tailieunhanh - Critical Care Obstetrics part 32

Critical Care Obstetrics part 32 provides expert clinical guidance throughout on how you can maximize the chances of your patient and her baby surviving trauma. In this stimulating text, internationally recognized experts guide you through the most challenging situations you as an obstetrician are likely to face, enabling you to skillfully:Recognize conditions early-on which might prove life threatening, Implement immediate life-saving treatments in emergency situations, Maximize the survival prospects of both the mother and her fetus | Thromboembolic Disease clotting profile and hematocrit should be drawn. There are three basic choices in the approach to anticoagulant management in such patients. 1 Continue therapeutic anticoagulation. This approach is recommended for particularly high- risk patients such as those with recent PE iliofemoral thrombosis or mechanical heart valve pros-theses. Because a more uniform therapeutic heparin level is desirable the patient may be changed from subcutaneous injection to continuous IV infusion. A heparin level of units mL or a low therapeutic aPTT close to times normal may be desirable in these surgical patients. 2 Reduce the subcutaneous heparin dose. In patients at lower risk of thromboembolism the heparin dose can be reduced to a prophylactic level 5000 units every 12 hours this dose is not associated with increased surgical bleeding. 3 Stop or withhold heparin administration. For patients at increased risk for operative bleeding . suspected placenta accreta and at relatively low risk of clot propagation heparin may be temporarily withheld or its effects reversed with protamine sulfate. Non-pharmacologic prophylaxis . pneumatic compression stockings may be substituted during the intraoperative period. With patients who are anticoagulated and in whom rapid reversal is deemed essential protamine sulfate can be used to reverse either UFH or LMWH. One milligram of protamine sulfate neutralizes 100 units of heparin. To determine the proper dose of protamine several approaches are available. One is to calculate the amount of circulating heparin by estimating the plasma volume at 50mL kg of body weight and multiplying the plasma volume by the heparin concentration 17 . In most institutions however this procedure may not be technically feasible. If heparin level is not available the amount of protamine sulfate to give should be underestimated or slowly titrated to the whole-blood clotting time because of the short half-life rapid metabolism of heparin