ALCOHOL SWABS AND VENEPUNCTURE

1388 ALCOHOL SWABS AND VENEPUNCTURE

SiR,—Referring to venepuncture to obtain blood from motorists the Independent of March 18, 1989, carried the front-page heading "Police swabs may wipe drivers’ slates clean". Although it has been shown that it is unnecessary to swab the skin before venepuncture for non-microbiological purposes’ most doctors continue to do so. This procedure does not interfere with most blood analyses. However, the presence of an alcohol on the skin could affect blood ethanol measurement. We investigated this in ten healthy medical students aged 20-25 during an evening of heavy social drinking. The students had five pairs of venepuncture samples taken hourly during the evening-one sample from the right arm, which was not swabbed, and the other from the left arm which was

swabbed five times and then allowed to dry before sampling. The swabs used were isopropanol (’Mediswab’) and absolute ethanol, in five students each. Blood was taken with 21 G needles into 5 ml disposable syringes and stored in fluoride tubes (’Vacutainer’). After precipitation of protein with 6-25% w/v trichloroacetic acid, the plasma was assayed for ethanol by an enzyme method (Sigma

Diagnostic).2

significant difference in blood ethanol between and control arms (mean difference only 0 36 swabbed isopropanol when the arm had been swabbed with ethanol However, mg/dl). there was a significant increase in apparent blood alcohol (mean difference 521 mg/dl (paired t test 3 26, p < 0-005). We conclude that swabbing with isopropanol does not affect the measurement of blood ethanol. In contrast, swabbing with absolute ethanol may increase the apparent blood ethanol by up to 18 mg/dl (the biggest difference we found for blood alcohol levels of up to 250 mg/dl) and this may have medicolegal significance. There

was no

Department of Clinical Biochemistry, King’s College Hospital Medical School, London SE5 9PJ

GILES J. P. PEEK JIM W. KEATING ROBERTA J. WARD TIMOTHY J. PETERS

1. Dann TC. Routine skin preparation before injection: is it necessary? Nurs Times 62: 1121-22.

1966;

2. Bucher T, Redetzki H. Eine spezifische photometrische Bestimmung Athylalkohol auf Fermentativen Wege. Klin Wochenschr 1951; 29: 615.

von

S:R,—The fiasco of alcohol-soaked swabs being used before for alcohol estimations on motorists has drawn attention to a useless and extravagant procedure that should now be relegated to the archives of medical history. Swabbing of the skin with alcohol for a few seconds performs no useful function. In no way can it sterilise the skin;’ giving injections without skin preparation does not cause infection (local or systemic);2 and shaving the skin and then rubbing with alcohol swab, before putting in a catheter, may not only cause discomfort but also increases the risk of sepsis. Furthermore, trying to stem the bleeding point with a wafer-thin pad soaked with alcohol is inefficient and tends to let blood soak onto the operator’s fingers.

taking blood

Stepping Hill Hospital, Stockport SK2 7JE

group. Departments of Paediatric Pulmonary Medicine, Erasmus University and University Hospital Rotterdam/Sophia Children’s Hospital, 3000 Rotterdam, Netherlands; and Juliana Children’s Hospital, The Hague, Netherlands

NEBULISED BUDESONIDE IN SEVERE CHILDHOOD ASTHMA may effectively control severe asthma in children.1,2 Since November, 1987, we have treated with young budesonide nebuliser suspension 56 infants and preschool children (mean age 35 months, range 7-76) who had frequent severe asthma despite maintenance treatment (nebulised salbutamol, ipratropium, cromoglycate, beclomethasone suspension, oral theophylline and/or oral prednisone). Budesonide suspension (0-25 or 0-50 mg/ml) was administered via a face mask or mouth piece and a jet

