541

Thrombophlebitis after Infusions

LEADING ARTICLES

THE LANCETLONDON: : SATURDAY, SBPT. 10, 1955

BETWEEN a half and two-thirds of all infusions,whether of blood, glucose, or salt solutions, are followedby thrombophlebitis-that is, perivenous cellulitis,with or without thrombosis.1-4 This troublesome

complication seems to have no single cause, but therisk of it is increased when an infusion at one sitelasts for longer than eight hours.1-5 Bacterial infec-tion plays no part,2 4 6 and one group of workers claimthat change of pH between 4-5 and 6 does not affectthe incidence. The most important causal factor seemsto be the slow leaching out by the infusion fluid ofsome unidentified irritant substance present in thered rubber tubing of the giving set.8 The vein walltolerates this irritant for about eight hours, but

longer exposure causes a response whose severityincreases rapidly with continued exposure. This

hypothesis is supported by several workers, whohave found that the use of Polythene ’ tubing 3 or alatex rubber tubing made in the U.S.A.2 greatlyreduces the incidence of thrombophlebitis. Butneither of these ensures complete freedom from

thrombophlebitis ; in fact, one worker using latexrubber 1 encountered thrombophlebitis in 47 out of100 transfusions, though in only 4 did this developduring the first twenty-four hours.

This problem can be attacked by modifying thetransfusion equipment, and by improving the trans-fusion technique. Modification of equipment wouldrequire action on a national or international scale,and it is good to know that several practical trans-fusionists are members of a committee which has been

charged with the duty of designing a disposableplastic giving set. Let us hope that this will provemore satisfactory than the international-pattern givingset which was distributed in September, 1954, butwithdrawn a few weeks later. In transfusion techniquethere is plenty of scope for improvement. Often,1. Richards, H. J. Med. J. Aust. 1955, ii, 7.2. Jones, P. F. Lancet, 1954, ii, 970.3. Morris, J. Ibid, 1955, i, 154.4. Banerji, R. Ibid, p. 514.5. Bolton Carter, J. F. Ibid, 1951, ii, 20.6. Michaels, L.. Ruebner, B. Ibid, 1953, i, 772.7. Bolton Carter, J. F., Milne, E. H., Whittett, T.D. Ibid, 1952,

ii, 660.8. Handfleld-Jones, R. P. C., Lewis, H. B. M. Ibid, 1952, i, 585.

nowadays, an infusion is set up by thrusting the largestconvenient needle into some superficial vein, which isthereby occluded, and running in the more or less irri-tant solution, which fills the vein and is not diluted untilit reaches a junction with another vein. This infusionis then left running as long as possible-often fortwenty-four hours, sometimes for several days. Not

infrequently a cannula is tied into the saphenous veinat the ankle, despite the particularly great risk atthis site of thrombophlebitis,3 4 which contributesto that major disability-chronic ulceration of theleg. 9No infusion should be allowed to run for more than

eight hours at a time. Often during this period all thefluid needed in twenty-four hours can be adminis-tered, thus giving the patient sixteen hours a day offreedom from needles or cannulse ; and if a moreuniform intake of fluid is desired, it should be possibleto change the site of infusion several times daily.If neither of these methods is practicable, a polythenecatheter can usually be introduced into the vena cava,so that irritants will be quickly diluted. The resident

responsible for maintaining transfusions will be well advised to use as small a needle as possible, and toinsert it into the largest convenient vein just distal toa venous junction, securing it by some means whichdoes not occlude the vein distal to the point ofinsertion. Thus he should try to enter large veinsat the proximal end of a limb, and avoid the smallveins at the distal end which hitherto have been most

commonly used. He should also prefer to enter avein in the arm rather than in the leg, and shouldparticularly avoid tying a cannula into the saphenousvein. This is a radical subversion of the ideas currenta few years ago, and at first it might seem to place aheavy burden on the resident. But if a limb is properlywarmed, by surrounding it with a thermostaticallycontrolled electric blanket, full vasodilatation willhave taken place in twenty to thirty minutes, andthis will ease venepuncture and, by increasing blood-flow, make sure that any irritant is quickly diluted.The thermostatic electric blanket, which can be keptover the infused limb for hours, is in every waypreferable to a hot-water bottle, which is ineffectiveand can cause severe local injury.

