summarizes errors Rev 1.02 that can occur in Visit www.albertaprecisionlabs.ca for the most current version of this document for the most current version of this document PX-SC250 Phlebotomy Related Risk - Attachment 1 Factors Affecting Blood Test ResultsPage 1 of 3 GTS 2 3 This content is owned by the AAFP. Chang et al There is no typical presentation or pathognomonic signs and symptoms of hereditary hemochromatosis. It is characterized by erythrocytosis, often with associated leukocytosis and thrombocytosis. All rights reserved. Sign up for free and stay up to date on research advancements, health tips, current health topics, and expertise on managing health. HHS Vulnerability Disclosure, Help Nearly half of the patients in both groups were male, and 80% were white race. Received 2021 Nov 3; Revised 2022 Jan 15; Accepted 2022 Jan 18. All people who have polycythemia vera without contraindications should take daily low-dose aspirin (40 to 100 mg). 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Covariates associated with the outcome variable in crude analyses at = 0.1 were included in a multivariable logistic regression model. Polycythemia vera (pol-e-sy-THEE-me-uh VEER-uh) is a type of blood cancer. Physicians may refer patients to a specialty laboratory for this study. Copyright 2023 American Academy of Family Physicians. 8600 Rockville Pike We sought to identify patient-related factors that contribute to blood culture contamination in hospitalized patients. IntroductionApproximately 40% of patients with acute low back pain (LBP) develop chronic low back pain, which significantly increases the risk of poor prognosis. Inclusion in an NLM database does not imply endorsement of, or agreement with, Agents under investigation include interferon alfa-2b, anagrelide, and aspirin. The U.S. Food and Drug Administration (FDA) is responsible for ensuring safety of . Cuthbert D, et al. Annals of Hematology. Patients in a critical condition had higher odds of having contaminated blood cultures, and this has been observed in other studies. Copyright 2021 by the American Academy of Family Physicians. Currently, no medications have been shown to cure the disease or to reduce the risk of conversion to leukemia and myelofibrosis. Chest pain with shortness of breath can mean a possible pulmonary embolism. Patients in this group stand to gain from the benefit of lower early thrombosis rates with myelosuppressive medications. 2.Phlebotomy - standards. Polycythemia vera is rare. Norberg A, Christopher NC, Ramundo ML, Bower JR, Berman SA. Variables such as race, marital status, health insurance and BMI had <5% missing data. We observed a significant association between COPD and contamination of blood cultures (AOR, 1.67; 95% CI, 1.202.34) as was also noted in the study by Klucher et al. For example, Blacks are more likely to develop early-onset COPD, which puts them at higher odds of blood culture contamination. To provide you with the most relevant and helpful information, and understand which information is beneficial, we may combine your email and website usage information with other information we have about you. Contaminated blood cultures result in extended hospital stays and unnecessary antibiotic therapy. The liver, pancreas, joints, heart, skin, and pituitary glands are the most commonly involved organs.3,4 This article summarizes the best available patient-oriented evidence regarding hereditary hemochromatosis. Risk factors and clinical outcomes associated with blood culture contamination, Contaminant blood cultures and resource utilization. The 20-min whole blood clotting test (20WBCT) is a simple, inexpensive bedside test which may be performed to identify incoagulable blood of patients envenomed by snakes such as Echis spp., which induce a consumptive coagulopathy (Benjamin et al., 2018; From: Advances in Protein Chemistry and Structural Biology, 2022 View all Topics Add to Mendeley Symptoms and risk factors are the main determinants of treatment options for patients with essential thrombocythemia. 15,16 Prediction of bacteremia using TREAT, a computerized decision-support system, Antimicrobial Stewardship & Healthcare Epidemiology : ASHE, http://creativecommons.org/licenses/by/4.0/. 