International Education—a Kaleidoscopic View

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International Educationa Kaleidoscopic View

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raveling to 22 countries around the world as an educator and consultant has forever changed my perception of how people learn, how health care professionals worldwide judiciously and wisely use the resources they have, and how they perceive their roles in patient care. My goal was to make a small difference in the knowledge base of health care professionals. This article outlines my personal experiences with international travel, educational pursuits, and conferring with nurses, physicians, epidemiologists, ministers of health, hospital administrators, and medical product company representatives. It also discusses my impressions of culture and values, teaching and learning, and accomplishments in settings where both fmancial and human resources are sparse, but outcomes are positive and meaningful.

our clean and well-equipped surgical suites and enjoy the best of technology and the most in resources. Seldom, if ever, are we “right” and others “wrong” because practices all over the world, including those in the United States, are deeply entrenched in culture, hidden values, and what we know and think about health care. It was a revelation to me to discover that many principles of care, even though they may reflect local themes and different settings, are common around the world. Innate respect for each other and disregard for believing in only one way of caring for patients are the first steps in becoming versed in international education. Health care practitioners in the United States can become partners with our international colleagues. We cannot drive practices in other cultures, as perioperative nursing and infection prevention are practiced in many different forms. Technical, human, and HELPING IS NOT GOOD ENOUGH financial resources; country regulations; traditions; We have many colleagues around the world, culture; and educational backgrounds often determany of whom are “smarter” than us. We can learn so mine what can and should be done in certain areas of much from these peers, not only because they may do the world. things differently, but also because their environHelping is not good enough, nor is it even the ments mandate that they be creative and resourceful. correct approach. Expertise should be shared when There are many lessons in this for us as we work in requested. Knowledge, information, and practices cannot be imposed, but can be disseminated by allowing for meanA B S T R A C T ingful and careful assess- planning international travel presents opportunities for perioperative ment of the environment, need, nurses to share their knowledge about surgical patient care and pre- and implementation implications.

venting the spread of infection. This article outlines the author‘s personal experiences with international travel, educational pursuits, and conferring with nurses, physicians, epidemiologists, hospital administrators, and medical product company representatives. It also discusses culture and values, teaching and learning, and accomplishments in settings where both financial and human resources are sparse, but outcomes are positive and meaningful. AORN J 70 (OCt 1999) 608-617.

OBSERVATIONS OF WORLD H W T n CARE

The following observations are generalizations only and apply mostly to developing countries. Practices vary both within and among countries and states.

BARBARA J . GRUENDEMANN, RN

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A truck carries supplies of Johnson & Johnson consumer and professional products in Zambia.

A Johnson &Johnson executive presents a check to a representative of the prize-winning clinical unit at University Teaching Hospital, Lusaka, Zambia, after an infection prevention seminar by the author.

Health care practices are inconsistent, especially when comparing urban and rural hospitals. Distribution of health care professionals often is radically uneven, even from hospital to hospital. Unstable currencies and governments and uneven economic growth rates are reflected in health care, and liability concerns are emerging. Hospital administrators primarily are physicians. Public hospitals (ie, funded by the government) are common; however, more and more private hospitals are being built. Hospitals often range from 1,000 to 3,000 beds; lengths of stay and waste management are becoming issues; and ambulatory surgery is just beginning to emerge. Hospitals focus on treating disease, not on preventing it. Physicians, who often speak English, are very powerful and dictate practices. Health care peer review and oversight of practices is only beginning. Data, particularly on infections and rates, often

are inaccurate or nonexistent. Bribes and corrupt business dealings are common. Family members often participate in the hospital care of patients. Building relationships is an important first step to doing business or conducting education sessions. Hospitals often are visited by foreign consultants who come in without knowing the culture or following up. Physicians and nurses place value on foreigners who establish true partnerships by spending time understanding their culture, advising them when asked, and following up. Product use often is not determined by clinicians or end-users. Ministry of health officials are significant health care decision makers. Medical product companies often sponsor education programs for health care professionals. Health care personnel are very resourceful, work hard, and often read American and European journals; however, many books and journals available to them are not current. Health care professionals are open to suggestions on practices that can make their jobs easier, safer, and more efficient and that will protect them and their coworkers, especially with regard to infectious diseases and medication-resistant microbes (eg, basic hygiene practices, care and handling of instruments). There is a dire need for basic hygiene practices. We, as educators and consultants from the United States, can build friends for life if we are willing to research cultures, invest time to build trust and relationships, and supply good basic education and information that is reinforced by scientific studies and journals. It is easy to pass judgment when traveling internationally. Practices and traditions may seem antiquated or against all of the perioperative and infection control principles that we have learned through the years. We must refrain from criticism because this may be all that health care practitioners in developing countries know or can do. Partnership is the only approach that has a long-lasting effect. A FMMRWORK FOR CONSULTING AND TEACHING