" Letterer-Christian " DiseaseTHERE has been a considerable improvement

recently in our knowledge of what for the momentmay be terwed

" Letterer-Christian " disease. Threeconditions once regarded as distinct fall under thishead. The first to be described was Hand-Schuller-Christian disease, with its triad of cranial bonydefects, exophthalmos, and diabetes insipidus. Thiswas a chronic disorder of uncertain prognosis whichwas shown by ROWLAND in 1929 to have as its mostcharacteristic element a xanthoma cell, a histiocytewith cholesterol ; THANNHAUSER in 1938 distinguishedit from other general xanthomatoses by the absenceof a raised blood-cholesterol level. Next came

Letterer-Siwe disease, described in 1933-34-anacute generalised fatal -reticulosis of children, whosecharacteristic cell was a proliferating histiocyte withno trace of lipid. And finally there was the eosino-philic granuloma of bone described in 1940 by JAFFE

9. Anning, S. T. Ibid, 1954, ii, 1126.

542

and LICHTENSTEIN-a solitary slow-growing lesion ofolder children, clinically often tumour-like but curedby any local treatment or sometimes none at all. Itscharacteristic cell was an eosinophile granulocyte,though again histiocytes were present : a lesion morelike inflammation than tumour.

Recognition that these three conditions are one camewith the description of many borderline and mixedcases.’ 2 The picture which emerges is of a continuousspectrum ranging from a solitary non-progressive bonelesion through multiple more or less progressive bonelesions to an acute disseminated lesion in whichskeletal lesions, though rarely absent, do not dominatethe picture. Recent writers unanimously accept thisunified conception, but agree on nothing else : viewson the nature of the disease, and on what it should becalled, are exceedingly various. THANNHAUSER wouldappear to regard it still as a disturbance of lipidmetabolism (a local defect in the tissues concerned,not a general disorder) and proffers the names" normocholesterolaemic xanthomatosis " or " eosino-philic- xanthomatous granuloma." ROBB-SMITH,3 ifwe understand him aright, regards it as a progressivereticulosis-" reticulum-celled medullary reticulosis."HARRISON 4 seems also to regard it as a reticulosisand uses the name " non-lipid histiocytosis," whichproperly speaking is a synonym for the Letterer-Siwevariant. (So also is the word " reticulo-endothelio-matosis " used by other workers.) LICHTENSTEIN 2

frankly admits that the nature of the disease is

unknown, but obviously he is especially watchful foran infectious agent. Emphasising the histiocyticproliferation which is more or less prominent in allcases, and the unknown cause, he suggests the name"

histiocytosis X." If generally accepted, this mightsuffice for lack of a better: but, so far as we know, onlyone group 5 has accepted it even as an alternative title." Letterer-Christian " disease is a mere colloquialism,and it is most unfair to others who could claim to be

co-eponyms ; but it is convenient and non-commital.Two recent reports deserve notice.In one GOLDNER and VOLK 5 record, under the name

" fulminant norniocholesterolsemic xanthomatosis (histio-cytosis X)," a case of an acute disease of the Letterer-Siwe type in a 67-year-old woman, who died only sixmonths after the onset. In the early stages she hadweight loss, bone pains, and diabetes mellitus ; in thelast two months she had skull radiolucencies, enlargedlymph-nodes in the neck, gingivitis, and skin infiltration ;the diagnosis was made on lymph-node and gum biopsies.At necropsy the lymph-nodes and spleen showed a lipid-free histiocyte overgrowth ; elsewhere (notably in therenal pelves and bones) the histiocytes contained sub-stantial amounts of lipid (a cholesterol/cholesterol-ester/fat mixture of " xanthoma " type) and there were foci ofeosinophils and giant cells. Although this patient was mucholder than any previously recorded, the diagnosis seemswatertight. The disease-especially the acute Letterer-Siwe form-is generally described in children ; and it isperhaps sometimes missed through the assumption thatit does not occur in adults.A report from The Hospital for Sick Children, Great