17 Polycythemia vera should be suspected in patients with elevated hemoglobin or hematocrit levels, splenomegaly, or portal venous thrombosis. When performing a phlebotomy procedure, the successful completion of the procedure depends on the physicians ability to identify any potential risk factors and take appropriate measures to prevent them. Likewise, 35% of patients with contaminated blood-culture episodes included ICU stay at some point during the hospitalization, compared to 28% of patients with negative blood-culture episodes. Federal government websites often end in .gov or .mil. Patients treated with myelosuppressive agents and supplemental phlebotomy avoid this early thrombotic risk but in turn have significant rates of malignant transformation after about six years of therapy. Copyright 2004 by the American Academy of Family Physicians. Although new diagnostic modalities have been developed, these criteria remain the standard method to diagnose PV.8. Other than menses and shedding of senescent cells, there are no physiologic mechanisms of iron excretion. Many people with polycythemia vera don't have noticeable signs or symptoms. All patients, regardless of risk stratification, are treated with low-dose aspirin [ 15 ] and phlebotomy leading to iron deficiency that maintains hematocrit levels <45% [ 10 ]. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. It can help prevent serious complications such as liver disease, heart disease and diabetes. Polycythemia vera treatment algorithm 2018. These comorbidities were extracted from International Classification of Disease, Tenth Revision (ICD-10) codes listed in the electronic medical record of each admission. Examples of thrombotic events include arterial and venous thrombosis, cerebrovascular accident, deep venous thrombosis, myocardial infarction, peripheral arterial occlusion, and pulmonary infarct.14 Of additional importance to the family physician is the symptomatic treatment of the bothersome microvascular sequelae, such as pruritus and distal extremity erythromelalgia (Table 31,1517). Check out these best-sellers and special offers on books and newsletters fromMayo Clinic Press. In addition to interferon alfa-2b (Intron A) therapy, agents that target platelet number (e.g., anagrelide [Agrylin]), and platelet function (e.g., aspirin) are being investigated as potential therapies. Specificity is much better. AskMayoExpert. In this study, we sought to determine patient-specific factors contributing to blood culture contamination in hospitalized patients. Often the condition is found during a blood test done for another reason. 17 Little JR, Murray PR, Traynor PS, Spitznagel E. A randomized trial of povidone-iodine compared with iodine tincture for venipuncture site disinfection: effects on rates of blood culture contamination, Sterilization of skin and catheters before drawing blood cultures, The effect of skin disinfection materials on reducing blood culture contamination, Phlebotomy teams reduce blood-culture contamination rate and save money. In addition to end-stage renal disease (ESRD), which has been previously implicated in increased blood culture contamination, we also included COPD, liver cirrhosis, and diabetes mellitus in the analysis. If we combine this information with your protected health information, we will treat all of that information as protected health information and will only use or disclose that information as set forth in our notice of privacy practices. Previous studies have shown that, compared to patients with negative blood cultures, emergency department (ED) patients with contaminated blood cultures were more likely to be older; to be of black race; to have higher BMI; to have end-stage renal disease, chronic obstructive pulmonary disease (COPD), or paralysis; and to be in a critical condition (triage level I and II) or septic shock. 14 In some cases, it may even reverse it. Ferrari A, et al. Major diagnostic criteria include increased RCM, normal oxygen saturation, and the presence of splenomegaly. Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Griesshammer M, et al. Liaquat S, Baccaglini L, Haynatzki G, Medcalf SJ, Rupp ME. Bethesda, MD 20894, Web Policies Some people might develop vague symptoms such as headache, dizziness, fatigue and blurred vision. But in polycythemia vera, your bone marrow makes too many of some of these blood cells. This lack of sensitivity has led to some discussion about the use of imaging techniques to answer the question, although such a finding by imaging might be relegated to the status of a minor criterion.10 In addition, the minor criteria of leukocyte alkaline phosphatase (LAP) and serum vitamin B12 and B12 binding capacity may be dropped in the future because of inter-laboratory error regarding LAP and the unavailability of vitamin 10 B12 binding capacity. Learn Test Match Created by sdrburkhart TEACHER Terms in this set (27) the Joint Commission (TJC) What organization establishes standards for the operation of hospitals and other health care facilities and services? Phlebotomists should take at least ten seconds to observe a . Smoking cessation and cardiometabolic disease are modifiable risk factors that should be addressed to reduce the risk of thrombosis. As a result, patients with COPD might be more prone to blood culture contamination. Your email address will not be published. Current risk stratification in PV and ET is designed to estimate the likelihood of thrombotic complications: high-risk is defined by the presence of age greater than 60 years or presence of thrombosis history; low-risk is defined by the absence of both of these 2 risk factors. Occupational exposure to infectious agents associated with phlebotomy is an important risk-management issue that affects the safety and well-being of employees. The risk of thrombosis was also significantly lower with phlebotomy use (29% vs. 46%). Polymicrobial blood cultures in which a likely contaminant was recovered in combination with a likely true pathogen were regarded as positive episodes. 2018; doi:10.1038/s41408-017-0042-7. Electronic medical record data from adult inpatients aged 18 years or older admitted between June 1, 2014, and December 31, 2016, at the University of Nebraska Medical Center were included in the study. Men are more likely to get polycythemia vera, but women tend to get the disease at younger ages. For each Period, stratified rates of fainting in relation to various donor and donation characteristics were calculated and multivariable logistic regression analyses to identify factors associated with fainting were conducted. In these patients, ruxolitinib achieved better hematocrit control and spleen volume improvement (decrease in volume greater than 35%) compared with other single-drug alternatives selected by the investigator, such as hydroxyurea (tolerable doses), pegylated interferon-alfa, pipobroman (not available in the United States), anagrelide (Agrylin), immunomodulators, or no medication (busulfan was prohibited) over a 32-week period (21% with ruxolitinib vs. 0.9% with other single-drug alternatives; P < .001; number needed to treat = 5).30, Immunosuppressive adverse effects made herpes zoster infection more likely (6% with ruxolitinib vs. 0% with other single-drug alternatives).30, Pruritus may be present in up to 68% of patients and is severe in up to 15% of patients.10, First-line therapy includes aspirin, antihistamines, and paroxetine (Paxil).22,31,32, Other treatment options include ruxolitinib, interferon-alfa, and narrow-band ultraviolet B phototherapy.3335, PV during pregnancy is rare, with a prevalence of less than 0.03 per 100,000.36, A multidisciplinary team, including an obstetrician, maternal-fetal medicine specialist, and hematologist, is recommended.37, Potentially teratogenic medications should be stopped in men and women at least three months before conception.36,37, All pregnant patients who have PV should receive low-dose aspirin, avoid iron supplementation in the absence of actual depletion, maintain gestational age-appropriate hematocrit levels, and be treated with enoxaparin (Lovenox) for six weeks postpartum if no contraindications occur.36, Interferon-alfa is the drug of choice for cytoreductive therapy if needed.36, Follow-up appointments every three to six months are recommended for routine history, physical examination, and complete blood count.15, Poor prognostic features include age older than 60 years, history of thrombosis, leukocytosis, high JAK2 burden, abnormal karyotype, and established cardiovascular risk factors such as smoking, hypertension, diabetes, obesity, and hyperlipidemia.5,9,38, Smoking cessation decreases the risk of thrombosis.39, Without treatment, death typically occurs within two years, mostly from thrombotic events.40, Median survival of patients with PV using standard-of-care treatment, including aspirin and hydroxyurea, is 13.5 years.4, For those diagnosed before 60 years of age, median survival is 24 years.4, The risk of blast transformation to acute myeloid leukemia or myelodysplastic syndrome over 15 years is 5.5% to 18.7%.4,41, Progression to myelofibrosis over 15 years is 6% to 14%.4,41 A practical tool to calculate survival has been developed and is shown in Table 6.5, This article updates a previous article on this topic by Stuart and Viera.1. Additionally, we could not evaluate the association between ESRD and blood culture contamination, since we did not have a sufficient number of participants with ESRD. We identified 19,255 admissions between June 1, 2014, and December 31, 2016. Changes to these diagnostic criteria have been proposed. Phlebotomy can resolve or markedly improve weakness, fatigue, and lethargy; and darkening of the skin. Untreated patients may survive for six to 18 months, whereas