Numerous references exist that provide information for traveling internationally; however, journal articles rarely deal with structure and outcomes of nurse education and consultation in foreign countries. There is one article in which the author focuses on 610

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decision-making strategies for foreign nurse consultation.’ Keys to being an effective nurse consultant include learning about another culture and the social skills appropriate for that culture; understanding a different health care system with different practices; sharing information; learning from the host country; and being creative, innovative, and flexible in a complex, changing global environment? The author suggests using a framework that relies on mutual understanding and encourages growth and development through reciprocal learning, exchange collaboration, and consensual deliberation? It is vital at the outset to elicit from the leaders in the host country what they believe they need and their perceptions of the solutions. If health care practices are inherently harmful or even grossly questionable, rather than simply different, the consultant must judiciously inform those leaders while asking questions and coming to an agreement about certain practices. Reciprocal learning takes place when there is mutual respect and true understanding of each other’s perspective. Americans often give the impression that they know everything and that they can tell others how to solve their problems: This, and other references, point to the necessity of doing adequate planning and research before the visit to ensure that the results are satisfactory to all concerned. To ensure a successful consultation or education venture, educators and consultants must assess learning needs and expectations with the client; identify expected roadblocks and barriers to the project, class, or seminar; collaborate with the client on goals that are mutually understood and prioritized; write clear and achievable objectives; create realistic time allocations; define expected outcomes (eg, success will be measured by improved hygiene practices); collect feedback from learner evaluations and positive and negative comments; create plans for changes; plan short- and long-term follow-up with or without the presence of a consultant; and identify the next steps to be taken. Hosts often will ask for information, guidelines, recommended practice statements, journal articles, and books that reflect health care practices in the United States. Health care professionals are anxious to learn new trends and technologies but often need help with assimilating information into their own

practices and cultures. This is the most challenging, and yet the most exciting and satisfying, part of lecturing, consulting, and teaching in global settings. TOPICS FOR EDUCATION

We live in a world where emergent and re-emergent infectious conditions are becoming more common, and pathogenic microbes are developing increased resistance to antibiotics. Nosocomial infections provide the world’s health care systems with one of the greatest challenges of all time. It is no surprise that the issue of greatest concern around the world is infection prevention and control

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(above) Zambian mothers and babies outside of the University Teaching Hospital, Lusaka, Zambia. (let) Chief of cardiac surgery at Vilnius University and the author (fight) after a conference on hand washing in Lithuania.

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throughout the entire hospital, especially within surgical settings. Education topics can include discussion of beliefs (eg, “dirty” procedure technique, the use of ultraviolet lights and fans for disinfecting the air, sterilization of air, sterile water for surgical hand scrubs, tacky mats) or helping health care practitioners understand environmental sanitation and cleaning, traffic patterns, use of shoes and boots in the OR, washing and reprocessing of instruments, and glove use. Effective and practical disinfection and sterilization procedures also are commonly requested topics for education programs. Prevention and treatment of surgical site infections is a frequently mentioned theme, as are the role of infection control nurses; setting up hospital infection control committees; the importance of hand washing, scrubbing procedures, and antimicrobial soaps; and using reusable versus disposable items. Other topics of interest include elevating the status of nurses and forming professional nursing societies, the changing roles of theatre and OR nurses, managing the OR, and preoperative patient preparation. There are opportunities for presenting research

Operating

room nurses in a Moscow hospital. An OR in MOSCOW-

note the sterilization containers and back table.