J. C. DE JONGSTE E. J. DUIVERMAN

S, Avital A, Rosier A, Manddberg A, Uwyyed K. Nebulised budesonidem infantile asthma. Lancet 1987; ii: 851-52. 2. Gleeson JGA, Price JF. Controlled trial of budesonide given by the Nebuhaler in preschool children with asthma. Br Med J 1988; 297: 163-66. 1. Godfrey

severe

SUBCUTANEOUS ERYTHROPOIETIN AND PERITONEAL DIALYSIS

G. J. ARCHER M. K. KHAWAR

1. Dixon B. Clean shaven? World Med 1984 (July): 15. 2. Dann TC. Routine skin preparation before Injection: an unnecessary procedure. Lancet 1969; ii: 96-97. 3. Court-Brown CM. Pre-operative skin depilation and its effect on post-operative wound infection. J R Coll Surg Edin 1981; 26: 238.

SIR,-Budesonide

nebuliser (Pari ’Inhalierboy’), and was mixed with various combinations of the maintenance drugs and saline to a total volume of 3-4 ml. The initial budesonide dose ranged from 0-5 to 25 mg per day (mean 0-8). To date, these children have been followed up for 1-17 months (mean 9) after the start of budesonide. Treatment with budesonide was well tolerated. Striking improvement was seen in 27 cases, some improvement in 20, and no effect in 9, as judged subjectively by one of us. All 5 children who were on daily oral prednisone could be weaned off this medication during budesonide treatment. Co-medication could be reduced substantially; 14 out of 55 stopped salbutamol; ipratropium could be stopped in 14 of 34 children, cromoglycate in 12 of 19, and theophylline in 15 of 26. Beclomethasone was replaced by budesonide in all 23 subjects on this compound. Of these 23, 20 improved considerably while on budesonide and 3 were unchanged. This improvement can be attributed to the much higher budesonide dose (mean 0-77 mg per day in this subgroup) compared with the beclomethasone dose used previously (mean 0.1 mg per day), and therefore does not indicate superiority of budesonide above beclomethasone. A total of 123 prednisone courses were given in the 12 months before budesonide treatment (2-2 per child per year), compared with 41 courses during budesonide therapy (0-9 per year of follow-up). Before budesonide, 1 -3 clinical admissions per child per year were necessary compared with 0-5 admissions per year during budesonide treatment. Side-effects were mild and rare: hoarse voice (1) and peri-oral dermatitis (2). No clinical signs of adrenal insufficiency were noted. Adrenal cortisol reserve was assessed by means of a short ACTH test (250 IU of synthetic ACTH administered intravenously; cortisol measured in venous blood before and 30 min after ACTH). All 11tested children, who had received a mean daily dose of 06 mg budesonide during an average follow-up of 10 months, showed normal cortisol responses (mean cortisol level before, 0-22 [range 0-08-0-40] umol/1; after 0-70 [0’40-0’90] umol/1). Our uncontrolled observations on the effect of nebulised budesonide in 56 infants with severe asthma suggest that this treatment is successful in many of those in whom other therapies fail to control symptoms. The high concentration of this new formula now makes it feasible to administer a high dose of an inhaled corticosteroid to young children, which may prove to be an important advance in the treatment of severe asthma in this age

SiR,— Dr Macdougall and colleagues (Feb 25, p 425) described single-dose pharmacokinetic profiles of intravenous,

the

intraperitoneal,

and

subcutaneous

recombinant

human

erythropoietin (r-HuEPO) in patients on continuous ambulatory peritoneal dialysis (CAPD). They suggest that the subcutaneous route would be satisfactory for regular administration. We have treated twelve anaemic (Hb below 9 g/dl) CAPD patients with thrice-weekly subcutaneous r-HuEPO for more than 26 weeks (range 26-71 weeks). All responded with a rise in Hb of more than 2 g/dl, and in 10 the Hb reached 11-11-5 g/dl (figure). The two partial responders had occult chronic bacterial infection. r-HuEPO, formulated at 10 000 IU/ml (Ortho), allows subcutaneous doses of less than 1 ml. The self-administered injections into the thigh caused very little discomfort and no local reactions, and no patient experienced the influenza-like symptoms described by some patients receiving intravenous r-HuEPO.’ Aggravation of hypertension was the major adverse effect of raising