Intravenous Site Research Articles

Comparison of whole blood collection and double-unit erythrocytapheresis in preoperative autologous blood donation

We compared preoperative autologous blood donation (PABD) using serial manual whole blood (WB) and PABD using a single session, double-unit erythrocytapheresis in terms of the hemodynamic recovery and clinical outcomes. This study included 56 donors in the WB PABD group and 117 donors in the double-unit erythrocytapheresis PABD group. All subjects were men with body weight >70 kg, Hb level >13.3g/dL, Hct >40%, and who were scheduled for oral and maxillofacial surgery. Three cycles of manual WB collection for PABD or a single session, double-unit erythrocytapheresis using the Alyx was performed. There were no significant differences in donor demographic variables including age, height, weight, Hb, Hct, or red cell mass between the 2 groups. The double-unit erythrocytapheresis was completed earlier than the last manual WB PABD (at 15.3 ± 4.7 days and 6.5 ± 3.2 days before surgery, p<0.001). Hct values before surgery were higher in the double-unit erythrocytapheresis PABD group than in the manual WB PABD group (39.7 ± 3.2 vs. 38.6 ± 2.7, p=0.024). ΔHct and %ΔHct before the first PABD and before surgery were lower in the double-unit erythrocytapheresis PABD group than in the manual WB PABD group (-5.6 ± 2.8 vs. -6.8 ± 2.7, p=0.010 and -12.3 ± 5.9 vs. -14.8 ± 5.6, p=0.008, respectively). The incidence of additional allogeneic blood transfusions during or after surgery and the post-operative Hb and Hct values were similar in the 2 groups. The length of hospital stay after surgery was significantly longer in the manual WB PABD group than in the double-unit erythrocytapheresis group (6.1 ± 2.5 vs. 5.4 ± 1.9, p=0.043). Of the 33 donors in the double-unit erythrocytapheresis PABD group, 7 (21.2%) reported discomforts related to the procedure, and 6 graded the discomforts (hypocalcemia, perioral tingling sense, paresthesia, dizziness, stuffiness, pain on the intravenous site, and muscle tension) as mild. The single session, double-unit erythrocytapheresis prolonged the time interval between PABD and surgery and led to better hemodynamic recovery than the serial manual WB PABD, and hypocalcemic symptoms were mild.

NAP5 and depth of anaesthesia monitoring

We read with interest the editorial by Avidan and Mashour 1 accompanying the National Audit Project (NAP)5 baseline report by Pandit et al. 2. We are somewhat surprised at the criticism of the methodology of this study and the inference that this may lead to an under-reporting of the true incidence of awareness. Considering that surgical procedures are commonly performed under regional anaesthesia or monitored anesthesia care in fully awake or sedated patients, we question the significance of awareness during surgery that is not reported. If it isn't reported then it could be contested that it is not something that has distressed the patient, especially when this is a topic that is widely reported in the media and when UK patients do not appear reluctant to complain or even litigate. It is also important, from the same perspective, to differentiate between awareness with and without pain, the latter, as with regional anaesthesia, being unlikely to trouble patients. It is also difficult to understand how the results from the NAP5 baseline report support Avidan and Mashour's elaboration on total intravenous anaesthesia (TIVA), bispectral index (BIS) and end-tidal anaesthetic concentration. Firstly, the assertion that TIVA is associated with a higher incidence of awareness with recall is based on a study from Spain (in which the interview details were not published) 3 and one from China 4. In the former, the incidence of awareness with recall in TIVA was even less than the average US incidence reported in the AIM trial 5, and the latter reports exceptionally high incidences of awareness with recall no matter what technique of anaesthesia was used. Neither of these studies could provide details on the TIVA technique and the dose of anaesthetic. Such figures suggest serious problems with the way anaesthesia is being delivered generally and make it impossible to know whether TIVA was being used appropriately. Other studies suggest no difference in the incidence of awareness with TIVA compared with inhalation anaesthesia 6-8. Secondly, TIVA has meanwhile gained in popularity. In many earlier audits, it was an uncommon technique mainly performed by ‘enthusiasts’, hence the risk of awareness was difficult to quantify in comparison with inhalation anaesthesia techniques. Although TIVA requires careful monitoring of the intravenous infusion site there is, however, no other reason why TIVA should increase awareness risk. In fact, the ability to titrate to clinical effect at induction using target controlled infusions is a distinct advantage over inhalational anaesthesia, induction of which is usually with an intravenous drug and subsequently delivered according to minimum alveolar concentration (MAC), the statistically ‘mean’ dose. Although it is possible to measure end-tidal concentrations of inhalational agents, anaesthetic management based on concentration has not been shown to reduce awareness in itself. In the B-unaware study 9, awareness with recall occurred even when BIS values and end-tidal anaesthetic concentrations were within the target ranges. Indeed, the incidence of explicit recall was no different whether end-tidal anaesthetic concentration was used or not in a large prospective Scandinavian study 7. The inherent variability of MAC 10 makes it, therefore, problematic to suggest protocols to reduce awareness with recall based on end-tidal anaesthetic concentration only. Thirdly, it is erroneous to recommend that a processed EEG-based monitor (pEEG) be used in order to decrease the likelihood of awareness with recall if TIVA is chosen. These monitors may be useful irrespective of the anaesthesic technique used but also have significant limitations. The only reason that they could be more useful with TIVA is for the same reason that TCI can be titrated. As for pEEG, for intravenous and volatile agents alike, at least with TCI this can be titrated during induction. Not only does pEEG show remarkable intra-individual variability at loss of consciousness, it also varies according to the anaesthetic drug(s) used 10. With TIVA the same drugs are used during induction and maintenance. Consequently, if used, pEEG can be titrated to clinical signs of loss of consciousness, potentially increasing reliability and effectiveness. When intravenous induction is followed by volatile maintenance, this advantage is lost and, again, effectiveness is based on statistical probability. Bispectral index (BIS) monitoring is probably the most commonly used pEEG monitor. Only two relevant prospective, randomised, controlled trials, concluded that BIS monitoring was of benefit to high-risk patients, the B-aware study (supported in part by the manufacturer) and the BIS cardiopulmonary bypass study, which was underpowered to detect an effect 11, 12. Although brain function monitors in general may add a certain value in titrating anaesthetic drugs, the low utilisation of these devices found in the NAP5 baseline report still appears to be associated with a lower incidence of awareness with recall than expected. Therefore, it seems that more evidence needs to be produced to promote their use solely to prevent awareness with recall.