studies and factual information about questionable practices that may actually cause harm. There also are opportunities to present and learn about different perspectives on a subject where there may be no clear scientific directives. Sometimes simply presenting new thoughts and information will set in motion the strategies for novel approaches to effective patient care. The use of standard and transmission-based precautions often clarifies the notion of a consistent standard care for each patient but also eliminates the necessity of special, often cumbersome and ineffective practices for patients who are diagnosed with an infectious di~ease.~ At times, an educator or consultant can help with setting reasonable priorities. I was asked to condone the purchase of an expensive, state-of-the-art sterilization system for a hospital in a developing country where basic cleaning and decontamination procedures were virtually nonexistent. Hospital administrators and I embarked on a discussion of the principles of care of instruments and equipment that start with proper cleaning. We considered the resources available and together decided that, first, central supply personnel would receive intense training in cleaning procedures. The training would then progress to decontamination and appropriate disinfection protocols. Only much later would a new sterilization system be considered. What I find most lacking in developing countries are the principles of underlying processes (eg, why certain decontamination procedures are performed, the way practices for preparing instruments for disinfection or sterilization should or should not be done). Overuse of antibiotics is seen around the world, including in the United States. In many countries, antibiotics are readily available without a prescription. The prevalence of multimedication-resistant pathogens continues to increase due to overuse and misuse of antibiotics. Proper interpretation and implementation of standard and transmission-based precautions are ways to institute policies and

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practices that help combat and prevent infections in both patients and personnel. Concern for the spread of infections to family members is widespread around the world, especially in cultures in which spouses, relatives, and even children provide much of the care of hospitalized family members. Diseases (eg, tuberculosis; hepatitis A, B, and C) are rampant in many countries of the world. When asked about the prevalence of HIV and AIDS, an African host said, “We don’t have time to think about AIDS now because many more of our people die every day of malnumtion and starvation. We need to solve these problems first.’’ Yet, in parts of the world, entire villages have almost been destroyed by AIDS, often leaving only children, who then must be sent to live in orphanages. In the United States, serious nosocomial infections include bloodstream, surgical site, and urinary tract infections and pneumonia. In developing countries, nosocomial gastrointestinal infections and postpartum infections also cause major morbidity and mortality. Nosocomial spread of HIV is a particular problem in areas where blood products are not screened or where contaminated needles are used.6 In some countries, access to effective care and treatment may be reserved for privileged classes of patients. Patients may receive different care according to their race, gender, or religious beliefs. Cultural and social mores may support a two-tiered system of care.’ Many infection control measures are inexpensive (eg, improved hand washing, control of antimicrobial prescribing, providing surgical site infection rates to surgeons) but difficult to implement.* Caution must be used when attempting to integrate infection control practices in other countries. Listed below are some of the integration problems encountered in one country as described by one researcher:’ physicians and hospital administrators may not be concerned about the economic consequences of nosocomial infections because of payment systems that allow hospitals to pass along such costs to insurance companies or other third-party payers; epidemiologists may be poorly trained or may be mere figureheads; infection control personnel may be overworked and may not be held accountable; there may be insufficient time to identify hospital practices that contribute to infections and require change;

The author conducts a seminar in Tokyo on preventing surgical site infections.

Travel in Japan via the Shinkansen bullet train at 200 miles per hour.

data often are inaccurate; voluntary reporting from physicians and surgeons often is ineffective; surveillance is conducted without analysis and use of data to formulate preventive measures; and financial and other support is lacking from institutions or governments. There are, however, reports of appropriate implementation of educational efforts that resulted in dramatic decreases in surgical site infection rates or other positive outcomes (eg, substitutions for expensive supplies) in countries other than the United States.lo Tailoring US practices to other cultures, countries, and health care systems is an art in itself, and often the process is more difficult than the actual presentation.