adequate treatment may extend life expectancy to more than 10 years. These pathogens include ( 2, 5, 12, 14, 17, 23, 31 ): viruses, such as HBV, HCV and HIV; bacteria, such as syphilis; parasites, such as malaria. Taking the time to identify risk factors can not only provide a safer experience for the patient, but also help the phlebotomist prevent any potential accidents or injuries during the procedure. Patients admitted from the ED had 1.20 higher adjusted odds of having contaminated blood cultures than those not admitted from ED (AOR, 1.20; 95% CI, 0.961.50). Polycythemia vera is rare. 17 Additionally, phlebotomy is performed to lower iron levels and stop buildup in other organs. M.E.R. After exclusions, the final analytical sample consisted of 11,474 patient admissions with 11,010 negative and 464 contaminated episodes (Table1). The mainstay of treatment for PV is phlebotomy, which is aimed at reducing hyperviscosity by decreasing the venous hematocrit level to less than 45 percent (0.45) in white men and 42 percent (0.42) in blacks and women.1,14,18 The PVSG reported the best median survival, 12.6 years, for this type of treatment.14 Some features of using phlebotomy alone are attractive, primarily because it is a simple procedure without many risks, except for the eventual development of iron deficiency.8 Some experts have cast doubt on the PVSG findings regarding median survival, noting that up to 50 percent of patients treated with phlebotomy alone had to switch to other treatments by the fifth year.19 The PVSG found a statistically significant increase in the number of thrombotic events within the first three years of initiating treatment, compared with the use of myelosuppressive agents.14 After this period, however, the rate of thrombosis remained the same for both treatment approaches. Consultation with a hematologist is recommended. Trends in blood culture contamination: a College of American Pathologists Q-Tracks study of 356 institutions. 22 Erythromelalgia is rare, occurring in approximately 3 percent of patients with PV. 1 / 90 Flashcards Learn Test Match Created by jaaykaayaay Chapters 1-4 HW Questions 7th Edition Phlebotomy Essentials Terms in this set (90) In the 17th century, the name given to the blood-letting tool or lancet was: A. cup B. fleam C. hemostat D. leech B. fleam Polycythemia vera (adult). Patient-specific factors associated with blood culture contamination remain largely unexplored. Note: OR, odds ratio; CI, confidence interval; COPD, chronic obstructive pulmonary disease; ED, emergency department; ICU, intensive care unit. In the United States, 0.6%6% of all blood cultures are contaminated with skin-residing organisms resulting in increased hospital stay and unnecessary antibiotic therapy, and emergence of antibiotic resistance. See permissionsforcopyrightquestions and/or permission requests. Therefore, recommendations for treatment are based on lower quality evidence from case series and uncontrolled trials. Advertising revenue supports our not-for-profit mission. Those considered at indeterminate risk are younger than 60 years and have no history of thrombocytosis, but do have cardiovascular or other risk factors.1 Therapy in this group should be individualized, possibly with the addition of agents acting on platelet function or number. Women typically present later in life when they are postmenopausal, likely because of menstrual blood loss delaying the development of symptomatic iron overload.1,3, Genetic testing for the C282Y and H63D mutations of the HFE gene is recommended for first-degree relatives of people with hereditary hemochromatosis; screening does not need to begin until 18 years of age because clinical manifestations are rare before this age.1,3, Population-level genetic testing or laboratory screening for hereditary hemochromatosis is not recommended because of the cost and the variable prevalence and incomplete penetrance of the C282Y mutation.1,35,9, The presentation of hereditary hemochromatosis varies, with biochemical expression occurring first and clinical expression occurring in later stages of disease.3,8 Table 2 summarizes the stages of hereditary hemochromatosis.1,2,4,5, The differential diagnosis includes other causes of secondary iron overload via excess absorption and organ deposition of iron (Table 3).15,10, Hereditary hemochromatosis should be considered in the differential diagnosis of patients with elevated liver enzymes and abnormal iron study results.24,11. Being a historical cohort, it was not possible to control for all possible confounders. Pruritus, particularly after bathing (aquagenic pruritus) is a common symptom and various treatment options