A case of Ralstonia paucula septicaemia in an intensive care patient following blood transfusion via a level-1 fast flow fluid warmer, successfully treated with meropenem

Abstract number: 1733_1202

Clark B.M., Townsend R., Norman P.

Case: An 80-year-old woman on warfarin therapy underwent emergency surgery for a suspected leaking aortic aneurysm. Instead a tear in the lower pole of the right kidney was found and repaired. She had 2 cardiac arrests during the operation and was resuscitated with fluid infused via a Level-1 Fast Flow Fluid Warmer, including 7 units of blood. Following the operation it was noted that the water bath of the fluid warmer, which warms the infused fluid, had been contaminated with blood. IV (Intravenous) cefuroxime and metronidazole were commenced.

She was transferred to the ICU (Intensive Care Unit) for invasive ventilation and inotropic support. On the second day she became pyrexial and blood cultures were taken, from which a Gram-negative bacteria was grown. Antibiotics were changed to IV pipericillin-tazobactam. On the third day she developed septic shock. The bacteria had now been identified as a likely environmental organism, but given the possible contamination of the patient's blood transfusion this was thought to be relevant and IV meropenem was commenced. She improved clinically and received a total of 6 days of meropenem. She was eventually discharged home after a lengthy hospital stay, including 41 days on the ICU.

Subsequently the organism was identified as Ralstonia paucula using API and confirmed by the reference laboratory (Colindale, UK). Unfortunately the fluid warmer used in the operation was sterilised immediately after the operation. However, the water bath from a second fluid warmer was sampled. This was in the same operating theatre as the other fluid warmer, and had been filled from the same water source and maintained in the same way. From this we also cultured R. paucula.

Discussion: We propose that contamination of transfused blood possibly occurred during the operation via the Level-1 Fast Flow Fluid Warmer. The water bath of the fluid warmer used in the operation was blood stained, and we believe conversely that fluid from the non-sterile water bath, containing R paucula, was infused into the patient. We will illustrate how this may have occurred and will also describe the organism R. paucula in greater detail.

This case has wide reaching implications as fast flow fluid warmers are used in hospitals across the UK and Europe. Whilst they have contributed to the saving of countless lives during medical and surgical emergencies we believe that this case illustrates an important infection control issue regarding the use of this equipment.