Ormond Street,’ describes 16 cases of the disease diag-

1. Thannhauser, S. J. Arch. intern. Med. 1947, 80, 283.2. Lichtenstein, L. Arch. path. (Lab. Med.) 1953, 56, 84.3. Robb-Smith, A. H. T. In Recent Advances in Clinical Pathology.

London, 1947.4. Harrison, C. V. In Recent Advances in Pathology. London,

1953.5. Goldner, M. G., Volk, B. V. Arch. intern. Med. 1955, 95, 689.6. British Empire Cancer Campaign Report for 1954. London,

1955 ; p. 188.

nosed in children there during a period of thirty years.(By way of giving an idea of the incidence, during thesame period 18 lymphosarcomas, 17 cases of Hodgkin’sdisease, and 94 neuroblastomas have been diagnosed atthis hospital.) The series gives an unusually valuableview of the disease as a whole and the frequency of itsvarious manifestations. There were 4 cases of solitarybone lesion, 4 cases of multiple bone lesions (3 with theclassical Christian triad), 2 with bone and skin lesions,and 6 with widespread lymphoid and visceral dissemina-tion in 2 of which there were no bone lesions. Themixture of histological features in different cases was

convincing evidence of the unity of the group. The 4solitary lesions all healed under local treatment. Of the6 children with multiple lesions confined to bone and skin3 are cured and none has died. Even of the 6 childrenwith acute disseminated disease, 2 are apparently cured.This is a distinctly less gloomy picture than most peoplewould have expected, and underlines the importance ofdistinguishing the Letterer-Siwe type of lesion from thatof malignant reticulosis.

,

The lipoidoses group seems to be shrinking.Gaucher’s disease and Niemann-Pick’s disease remainunattacked. But gargoylism can no longer be regardedas a lipoid disorder, since it has been shown histo-

chemically that the abnormal material is probably amucopolysaccharide.7 A substantial proportion of thehypercholesterolæmic xanthomatoses are now knownto follow biliary obstruction, diabetes, or the like.And it is increasingly difficult to regard even theSchuller-Christian variant of Letterer-Christian diseaseas anything but the most secondary of xanthomatoses.

High-humidity Rooms in Children’sHospitals

IT has long been recognised that high atmospherichumidity may have a beneficial effect on certaininfections of the respiratory tract, particularly in

children ; and this knowledge is reflected in widespreaduse of the steam-kettle. But steam humidification

may raise the environmental temperature so high thatit embarrasses the patient, especially where it is com-bined with oxygen therapy in the confined space ofan oxygen tent or box. This difficulty is overcomeby " cold " humidification at room-temperature bymeans of a mechanical water-vaporiser operatedeither independently near the patient or in an oxygentent in conjunction with the oxygen supply. The

practice of therapeutic humidification of the atmo-sphere has been further extended at the Children’sHospital in Vancouver, where for the past five yearsa high-humidity room has been in operation. Inthis specially constructed room, which is large enoughto hold several children, the relative humidity is keptat 100% and the temperature at 70-72°F. Reviewingfive years’ experience, BAKER 8 concludes that theroom has important advantages over methods ofindividual humidification. The sense of confinementand restraint inevitable in a tent or box-oftendisturbing and sometimes intolerable-is avoided;older children are easily accommodated ; humidifica-tion can be maintained much longer than would beacceptable in a confined space ; nursing is much easierand can be carried out with less disturbance to the

patient ; and there is no delay in an emergency. Inaddition high humidity applied in this way has beenfound to combat the tendency towards dehydration

7. Brante, G. Scand. J. clin. Lab. Invest. 1952, 4, 43.8. Baker, H. Canad. med. Ass. J. 1955, 72, 914.