are available (Table 31,1517). Hydroxyurea is considered first-line cytoreductive therapy, if indicated. A number of new therapeutic agents have been developed. A blood culture is a test that checks for foreign invaders like bacteria, yeast, and other microorganisms in your blood. While this process is usually straightforward, there are always risks associated with any medical procedure. Learning your risk can help you prevent thrombosis, and learning the symptoms can help you recognize problems if they occur. knowledge of patient-specific factors associated with contamination could help in formulating predictive equations to better identify patients at higher risk of blood culture contamination. A risk-stratified approach to the management of PV is currently recommended (Table 5).1 [Level of evidence: C, expert opinion] Patients treated with phlebotomy alone benefit from low rates of malignancy but experience more thrombosis events during the first few years of treatment. A sample of 11,010 negative blood culture episodes and 464 contaminated episodes provided 80% power to detect a standardized mean difference of 0.132. To date, only limited studies have systematically explored patient-related factors in hospitalized adult patients that might contribute to blood culture contamination. Hereditary hemochromatosis is usually diagnosed in the 40s or 50s. Hereditary hemochromatosis is an autosomal recessive condition that results in systemic iron overload due to a deficiency in hepcidin, an iron regulatory protein.1,2 The body's iron stores are primarily regulated by controlling intestinal absorption. Hydroxyurea is the first-line agent for cytoreductive therapy in PV. Polycythemia vera. A subgroup analysis of patients admitted to the hospital from ED showed similar results. The median age of patients diagnosed with PV is 60 years, although it can occur in persons in all age groups.1 PV occurs with a slight predominance in men. Identify clinical and legal ramifications. Hemolysis is the destruction of red blood cells (erythrocytes). Some people face a higher risk of thrombosis due to medical conditions or other factors. Your email address will not be published. 4. Course director(s), planning committee, faculty, and all others who are in a position to control the content of . Additionally, for patient admissions that included ICU stay, we were not able to ascertain whether the first blood culture was drawn during an ICU stay or at any other time during the hospitalization. Among adult patients, we identified 464 contaminated episodes and 11,010 negative blood-culture episodes. Figure 2 presents a suggested approach to the treatment of PV.12,16,17, All patients should receive phlebotomy with a goal hematocrit level of less than 45%.1820, A randomized controlled trial of 365 patients who had PV with an average age of 65 years showed a decreased incidence of death from cardiovascular events and thrombotic events if phlebotomy was used to keep the hematocrit level at less than 45% vs. 45% to 50% over a median follow-up period of 31 months (1.1 events vs. 4.4 events per 100 person-years; number needed to treat = 30).18, In a retrospective cohort study, 820 predominantly White patients with Medicare, a median age of 77 years, and a low rate of previous thrombosis (13%) were followed for 2.8 years. Health-care facilities should follow the lead of Dale and coworkers and consider every possible measure to eliminate the risk of needlestick injuries associated with phlebotomy. Finally, EEC growth is based on the ability of erythroid cells from peripheral blood and bone marrow samples in PV to grow in vitro without the addition of EPO.12,13 This unique finding, along with serum EPO levels, forms the basis for a new diagnostic approach,5 but has the disadvantages of expense and limited availability.10. More patients in the contaminated group (10%) had COPD versus patients with negative episodes (6%). 2019; doi:10.2147/JBM.S189922. Accessed Dec. 7, 2019. 813 BRIAN J. STUART, LT, MC, USNR, AND ANTHONY J. VIERA, LCDR, MC, USNR. The only minor criterion is a subnormal erythropoietin level, which helps differentiate polycythemia vera from common causes of secondary erythrocytosis such as smoking, sleep apnea, and testosterone use. Most phlebotomists stand up while drawing blood. Phlebotomy must be stopped after achieving remission or when iron deficiency anaemia occurs; however, relapse may occur during the first 5 years of treatment especially when risk factors are still present, such as excessive alcohol consumption 65. 