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1046 Letters
Source of infection in Hickman catheters skin entry site. On the other hand, of 89 Effect of in vitro sodium citrate anticoagulant
hubs from 16 patients cultured thus far, on results of arterial blood gas analysis
Infection is a principal complication of the including those associated with the catheter
use of indwelling, central venous (Hickman) related bacteraemias, 14 (16%) had been We report a case in which the mistaken use
catheters in immunosuppressed patients.1 2 colonised when there was no evidence of of sodium citrate as an anticoagulant in a
There has been disagreement about the catheter related bacteraemia, but in these sample of arterial blood intended for blood
pathogenesis of catheter colonisation and cases the degree of colonisation was gener- gas analysis resulted in a severe change in
sepsis, some workers judging the flora of the ally less severe than in those hubs associated pH and a calculated index of acid base state.
skin at the catheter entry site to be the with bacteraemia. We are not suggesting Venous and arterial blood samples from a
source of infection, and others suggesting that antimicrobial chemotherapy should be 59 year old man with sudden onset of dys-
contamination of the catheter hub.34 Liii- given on the basis of the results of hub cul- pnoea were received by the laboratory for
ares et al implicated the catheter hub as the ture, but our finding suggests that efforts to urgent biochemical analysis. Results on
most common site of origin of catheter prevent infection should be directed at the heparinised venous plasma using a Beckman
related bacteraemia in patients receiving procedures for catheter care and handling. ASTRA were: urea 6 3 mmol/l, potassium
total parenteral nutrition.5 We obtained NC WEIGHTMAN* 3-8 mmol/l, sodium 141 mmol/l, and total
preliminary data supporting this portal of EM SIMPSONt carbon dioxide 24 mmol/l. Results on arte-
entry in the course of a prospective study of DCE SPELLER* rial whole blood using a Corning 178 auto-
catheter related bacteraemia in children with *Department of Microbiology, mated blood gas analyser were: pH 7 29 car-
leukaemia and other malignant diseases. Bristol Royal Infirmary, and the bon dioxide partial pressure 3-4 kPa, oxygen
Hickman catheters, when not in use for tDepartment of Haematology partial pressure 5 3 kPa, calculated bicar-
intravenous infusion, were sealed with a and Oncology, Bristol Royal bonate 12mmol/l. The arterial results could
male Luer lock hub with a rubber mem- Hospitalfor Sick Children, be interpreted as reflecting a severe non-
brane (Vygon) through which injections Bristol BS2 8HW respiratory acidosis with respiratory com-
could be made. When these hubs were References pensation and hypoxia. The discrepancy
removed a quantitative culture technique Press OW, Ramsey PG, Larson EB, et al. Hick- between total carbon dioxide and calculated
was used to assess the degree of bacterial man catheter infections in patients with bicarbonate, however, alerted the labora-
colonisation of the inner surfaces.5 During malignancies. Medicine 1984;63:189-200. tory to the possibility of an error, and
the first 20 weeks of the study there were 2 Shapiro ED, Wald ER, Nelson KA, et al. Bro- enquiry showed that 3-8% sodium citrate
nine catheter related bacteraemias, diag- viac catheter-related bacteremia in oncology (trisodium citrate BP), comprising about
nosed on the basis of quantitative cultures of patients. Am J Dis Child 1982;136:679-81. 5% of the total volume of the sample, had
blood samples drawn through the catheter 3 Snydman DR, Gorbea HF, Pober BR, et al. been used instead of sodium heparin as an
(after the hub has been removed for culture) Predictive value of surveillance skin cultures anticoagulant for the arterial blood. Using
and from a peripheral vein. In seven epi- in total-parenteral-nutrition-related infec-
tion. Lancet 1982;i:1385-8. the blood gas analyser the pH of the sodium
sodes the same organism was isolated from 4 Sitges-Serra A, Jaurrieta E, Liiiares J, et al. citrate preparation was found to be 7 19.
the hub and from blood cultures, in one epi- Bacteria in total parenteral nutrition cath- Sodium citrate has previously been reported
sode the inner surface of the hub was sterile, eters: where do they come from? Lancet to have an acidifying effect on the pH of
and in one episode a different organism 1983;i:53 1. whole blood in vitro.'
from that causing the bacteraemia was iso- 5 Liiiares J, Sitges-Serra A, Garau J, et al. Patho- A heparinised arterial sample from the
lated (table). genesis of catheter sepsis: a prospective patient was subsequently analysed and
The skin around the catheter entry site study with quantitative and semiquantitative results were: pH 7 47, carbon dioxide partial
was also regularly cultured by a semi- cultures of catheter hub and segments. J Clin
Microbiol 1985;21:357-60. pressure 3 8kPa, oxygen partial pressure
quantitative method,6 but the organism 6 Bjornson HS, Colley R, Bowey RH, et al. 6-0 kPa, calculated bicarbonate 21 mmol/l.
causing the catheter related bacteraemia was Association between microorganism growth These results indicate that the patient had a
not isolated. at the catheter insertion site and colonisation mild respiratory alkalosis with hypoxia.
This finding suggests that catheter infec- of the catheter in patients receiving total par- The artefact caused by sodium citrate is
tions originate from the hub rather than the enteral nutrition. Surgery 1982;92:720-6. important as it may result in serious misin-
Table Isolates from catheter hubs terpretation of blood gas results, with the
consequent risk of starting inappropriate
Catheter related No simultaneous Catheter related
and potentially harmful treatment.
bacteraemia with catheter related bacteraemia with PE STEIN
same organism bacteraemia different organism DW GOODIER
Department of Chemical Pathology
Coagulase negative staphylococcus 3 11 I and Human Metabolism,
Straphylococcus aureus 0 1 0 The Royal Free Hospital,
Streptococcus faecalis I 0 0
Streptococcus sanguis 1 0 0 Pond Street,
Klebsiella oxytoca I 0 0 Hampstead,
Escherichia coli 0 1 0 London NW3 2QG
Enterobacter agglomerans + I 0 0
Acinetobacter calcoaceticus
var. lwoffi
Coagulase negative staphyloccus + 0 1 0 Reference
Acinetobacter calcoaceticus 1 Gambino SR. Heparinized vacuum tubes for
var.lwoffi
Total 7* 14 1 determination of plasma pH, plasma CO2
content and blood oxygen saturation. J Clin
*The inner surfaces of the hub associated with one catheter related bacteraemia were sterile. Pathol 1959;32:285-93.
 Downloaded from http://jcp.bmj.com/ on June 11, 2015 - Published by group.bmj.com

Effect of in vitro sodium citrate

anticoagulant on results of
arterial blood gas analysis.
P E Stein and D W Goodier

J Clin Pathol 1986 39: 1046

doi: 10.1136/jcp.39.9.1046-b

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