possibility to initiate and eventually perfect this approach in the USA for inpatient use, especially in view of the fact that US medicine is going to “bundled” payments in this upcoming era of ObamaCare. Before dismissing this approach out of hand, a serious discourse about its possibility/probability should be pursued by the appropriate information technology
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 2 | Apr-Jun 2014
185
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Chlorhexidine mediated access site ulceration Sir, A 45‑year‑old female presented to our institution with an acute myocardial infarction. She required venoarterial extracorporeal membrane oxygenation (ECMO) and mechanical ventilation (for acute respiratory failure/ pulmonary edema). Her hospital course was further complicated by sepsis, acute renal failure, and amputation of her right lower extremity secondary to a vascular insult that resulted from ECMO cannula placement. She had no known allergies. Here we report a rare case of serious skin ulceration secondary to a chemical burn produced by the antiseptic chlorhexidine (CHL) at the placement site of a central venous catheter. The patient required central venous cannulation for fluids, inotropic/vasopressor support, monitoring, and renal dialysis. Her right and left internal jugular veins were accessed. Both catheters were removed and replaced in the same locations 1 week later when a fever occurred. Three days later, a necrotic ulcer was discovered at the hub of the right‑sided internal jugular vein catheter [Figure 1]. Due to concerns for infection, the catheter was removed. The patient’s access site had been treated with CHL at the time of each line placement and the dressing changed as per the intensive care unit protocol. The catheter tip was sent for culture, along with a small tissue sample from the ulcer. CHL use was discontinued because of a high index of suspicion regarding its etiology as the offending agent. Both cultures were reported as negative. Within 48 h the affected access site demonstrated substantial healing [Figure 2]. CHL is a synthetic bisguanide that is a low cost, highly efficacious microbiocide commonly used in surgical fields. It can cause hypersensitivity reactions with resultant ulceration, and is an allergen that can cause anaphylaxis. [1] CHL’s bactericidal capacity is unquestioned.[2] However, its ability to cause deleterious cytopathic effects on human cells in the laboratory is also well‑documented.[3] Recent literature indicates that the type of chemical injury that occurred in our patient is underrecognized, especially in the very young, the critically ill, and the immunosuppressed.[4] Whenever patients have dressings applied, whether they are CHL impregnated or simply a sterile dressing placed over an area of skin where a CHL scrub has 184
Figure 1: Chlorhexidine ulcer
Figure 2: Healing ulcer
been performed, there should be vigilant monitoring of the site. Prabhav S Patil, Aly D Branstiter, Ravi S Tripathi, Thomas J Papadimos
Department of Anaesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
Address for correspondence: Dr. Thomas J Papadimos, Department of Anaesthesiology, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Room N417C, Doan Hall Columbus, OH 43210, USA. E‑mail: [email protected]
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 2 | Apr-Jun 2014
Letters to the Editor
REFERENCES 1. 2. 3. 4.
Calogiuri GF, Di Leo E, Trautman A, Nettis E, Ferrannini A, Vacca A. Chlorhexidine hypersensitivity: A critical and updated review. J Allergy Ther 2013;4:4. Hodge D, Puntis JW. Diagnosis, prevention, and management of catheter related bloodstream infection during long term parenteral nutrition. Arch Dis Child Fetal Neonatal Ed 2002;87:F21‑4. Goldschmidt P, Cogen R, Taubman S. Cytopathic effects of chlorhexidine on human cells. J Periodontol 1977;48:212‑5. Weitz NA, Lauren CT, Weiser JA, LeBoeuf NR, Grossman ME, Biagas K, et al. Chlorhexidinegluconate‑impregnated central access
catheter dressings as a cause of erosive dermatitis: A report of 7 cases. JAMA Dermatol 2013;149:195‑9. Access this article online Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.134188
Paying medical bills at Kiosks in China: Is it a viable model for the USA? Sir, On a recent visit to the new FirstAffiliatedHospital, Wenzhou Medical College, Zhejiang, China, we were not only impressed by its bed capacity (3,250 beds) and equipment, but also by its innovative way to collect fees and provide services. Many of our conversations throughout our visit to the medical center were in regard to reimbursement. [1,2] Much to our surprise what we thought were ATM machines were, in fact, fee payment transaction systems (FPTS). Throughout the hospital there are 64 FPTS machines [Figure 1]. These devices have multiple screens that direct payments to the proper area/code for services rendered. These machines take cash, credit cards, national hospital cards, and private insurance cards. They are used for many services. Deposits are made prior to the provision of clinical/medical, surgical, or laboratory services. The FPTS is also used for downloading medication prescriptions. Prescriptions from the “essential” list are free; a listing of government sponsored generic drugs. If a medication is imported there must be prepayment for it. Also, if the patient chooses, he/she may select the drugs for which they can afford to pay,
Figure 1: Fee payment transaction system, First Affiliated Hospital, Wenzhou, Zhejiang, China
that is, if the patient’s physician has written for drugs from the imported medications list. The FPTS also prints laboratory results and is used for clinic registration and same day surgeries. All medical insurance cards sanctioned by the government can be used. Certain services require higher levels of insurance, such as cardiac surgery. In other words, a copayment is needed. The government encourages use of local medical services before receiving care from a provincial capital (usually a larger hospital/medical center). As a patient seeks care at a larger facility, a higher a percentage of the patient’s bill will be borne by the individual. The Chinese national medical card requires no password for its use. This could present a problem if lost, but officials deny they have privacy violations to any significant degree. If the insurance card is lost, the patient can get another by presenting a driver’s license or an identity card at the nearest hospital. If for some reason they do not have a health insurance card they must go the emergency department for care. In this era of electronic media use in American medicine, there may be an opportunity in personnel savings if these types of transaction systems were in place. It would be interesting to explore the possibility. While the FPTS may be perceived to work better for the clinic system, it is within the near term realm of possibility to initiate and eventually perfect this approach in the USA for inpatient use, especially in view of the fact that US medicine is going to “bundled” payments in this upcoming era of ObamaCare. Before dismissing this approach out of hand, a serious discourse about its possibility/probability should be pursued by the appropriate information technology
International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 2 | Apr-Jun 2014
185
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
