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Adverse Occurrence type:
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
Eleven patients with fever >101 F, 7 patients with septic/endotoxic shock, 2 patients died.
Demonstration of imputability or root cause:
Eleven patients were cultured and found to have Pseudomonas species (7 with the same antibiogram). A vial of albumin was cultured and found to contain Pseudomonas species. Investigation showed that upon notification, 5 patients were identified in 4 additional hospitals, who developed endotoxic shock, blood culture positive for Pseudomonas sp, after receiving vials of albumin from the same manufacturer.
Suggest new keywords:
Septic shock from albumin
Pseudomonas in albumin
Steere et al. Pseudomonas Species Bacteremia Caused by Contaminated Normal Human Serum Albumin. The Journal of Infectious Diseases, Vol. 135, No. 5 (May, 1977), pp. 729-735