Record number:
1043
Adverse Occurrence type:
MPHO Type:
Time to detection:
1 day
Alerting signals, symptoms, evidence of occurrence:
On day 1 post-op, patient was febrile and had gastroenteritis. Sixteen hours later, the patient developed shock (drop in blood pressure, tachycardia, oliguria, anemia, thrombocytopenia and renal failure). Blood cultures performed on the day after the procedure yielded a gram-negative bacillus identified as Y. enterocolitica. A second patient experienced high temperature and shock after transfusion of 1 unit of autologous red cells.
Demonstration of imputability or root cause:
Only one of three units could be tested and was negative. However, the septic shock occurred in the immediate postoperative period after transfusion of the units. Moreover, a significant antibody titer was found to serotype 0:3 (the same serotype isolated from the patient) at the time blood was drawn. In addition, the patient had had gastroenteritis several days before blood was first taken, and diarrhea persisted for 2 weeks. In the second patient, Y. enterolitica was isolated from the RBC unit and from plasma recovered from the same unit as well as the patient.
Imputability grade:
3 Definite/Certain/Proven
Keywords:
References:
Suggest references:
Sire, J.M., Michelet, C. Mesnard, R., Tardivel, R., Minet, J., Bracq, H. and Avril, J.L. (1993). Septic shock due to Yersinia enterocolitica after autologous transfusion. Cin Infect Dis 17(5): 954-5. Haditsch, M., Binder, L., Gabriel, C., Muller-Uri, P., Watschinger, R. and Mittermayer, H. (1994). Yersinia enterocolitica septicemia in autologous blood transfusion. Transfusion 34(10): 907-909.