3.Needlestick injuries - prevention and It was a retrospective review of electronic medical records; thus, it was not feasible to verify the accuracy of archived patient data. the contents by NLM or the National Institutes of Health. Novis DA, Dale JC, Schifman RB, Ruby SG, Walsh MK. Genetic testing for the hereditary hemochromatosis genes should be offered after 18 years of age to first-degree relatives of patients with the condition. All Rights Reserved. Additional variables included stay in intensive care unit (ICU) during admission, admission from the emergency department, and anatomic location of blood drawn for blood culture (central intravenous catheter or peripheral vein). Learn more about Mayo Clinics use of data. A common initial presentation is an asymptomatic patient with mildly elevated liver enzymes who is subsequently found to have elevated serum ferritin and transferrin saturation. 5,6 Elsevier; 2020. https://www.clinicalkey.com. We used 2 and 2-sample independent t tests to determine associations between the outcome and the covariates. Before All people with polycythemia vera should receive phlebotomy with a goal hematocrit level of less than 45%. A patient information handout on polycythemia vera, written by the authors of this article, is provided on page 2146. A forward stepwise selection at = .05 was utilized to create the final model, and the Akaike information criterion (AIC) value was used to assess model fit. 17 Polycythemia vera. Accessed Dec. 8, 2019. we found that Blacks had higher odds of having a contaminated blood culture than Whites (AOR, 1.35; 95% CI, 1.001.81). _____ exposure is a risk for all health care workers. Patients may present with complaints of pruritus after bathing, burning pains in the distal extremities (erythromelalgia), gastrointestinal disturbances, or nonspecific complaints such as weakness, headaches, or dizziness. patient identification _____ is the most important aspect of specimen collection. reports research funding from Magnolia Medical Technologies. Reference What Is Phlebotomy? Having these pathogens in your bloodstream can be a sign of . Tefferi A. Prognosis and treatment of polycythemia vera. Required fields are marked *. For example, patients with conditions known to be associated with blood culture contamination (eg, COPD, elevated BMI, etc) could have an electronic alert directed to phlebotomists when blood cultures are ordered, notifying them of the increased risk and triggering additional measures to ensure aseptic technique or use of devices to limit blood culture contamination (eg, initial specimen diversion device). All other authors report no potential conflicts of interest. Clinical consequences of contaminated blood cultures in adult hospitalized patients at an institution utilizing a rapid blood-culture identification system, Preanalytic laboratory errors: identification and prevention. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. This content is owned by the AAFP. Copyright 2023 SlickSpring | Powered by SlickSpring. Basilic veins should be avoided unless there are no other antecubital options. Clinical and economic impact of contaminated blood cultures within the hospital setting. Study participants included 19,255 adult patients who had blood culture(s) performed during a hospital admission between June 2014 and December 2016. A more recent article on polycythemia vera is available. Haematologica. G*Power software was used for the power analysis. Phlebotomy may improve heart function, reduce abnormal skin pigmentation, and lessen the risk of liver complications. . 15 Polycythemia vera occurs when a mutation in a gene causes a problem with blood cell production. Take the time to adjust your workstation to your height and position clients to reduce strain on your back and neck. Weinbaum FI, Lavie S, Danek M, Sixsmith D, Heinrich GF, Mills SS. To avoid bias, if a patient had >1 eligible admission, only the first admission was included in the analyses. Because PV is a rare condition, it has been difficult to assemble patients for well-designed, randomized controlled trials with long- term follow-up. For example, determinations of RCM, classically given in milliliters per kilogram (mL per kg), can be misleading if the patient is obese, because body fat is relatively avascular. We applied the following exclusion criteria: patient <18 years of age (n = 1,419), positive/true bacteremia (n = 1,395), equivocal results (n = 431), and repeat hospital admissions (n = 4,506). Serum erythropoietin (EPO), bone marrow histopathology and karyotype, and the presence of endogenous erythroid colonies (EEC) have been proposed as diagnostic tests for PV. During venipuncture, bacteria on skin fragments can dislodge into the specimen.
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