Pyrogenic reactions in patients undergoing cardiac catheterization associated with contaminated glass medicine cups

Area of Science:

• Infectious Disease
• Cardiology
• Patient Safety

Background:

• Pyrogenic reactions, a severe complication of bacterial endotoxin exposure, pose significant risks.
• Two cardiac catheterization patients experienced rigors, prompting an investigation into the cause.

Purpose of the Study:

• To identify the source of pyrogenic reactions in cardiac catheterization patients.
• To determine the association between specific procedural elements and patient rigors.

Main Methods:

• A case control study was conducted involving patients who developed rigors within 3 hours of cardiac catheterization.
• Medical records were reviewed to identify case patients and randomly selected control patients.
• Exposure to intracoronary-nitroglycerin (NTG) and the reprocessing of glass medicine cups were specifically examined.

Main Results:

• Twelve case patients and 40 control patients were identified.
• Exposure to intracoronary-nitroglycerin (NTG) was significantly associated with developing rigors (odds ratio = 12.0).
• Reprocessed glass medicine cups used for NTG demonstrated elevated endotoxin levels (median 2,250 EU/mL), originating from contaminated enzyme cleaner.

Conclusions:

• Contaminated, reprocessed glass medicine cups likely caused pyrogenic reactions in cardiac catheterization patients.
• Endotoxin exposure from these cups contributed to the death of two critically ill patients.
• This highlights the critical importance of sterile processing and endotoxin control in medical devices and supplies.