Factors causing thrombophlebitis in horses: methods of prevention 2

The first part of this article explored the concepts of identifying high risk patients, correct preparation of intravenous catheter sites and using ultrasound to monitor catheter sites. This part of the article will explore the merits of using self-disinfecting catheter caps, dressings, culturing catheters and a catheter care bundle to help prevent intravenous catheter complications in horses. The development and use of a specific catheter care bundle could raise the standards of care for hospitalised horses and enhance the knowledge and skills held by the registered equine veterinary nurses looking after them.

Factors causing thrombophlebitis in horses: methods of prevention 1

Intravenous catheters are commonly used in equine practice but can often lead to complications such as thrombus and thrombophlebitis. Registered equine veterinary nurses should be vigilant when monitoring catheter sites so that complications can be prevented. This two part article identifies effective monitoring techniques and preventative strategies to help minimise the incidence of intravenous catheter site complications in equine patients. In this part of the article the focus will be on the correct preparation and monitoring of the catheter site.

Extensive Subcutaneous Emphysema Resembling Necrotizing Fasciitis

Necrotizing fasciitis is an aggressive, invasive soft tissue infection. Because it can rapidly progress to patient instability, prompt diagnosis followed by urgent debridement is critical to decreasing mortality. Despite the importance of early diagnosis, necrotizing fasciitis remains a clinical diagnosis, with little evidence in the literature regarding the effectiveness of diagnostic tools or criteria. Common clinical findings are nonspecific, including pain, blistering, crepitus, and swelling with or without fever and a known infection source.This article describes a patient who was transferred to the authors' institution from another hospital, where she had been taken following seizure activity and was treated with antibiotics for suspected cellulitis at the intravenous catheter placement site on her left dorsal hand. On admission to the current authors' institution, she presented with pain and swelling in the setting of significant left upper-extremity emphysema. She had undergone a left shoulder arthroscopy 4 weeks previously. Vital signs were within normal limits, and a preoperative chest radiograph was read as normal. The patient underwent an emergent fasciotomy, irrigation and debridement of the left upper extremity, and intravenous antibiotics for suspected necrotizing fasciitis. Intraoperative findings indicative of infection were absent, and a left apical pneumothorax was later found on postoperative chest imaging.In a stable patient with a normal chest radiograph on presentation who demonstrates upper-extremity crepitus suspicious for necrotizing fasciitis, a chest computed tomography scan may be indicated to rule out an intrathoracic source.