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“instrument nurse” duties), circulating (ie, “scouting,” “flooring,” Beginning educational efforts and “running” functions), and with basic infection control infor“assisting the anesthetist” learning mation, rather than elaborate sysexperiences. tems or practices, leads to better Outside of the United States, outcomes. Do not expect immeditechnicians and unlicensed assisate results-changing perceptions, tive personnel rarely function in beliefs, rituals, traditions, and either the primary scrub person or behaviors usually is a long-term circulating nurse roles. In most of process, and sometimes may not the countries I have visited, only be possible or even desirable. registered graduate nurses scrub Goals and expectations should be and circulate; assistants particirealistic. Sometimes “planting pate only as helpers to the circuseeds” of good practices (eg, simlating nurse. In many Countries, ple hand cleansing,) is all that is Banner for an educational conferthe scrub person-not the circulat‘needed or requested for that time ence in Dublin. ing nurse-is the nurse leader and and place. overseer of the OR. In these cases, There is a large body of evidence that supports the increasing importance of the scrub person is the most highly educated and infection control activities worldwide. Staphy- experienced nurse. The rationale is that the most lococcus aureus surveillance activities in several expertise is needed at the sterile field and at the surcontinents illustrate these trends. Long before the geon’s side, and that this person can direct activities United States became one of the leading countries in of the other nursing and assisting personnel even nosocomial infection control and prevention, several while scrubbed. The patient, they say, directly beneEuropean journals covered issues associated with fits because the procedure goes more quickly and smoothly as the surgical team members, especially infection control.” Problems of dealing with nosocomial infections the nurse and surgeon, function very effectively and are very real in most countries of the world. professionally and truly respect each other’s expertIncreasing use of epidemiological tools, intense inter- ise and roles. As one theatre nurse told me, “It all est in controlling these infections, and heightened happens at the sterile field. That’s where the patient educational efforts are positive signs of action for is, and that’s where the smartest and best of us should be!” We, in the United States, could do well to at least dealing with this ever-present dilemma. examine this thinking and ponder innovative role functions as others see and practice them. EDUCATION OF NURSES Education of professional nurses is extremely variable around the world, ranging from primitive INTERNATIONAL ETIQUEITE International travel not only provides opportunischools, classrooms, and cumcula to well-funded, technologically and conceptually advanced citadels ties for teaching and consultation, it also provides of higher learning. The shortage of nurses is of crisis opportunities for demonstrating a knowledge of manproportions in many developing and developed coun- ners, customs, and proper attitude. Often, it is the tries. Often, the status and salaries of nurses are very traveler’s sensitivity to local traditions and practices low and contribute to discontent and dismay. In spite that makes a visit successful. We can enhance our messages to others by of this, nurses are organized in many countries and hold regular education conferences and meetings. knowing the environment in which we will be placed Education seminars are highly valued and usually and the people with whom we will interact. very well attended. Foreign nurses often relish the Understanding another country and its mores, cusopportunity to go to conferences in other parts of the toms, and etiquette facilitates trust-a cornerstone of successful international travel and interactions. A world and actively work to make this a reality. Many basic nursing schools have “operating the- savvy traveler is prepared and has a thorough knowlatre and room blocks” that vary from a few weeks to edge of the country; its political systems; religious three to four months and incorporate scrubbing (ie, beliefs, traditions, and taboos; educational systems; LESSONS LEARNED

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culture; and the primary local and national newspapers. On several occasions, I was asked to delay the beginning of my seminars for a prayer meeting. Religious beliefs often play a large role in health care, hospitalization, and in feelings towards the body, surgery, and death. Information on the health system is required and should include the role of ministries of health, public versus private hospitals, health care funding sources, key opinion leaders, common infection control and perioperative practices, and the role of the family in health care and hospitalization of family members. It is always helpful to leam metric system basics and the country’s monetary exchange system. The traveler should be familiar with basic foods of the country and may even need to leam how to use local eating utensils. Education of the traveler includes partaking of and enjoying local dishes and specialties. An American who continually looks for “American” food (eg, hamburgers, french fries) will not be popular with the country hosts. Learning key phrases (eg, hello, good morning, good evening, thank you, excuse me) in the country’s language is essential. Beginning a seminar or hospital visit with a few sentences in the native tongue is certain to endear you to the hosts and always is appreciated. Using basic, simple language when giving lectures or presentations is the key to thorough understanding by the attendees. Cliches must be avoided whenever possible. For example, on a trip to South Korea, I used the clichC “knock on wood” during a presentation. After I detected snickering from the audience, I realized that the phrase had been translated into “hit the trees.” If translation is provided, a presentation should always be rehearsed in the presence of the translators before the actual presentation. Nursing and medical terminology may need special attention for translation. The dress code for seminars and hospital visits usually is conservative business attire. Asking for clarification of terms, such as casual or formal, is the safest practice. In some cultures, an elegant shirt for men-without a tie-is considered very appropriate formal wear or business attire. Social events should be attended with an attitude of active participation whenever appropriate. Business decisions in many countries are made during meals, sporting events, and social occasions, and not necessarily during formal meetings in a health care setting.

Beginning a seminar with a few sentences in the country’s language always is appreciated.

Timing for appointments often is unpredictable. In some Latin American countries, lateness is not considered disrespectful; guests are expected to arrive late for events and appointments. In other countries, it is considered disrespectful and rude to be late for any type of event. For lectures and hospital visits, it is best to always be on time. In many countries, business cards are seen as important symbols of status and credibility. Business cards may be studied and laid on a dining table in front of the place setting and may be referred to during a meal. Care should be taken to avoid visible and immediate placement of business cards in a purse, billfold, or briefcase. In some Asian countries, cards are exchanged in a symbolic manner by bowing and using both hands to present the card with the name facing the receiver. In some situations, business cards should be translated into the native language before the visit. Wherever one travels, it is important to know the function and value of business cards. Giving gifts is an established custom in most countries. It is best to bring small, wrapped items to have available when a situation in which giving a gift is appropriate (eg, when a gesture of thanks is needed). Examples of gifts that US travelers might give include music audiotapes or compact discs or brochures, books, or postcards of home cities, states, or hospitals. Stationery is another gift option. Receiving gifts is done with grace and thanks. A common concern among international travelers is misinterpretation of a lecture or opinion because of language or cultural gaps. In my experience, this seldom happens if basic concepts and words are used and if there is adequate communication between the speaker and the translator. Sometimes translation enhances the basic message. A number of foreigners have traveled and studied