Identification of highly concentrated dextrose solution (50% dextrose) extravasation and treatment—a clinical report

Treatment for significant hypoglycemia includes administration of dextrose containing agents, including 50% dextrose (D50%W) intravenously. Significant extravasation of D50%W can lead to complications, including skin and soft tissue injury, loss of limb, or death. The aim of this case report, using an interdisciplinary team approach, explores extravasation protocols as well as literature review, is to provide information about the proper use of hyaluronidase in patients with D50%W extravasations. A 46-year-old African American man presented to the emergency department (ED) after blood glucose level was initially 13 mg/dL. Emergency medical service established a large bore intravenous (IV) line in the right antecubital vein and administered a total of 50 g of D50%W. Upon arrival to the ED, the patient's level of consciousness had significantly improved. After arrival to the ED, the patient started complaining of pain in his right arm, near the site of the IV line insertion. On inspection, the IV site was grossly infiltrated. Hospital protocols for hyperosmolar infiltration were used. Extravasation is a common medical complication of infused medications and needs to be properly identified and treated. The multitude of skills from nursing, medicine, and pharmacy ensures that extravasation is managed appropriately and effectively to ensure safety to patients. Recognition, communication, and awareness of the institutional guidelines on how to treat infiltration and extravasation should be encouraged in all ED and intensive care unit medical personnel who deal with a variety of infusions and IV medications that have serious implications if not treated correctly.

Treatment of Neonatal Extravasation Injuries Using Non-Contact, Low-Frequency Ultrasound: Development of a New Treatment Protocol

Intravenous therapy is essential in the treatment of preterm infants in the neonatal intensive care unit; however, complications such as extravasation can occur. Extravasation, an inadvertent leakage of fluid from an intravenous site into the surrounding soft tissue, can cause partial and full thickness wounds. Therefore, wound management is an important component of care in the premature infant population and appropriate treatments are necessary. A review of the literature confirms there is currently no gold standard for treatment of extravasation injuries in neonates. Non-contact, low-frequency ultrasound, performed by physical and occupational therapists, can be a feasible and efficacious treatment for extravasation injuries sustained by preterm infants in the neonatal intensive care unit. This manuscript presents current evidence on treatment of extravasation and proposes a new protocol that can assist with guiding physical and occupational therapists, as well as other health care providers, in treating extravasation injuries using non-contact, low-frequency ultrasound in neonates.

Incidence of phlebitis in patients with peripheral intravenous catheters: The influence of some risk factors

Objective: To identify the incidence of phlebitis and the risk factors which contribute to its development in patients with peripheral intravenous catheters. Design: Prospective observational study. Setting: Medical ward of a central hospital in Portugal. Subjects: Patients with peripheral intravenous catheters hospitalised in the medical ward. Interventions: Nurses observed the peripheral intravenous (IV) catheterisation site daily. If there were complications, the catheter was replaced, and both the development of phlebitis and the procedure were recorded. Results: A total of 1,244 catheters were observed, and 317 were removed/inserted. Incidence of phlebitis was 11.09%. A multivariate analysis of risk factors for phlebitis showed patients with KCI (OR: 2.112; CI: 1.124‑3.969), who were on antibiotics (OR: 1.877; CI: 1.141‑3.088) and who had a catheter in an upper limb (OR: 0.31; CI: 0.111‑0.938) were at higher risk for phlebitis. Conclusion: Despite the patients’ profile (high mean age and high level of dependency), the risk factors are related to the use of prescribed medication and the catheterised limb. Although these findings show the development of phlebitis is not solely related to nurses’ practices, the authors believe these professionals can have an important impact on the prevention of phlebitis. The results show the accurate selection of the catheterisation site, which relies entirely on the nursing intervention, is an important factor for phlebitis.

Salvage Antibiotic-Lock Therapy in Critically Ill Pediatric Patients

Salvage Antibiotic-Lock Therapy in Critically Ill Pediatric Patients

Can Propofol Mimic Alcohol-related Pain in Patients with Hodgkin Lymphoma?

Alcohol-related pain was first reported in 1950 in association with Hodgkin lymphoma (HL).1Initially considered a highly predictive and specific symptom of HL, over the years however, it has also been seen in osseous diseases, pancreatitis, and malignancies of the thymus and pancreas.2We present the case of a patient who experienced a painful episode mimicking alcohol-related pain, in association with the anesthetic agent propofol.A 34-yr-old woman was scheduled for a diagnostic biopsy of an enlarged lymph node, possible right video-assisted thoracoscopic surgery, and biopsy of a mediastinal mass under general anesthesia. She had earlier presented with a 4-month history of episodic right shoulder discomfort with acute worsening after alcohol ingestion. A week before seeking medical help, she noticed a “lump” in her right shoulder, which on examination was provisionally diagnosed as an enlarged supraclavicular lymph node. Computed tomography scan of the chest revealed an anterior mediastinal mass. Of note, she had no history of anesthesia. On the day of surgery, general anesthesia was induced with the patient lying comfortably in a supine position on the operating table. Immediately after intravenous injection of the induction dose of propofol (150 mg), the patient complained of severe upper back pain on the right side (site of underlying disease) and became agitated and restless. Local extravasation of the induction agents was excluded by visual examination of the intravenous site. Because there was no significant change in vital signs and the patient remained hemodynamically stable, succinylcholine (100 mg) was administered intravenously and the airway was secured uneventfully. The procedure and remainder of the patient’s hospital course were uneventful. The histopathology report confirmed the diagnosis of HL (nodular sclerosis type). The peculiar set of circumstances, i.e ., severe pain in the upper back during intravenous administration of propofol, prompted us to review the literature regarding this particular symptom. Association of pain with alcohol ingestion is well known and has been reported in the past, particularly in the oncology literature.3–5Alcohol-related pain has been classically associated with HL. The reported incidence of this disorder is approximately 3%.6Women and those with nodular sclerosis subtype of HL are especially prone; the alcohol content of a liqueur-filled chocolate or even a sip of beer has been reported to trigger the pain.3,5,7The onset of pain is immediate; the patient descriptions of pain vary from “aching” to “stabbing,” and the intensity ranges from mild to unbearable, forcing some patients to give up alcohol entirely.5The exact mechanism is unknown, but it is hypothesized that a localized alcohol associated allergic response induces vasodilatation and swelling in the diseased tissue, activating nociceptive signals.5,8This may help explain the high correlation observed between the site of the pain and underlying disease.3Although it is difficult to establish an exact cause-and-effect relationship in our case, several features about our patient’s episode led us to speculate that her symptom was propofol associated. First, the patient’s pain was precipitated immediately after intravenous injection of propofol and in the absence of any other inciting factors, so this witnessed temporal relationship between the onset of pain and propofol infusion, and its location in the vicinity of her underlying disease lends credence to our assumption. The previous descriptions of alcohol-related syndrome have also been based on circumstantial evidence and establishment of a temporal association between alcohol consumption and pain.3–5Second, the vasodilatory effect of propofol could possibly have stimulated nociceptors by a similar mechanism. Finally, the patient’s sex, diagnosis of nodular sclerosis type of HL, and history of alcohol-related pain in the shoulder suggest that she may be susceptible to painful episodes of such nature.Despite the circumstances surrounding the patient’s episode and her suggestive history, in the absence of supportive literature, the reason for the cross-reactivity between alcohol and propofol (as manifested by a common symptom) is unknown. It would also be unfair to suggest that all patients with HL who experience alcohol-related pain will experience propofol-associated pain also. That said, it would be beneficial for anesthetists to be cognizant of this association.*Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. oshakil@bidmc.harvard.edu

Management of chemotherapy extravasation: ESMO–EONS Clinical Practice Guidelines

Extravasation is the process by which any liquid (fluid or drug) accidentally leaks into the surrounding tissue. In terms of cancer therapy, extravasation refers to the inadvertent infiltration of chemotherapy into the subcutaneous or subdermal tissues surrounding the intravenous or intra-arterial administration site. Extravasated drugs are classified according to their potential for causing damage as ‘vesicant’, ‘irritant’ and ‘nonvesicant’ (Table 1). Some vesicant drugs are further classified into two groups: DNA binding and non-DNA binding. Allwood et al. (2002) divided the drugs into vesicants, exfoliants, irritants, inflammitants and neutrals.