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in the United States and speak at least two languages fluently. Even though international travel may be eclectic collections of diverse expectations and values, I have found that there also are many commonalties, including concerns, issues, the regard for the primacy of education, and even language. Attention to details, simple manners, common courtesies, innate sensitivity, and the passionate desire to observe and learn are traits that make up what is called “international etiquette.” One author summarizes this etiquette by calling for careful preparation, asking proper questions, and obtaining good information about the people of a particular country, not just statistics or financial spreadsheets: We Americans tend to have trouble not only with foreign tongues but also with our own. We should watch what we say every waking hour in another country, because in blundering ahead with what we think is humorously teasing, we may actually be insulting our hosts. . . . The key to success in your business and personal relationships in a foreign country is preparation in learning about the country and a sincere desire to fit in.” A

KAL#DoscoPIcVIEW

Perched on a bookcase in my study is a handcarved miniature mahogany African hippopotamus, a symbol of strength and endurance. Also present is a magnificent, colorful Japanese fan, a symbol of a traditional culture where health care is a valued priority, and where practices and regulations both mirror and NOTES 1. M M Rosenkoetter, “A framework for international health consultants,”Nursing Outlook 45 (July/AuguSt 1997) 182-187. 2. Ibid. 3. Ibid. 4. Ibid, 184-185. 5. J S Garner, “The hospital infection control practices advisory committee. Guideline for isolation precautions in hospitals,’’Infection Control & Hospital Epidemiology 17 (January 1996) 53-80. 6. M D Nettleman, “Global aspects of infection control,” Infection Control & Hospital Epidemiology 14 (November 1993) 646-648. 7. Ibid.

differ from ours. There also is a miniature flag of the Republic of Ireland, where cultural ideologies and modern technologies are the root of advanced practices and a high regard for the value of education. These symbols only point out the wide diversity of cultures and beliefs that can unite, rather than divide, us. Perioperative nursing flourishes worldwide, with differing skin colors, languages and dress, and names all serving to unite us with the pervasive thread of providing the best for surgical patients around the world. The gifts I have been given and experiences I have had have created within me a deep respect for the ways in which our colleagues passionately regard their professional calling. Educators and consultants who travel intemationally have much to offer our colleagues around the world, but we also have a great deal to learn from them. To be successful, we need to leave our judgmental biases at home, truly partner with our intemational peers, and realize that there is power in collective worldwide nursing endeavors. All international transactions require vision and leadership, common goals, sensitivity, finesse, hardiness, a sense of wonder and awe, and a fierce desire for experiences that will forever change the way you see yourself, others, and the world. A

8. Ibid, 648. 9. H S Leu, “The impact of USstyle infection control programs in an Asian country,” Infection Control & Hospital Epidemiology 16 (June 1995) 359-364. 10. M D Cavalcante et al, “Cost improvements through the establishment of prudent infection control practices in a Brazilian general hospital, 1986-1989,” Infection Control & Hospital Epidemiology 12 (November 1991) 649-653; C P Coppola, S A Spector, “Mission to Brazil: A surgical perspective,” Bulletin of the American College of Surgeons 83 (August 1998) 24-33; D E Meier, J L Tarpley, “Improvisation in the developing world,” Surgery, Gynecology &

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Barbara J . Gruendemann,RN, M S , FAAN, is an educator and project director for G4 Productions, Dallas. Obstetrics 173 (November 1991) 404-406. 11. A F Widmer, H Sax, D Pittet, “Infection control and hospital epidemiology outside the United States,” Infection Control & Hospital Epidemiology 20 (January 1999) 17-21. 12. L Baldrige, “Traveling abroad It pays to be nice,” Hyatt Magazine (Mar~h/April1989) 12-15. SUGGESTED READING Adolph, H P; Adolph B J. “Surgery on the edge of the desert.” Bulletin of the American College of Surgeons 82 (June 1997) 8-19. Asefzadeh, S. “Tracking hospital deaths in a developing region.” Nursing Management 28 (July