A Pilot Project to Improve Neonatal Peripheral Intravenous Site Assessment and Documentation

A Pilot Project to Improve Neonatal Peripheral Intravenous Site Assessment and Documentation

Local Cutaneous Necrosis Secondary to a Prolonged Peripheral Infusion of Methylene Blue in Vasodilatory Shock

To report a case of methylene blue extravasation and subsequent tissue necrosis in a patient with refractory septic shock. A 47-year-old female presented with febrile neutropenia secondary to chemotherapy. The patient quickly decompensated to refractory septic shock in the critical care unit despite implementation of early goal-directed therapy as well as intravenous norepinephrine and vasopressin to stabilize her hemodynamic status. She received a 16-hour infusion of 1% methylene blue 0.25 mg•kg(-1)•h(-1), titrated up to 0.5 mg•kg(-1)•h(-1), via a peripheral intravenous catheter. Ten hours after the start of the methylene blue infusion, she experienced a local extravasation injury, which led to distal digital necrosis. While her hemodynamic status improved dramatically, allowing discharge from the intensive care unit and eventually to home, the extravasation site became necrotic and required debridement and skin graft. Methylene blue is a vasoactive chemical that has been shown to provide hemodynamic stability in the treatment of refractory septic shock. Methylene blue administration is not considered standard of practice in the treatment of refractory septic shock and many aspects of its dosing, route, duration, and adverse effects are poorly described. As such, there is little guidance for its administration. We postulate that, in our patient, in the presence of systemic vasopressin and norepinephrine, methylene blue caused extensive vasoconstriction at the site of extravasation, resulting in tissue ischemia and necrosis. Tissue necrosis secondary to peripheral intravenous extravasation has not been previously described and is not listed as an adverse outcome on the drug monograph. The Naranjo probability scale indicates that the tissue necrosis was probably caused by the methylene blue extravasation. To mitigate future risk to limb and skin, we recommend that methylene blue infusions be delivered via central venous catheter. Extra care should be given to patients with risk factors for extravasation, such as sedation, presence of systemic disease, proximal intravenous puncture sites, and improperly placed catheters.

The use of 50% nitrous oxide improves successful intravenous access in obese and growth-limited children in an outpatient setting

Commentary on: Ekbom K, Kalman S, Jakobsson J, et al. Efficient intravenous access without distress: a double-blind randomized study of midazolam and nitrous oxide in children and adolescents. Arch Pediatr...

Adverse events related to intravenous antibiotic therapy: a prospective observational study in the treatment of infective endocarditis

ObjectiveThe goal of this prospective observational study was to identify adverse events (AEs) related to the use of intravenous access sites used for infective endocarditis (IE) treatment in a tertiary...

A Case of Skin Necrosis after Extravasation of Intravenous Immunoglobulin

Extravasation of certain drugs can make an injury on the injection site. It occurs more often in the fragile skin of children and old people. Immunoglobulin treats immune-mediated diseases effectively, such as a primary deficiency of antibodies or autoimmune diseases. A 9 months old boy came to hospital complaining of a fever for 5 days. He had bilateral non-purulent conjunctival injection, erythema of the lips and rashes on the hands and feet. On the echocardiography, the left coronary artery was dilated. He was diagnosed with Kawasaki disease. We started an intravenous immunoglobulin injection. After 7 hours, edema and a change in skin color appeared at the intravenous injection site on his right hand. We removed the catheter and applied a cold pack. Under impression of phlebitis, we applied Mupirocin ointment and Prednicarbate ointment with a dressing, twice a day. Within an outpatient follow up period, a skin necrosis with pus emerged. Coagulase negative Staphylococcus was detected from the pus by microbial culture study. We referred the patient to the Department of Plastic Surgery, and operated a debridement of the skin necrosis and a full thickness skin graft. He was discharged from hospital without a certain problem. The lesion was cured and left a scar. There was no recurrence or exacerbation on the skin graft lesion within a follow up period of 6 months since the surgery. We report a rare case of skin necrosis after extravasation of intravenous immunoglobulin, which had not been reported in Korea before.

Chemical Burn Secondary to Propofol Extravasation

A 58-year-old female presented to the emergency department (ED) with pain and swelling to the right arm after receiving propofol during an outpatient procedure for nasal polyps. During the procedure, it was noted that propofol had infiltrated at the antecubital intravenous (IV) site. A new IV line was inserted, and the procedure was completed. The patient was discharged from the hospital and then presented to our ED. Examination showed a 7-cm-by-8-cm denuded area with erythema and edema in the antecubital region (1% total body surface area). An hour after presentation, ecchymosis developed medially (Figure). There was small amount of serous drainage and tenderness to palpation. She was neurovascularly intact. The burn service was consulted. The patient was admitted to the burn unit and treated with antibiotics. She received a skin graft and discharged on post-op day 5 without any complications.

Remember the Saphenous

The primary objective of this study was to measure the width and depth of peripheral veins using bedside ultrasound in children younger than 3 years. Secondary objectives included the evaluation of other vein and patient characteristics that may affect intravenous (IV) site selection. Assessment of nursing preferences for peripheral IV site selection was performed. Sixty children aged 0 to 3 years who presented to an urban pediatric emergency department were enrolled. Ultrasound measurements of the transverse diameter (width) and distance from the top of the vein to the skin (depth) were recorded. Upon examination, veins were categorized as visible, palpable, detectable only by ultrasound, or not detectable. Sixteen staff nurses rated the likelihood of successful IV placement among different peripheral veins. The mean width of saphenous veins was significantly larger than that of hand veins (2.8 vs 1.8 mm, P < 0.0001). When comparing saphenous veins to antecubital veins, no significant difference was measured between the mean width (2.8 vs 2.8 mm). The mean depth of saphenous veins was significantly greater than those of hand veins (1.9 vs 1.4 mm, P < 0.0001) and antecubital veins (1.9 vs 1.6 mm, P = 0.019). Differences in visibility and palpability were observed between different vein types. Hand veins and antecubital veins were rated by the nursing staff as the most likely sites for successful IV placement, whereas saphenous veins were among the least likely (P < 0.0001). In children younger than 3 years, the saphenous vein is larger than hand veins and is similar in size to antecubital veins, although marginal differences in depth exist. The sonographic findings of the saphenous vein and antecubital vein suggest that either should be considered a superior first choice for IV cannulation in this age group. Knowledge of these differences is important when choosing a site for peripheral IV placement. Future studies should evaluate peripheral IV success rates by vein type with or without ultrasound guidance.

Characterization of H5N1 highly pathogenic avian influenza viruses isolated from poultry in Pakistan 2006–2008

Nine avian influenza viruses (AIV), H5N1 subtype, were isolated from dead poultry in the Karachi region of Pakistan from 2006 to 2008. The intravenous pathogenicity indices and HA protein cleavage sites of all nine viruses were consistent with highly pathogenic AIV. Based on phylogenetic analysis of the HA genes, these isolates belong to clade 2.2 and both the HA and NA are closely related to each other (nucleotide identities above 99.0%) and to other Middle Eastern H5N1 AIV isolates (nucleotide identities above 98.0%). The phylogenetic data suggest that the virus in both epornitics of H5N1 HPAIV in commercial poultry in the Karachi region of Pakistan between 2006 and 2008 were from a very closely related source, however, there is inadequate epidemiological data to determine what the reservoir was for the virus between the 2006 and 2007 outbreaks other than that there was a single introduction into the region.

Hypersensitivity to Rabbit Antithymocyte Globulin in an Islet Transplant Recipient: A Case Report

Objective The aim was to describe a case of hypersensitivity to rabbit antithymocyte globulin (rATG) occurring in the context of islet transplantation. Methods A 36-year-old woman with type 1 diabetes was admitted for islet transplantation. rATG was administered the first day (1.5 mg/kg) with methylprednisolone (2 mg/kg), and on the second day (1.5 mg/kg) without glucocorticoid to avoid potential toxicity to the anticipated islet transplant. Results At the end of the rATG infusion on the second day she developed hives over her face, chest, and back and tender erythema at her intravenous site (Arthus reaction). Islet transplantation was not performed. She reported exposure to a pet rabbit for 2 years in childhood. Overnight, fever developed and the rash evolved into an erythematous morbilliform eruption affecting the torso. Serum high-sensitivity C-reactive protein (hsCRP) and the erythrocyte sedimentation rate (ESR) were elevated; serum complements C3 and C4 were normal. She received prednisone (50 mg) with subsequent resolution of the rash. Nine days after her initial reaction, she developed a recurrence of the rash and fever with arthralgias; levels of C3 and C4 had fallen. Methylprednisolone (125 mg, twice) was required for symptom improvement, and was gradually tapered as prednisone over the next 4 weeks with resolution of the complement, ESR, and hsCRP abnormalities. Five months after the initial attempt at islet transplantation, she returned to receive 7,879 IE/kg via portal vein infusion under basiliximab, etanercept, tacrolimus, and sirolimus immunosuppression and has required no to low-dose (0.1 U/kg/d) insulin to maintain near-normal glycemic control for > 12 months after transplantation. Conclusions Our patient's initial hypersensitivity reaction to rATG was followed by immune-complex type 3 hypersensitivity (serum sickness) requiring high-dose glucocorticoids. Canceling the initial islet infusion proved to be wise, and the patient subsequently did well with islet transplantation under an alternative induction agent.