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1997) 41-43. Association of Operating Room Nurses, Inc. International Resource Directoiy for Perioperative Nursing. Denver: Association of Operating Room Nurses, Inc, 1996. Carty R M , White, J F. “Strategic planning for international nursing education.”Nursing Outlook 44 (MarCh/April 1996) 89-93. Chang, M K. “Bridging the cultural gap.” Urologic Nursing 15 (December 1995) 123-126. Close, W T. “Despite all odds: How do we continue to practice good medicine.” Bulletin of rhe American College of Surgeons 8 1 (March 1996) 23-34. Finely, Jr, R K. “An old surgeon finds new work, part II.” Bulletin of the American College of Surgeons 81 (July 1996) 15-25. Geelhoed, G W. “Wanted: Worldclass surgeons.” Bulletin of the American College of Surgeons 83 (September 1998) 32-42. Gruendemann, B J. “The value of education.” In Perioperative Nursing, K Nightingale, ed. London: Arnold Publishing, in press.

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Gruendemann, B J; Fernsebner, B. “Global perioperative nursing.” In Comprehensive Perioperative Nursing Volume I : Principles, 333358. Boston: Jones & Bartlett, 1995. Howell, H S ; Furman, L. “An

experience in general surgery: Zambia, Africa.” Bulletin of the American College of Surgeons 8 1 (October 1996) 8-13. Huskins, W C, et al. “Infection control in countries with limited resources.” In Hospital Epidemiology and Infection Control, C G Mayhall, ed, 1176-1200. Baltimore: Williams & Wilkins, 1996. Kalnins, I. “Pioneers in academia: Higher education for nurses in Estonia, Latvia, and Lithuania.” Nursing Outlook 43 (MarchIApril 1995) 84-87. Karosas, L M. “Life in Lithuania as perceived by Lithuanian nurses.” Nursing Outlook 43 (July/August 1995) 153-157. Morrison, T; Conaway, W A; Borden G A. Kiss, Bow, or Shake Hands: How to do Business in Sixty Countries. Holbrook, Ma: B Adams, Inc, 1994.

Nettleman, M D. “The global impact of infection control.” In Prevention and Control of Nosocomial Infections, second ed, R P Wenzel, ed, 13-20. Baltimore: Williams & Wilkins, 1993. Pannuti, C S. “The costs of hospital infection control in a developing country.” Infection Conrrol & Hospital Epidemiology 12 (November 1991) 647-648. Ponce-de-Leon Rosales, S; Frausto, S R. “Organizing for infection control with limited resources.” In Prevention and Control of Nosocomial Infections, third ed, R P Wenzel, ed, 85-93. Baltimore: Williams & Wilkins, 1997. Reeder, J M. “Secure the future, a model for an international nursing ethic.” AORN Journal 50 (December 1989) 1298-1307. Soderdahl, D W. “Is a thirdworld mission right for you?” Bulletin of the American College of Surgeons 83 (September 1998) 26-3 1. Thornhill, A M. “Perioperative nursing in a national health care system.” AORN Journal 60 (August 1994) 302-309.

Bedside Leukocyte Reduction Filters May Cause Hypotension Patients who receive blood products transfused through bedside leukocyte reduction filters may develop precipitous drops in blood pressure, according to a May 4, 1999, letter from the US Department of Health and Human Services. The hypotensive reactions have a rapid onset, and in some cases patients also develop respiratory distress and shock, faciat flushing, abdominal pain and nausea, and loss of consciousness. In most situations, the symptoms are reversed by discontinuing the transfusion and performing appropriate medical intervention. According to the letter, some sources attribute many of these events to the use of angiotensin converting enzyme inhibitors and the use of negatively charged filter surfaces. An analysis of the data by the US Food and Drug Administration (FDA), how-

ever, shows that neither of these variables is consistently associated with the reactions. The common variable in almost all of the hypotensive events appears to be bedside leukocyte reduction filtration. The FDA also found that almost no adverse events associated with the use of in-process, leukocyte-reduced blood products have been reported. It has been hypothesized that these products allow for the breakdown of bradykinin, a potent vasodilator. The FDA therefore recommends using blood products that have been leukocyte-reduced during collection or during laboratory storage. US Department of Health and Human Senlices, Hypotension and Bedside Leukocyte Reduction Filters (IetteL Rockville, Md: US Food and Drug Administration, May 4, 1999) 1-3.

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