By W. Jaffar. State University of New York College at Fredonia. 2019.
Currently buy generic top avana on line, the most widely used diagnostic criteria are the Duke University criteria that were notably amended to include Q fever serology as a new major criterion [6 generic top avana 80 mg amex, 41] cheap top avana 80 mg overnight delivery. However purchase top avana online, the sensitivity of these modiﬁed criteria is limited, especially in the early stages of the disease, in cases of negative blood culture and in the presence of prosthetic valve or pacemaker/deﬁbrillator leads. In addition, special attention should be paid to the medical history of the patient that may point towards a speciﬁc diagnosis. In particular, the following epidemio- clinical clues may facilitate the diagnosis. Bartonella quintana should be suspected in homeless, alcoholic and/or patients coming from Maghreb; Tropheryma whipplei in patients >50 y-o with chronic arthralgias; Coxiella burnetii in patients >40 y-o with bicuspid aortic valve; Brucella sp. Blood Cultures Signiﬁcant improvements have been made in blood culture over the past decades , notably permitted by enhanced automated systems (that enable cultivating most pathogens including Candida sp. These include the recommendations that three sets of blood cultures consisting of ≥10 mL of blood per vial should be collected prior to antibiotic admin- istration  and that extended incubation of vials should only be performed when cultures remain sterile after 48–72 h [46 ]. The former two agents being the most common world- wide , these assays should be prioritized. Assays for the other agents should be used according to the local epidemiology (see above). The usefulness of testing patients for antibodies to Chlamydia species appears 250 P. The role of mannan:anti-mannan antibodies and (1,3)-β-d-glucans in the diagno- sis of Candida sp. Valve Culture When valvular surgery is necessary, it is essential to obtain valve samples for histol- ogy, culture, and molecular detection assays. Valvular biopsies may remain culture- positive longer than blood in the case of early antibiotic therapy. Other Laboratory Assays Antinuclear and antiphospholipid antibodies and rheumatoid factor may be searched in patients with a history of chronic athro-myalgias. It may espe- cially be useful in pauci-symptomatic patients, as may be the case in Bartonella or T. This is especially important for fastidious micro- organisms, many of which are not susceptible to the empirical therapy (Table 18. Doxycycline (200 mg/day) + cotrimoxazole (960 × 2/ [ 79] day) + rifampin (300–600 mg/day) p. Lifelong ﬂuconazole when surgery is contraindicated Coxiella burnetii Doxycycline (200 mg/day, to be adapted to serum  (agent of Q fever) level) + hydroxychloroquine (200–600 mg/day, to be adapted to serum level) p. Doxycycline (200 mg/day) for 6 weeks [70 – 73] Tropheryma whipplei Doxycycline (200 mg/day, to be adapted to serum  (agent of Whipple’s level) + hydroxychloroquine (200–600 mg/day, to be disease) adapted to serum level) p. The plasma levels of both drugs should be monitored throughout the treatment (objective: 0. It should be noted that the same therapy, prescribed for 1 year, was demonstrated to efﬁciently prevent the development of endocarditis in patients with a valvular defect who develop acute Q fever [66 , 67]. The rationale for using this combined therapy and for monitoring plasma levels of both drugs is similar to that for C. Trimethoprim-sulfamethoxazole, once considered as the reference antibiotic for Whipple’s disease, should no longer be used as T. However, among the published cases of Mycoplasma endocarditis, the three patients treated with doxycycline recovered [70 – 73] vs only one of four patients who received other antibiotics [74–77]. Therefore, doxycycline, rather than ﬂuoro- quinolones, should be used for these infections. Conclusion Blood culture-negative endocarditis is a severe disease that remains a diagnostic challenge. As several fastidious agents of endocarditis require a speciﬁc antibiotic therapy, diagnostic assays should be diversiﬁed and adapted to local epidemiology and to the patient’s medical and exposure history. Lamas was supported by Novartis Laboratories to attend national and international conferences. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Contribution of systematic serological testing in diagnosis of infective endocarditis. Proposed modiﬁcations to the duke criteria for the diagnosis of infective endocarditis. Comprehensive diag- nostic strategy for blood culture-negative endocarditis: a prospective study of 819 new cases. Surgical results for active endocarditis with prosthetic valve replacement: impact of culture-negative endocarditis on early and late out- comes. Differences between endocarditis with true negative blood cultures and those with previous antibiotic treatment. Comparison of out- come in patients with culture-negative versus culture-positive active infective endocarditis. The infective endocar- ditis team: recommendations from an international working group. Dramatic reduc- tion in infective endocarditis-related mortality with a management-based approach. A 10-year survey of blood culture negative endocarditis in Sweden: aminoglycoside therapy is important for survival. Infective endocarditis in the Western Cape Province of South Africa: a three-year prospective study. Infective endocarditis: a ﬁve-year expe- rience at a tertiary care hospital in Pakistan. Blood culture negative endocarditis: analysis of 63 cases presenting over 25 years. Current characteristics of infective endocarditis in Japan: an analysis of 848 cases in 2000 and 2001. Reassessment of blood culture-negative endocarditis: its proﬁle is similar to that of blood culture-positive endocardi- tis. Preeminence of Staphylococcus aureus in infective endocarditis: a 1-year population-based survey. Infective endocar- ditis in patients with negative blood cultures: analysis of 88 cases from a one-year nationwide survey in France. New trends in the epidemiological and clinical features of infective endocarditis: results of a multicenter pro- spective study. Community- acquired culture-negative endocarditis: clinical characteristics and risk factors for mortality. Characteristics of infective endocarditis in a developing country-clinical proﬁle and outcome in 192 Indian patients, 1992–2001. A retrospective review of 228 episodes of infective endocarditis where rheumatic valvular disease is still com- mon. Epidemiology of infective endocarditis in Tunisia: a 10-year multicenter retrospective study. Prospective compari- son of infective endocarditis in Khon Kaen, Thailand and Rennes, France. Impact of serology and molecular methods on improving the microbiologic diagnosis of infective endocarditis in Egypt. Bartonella and Coxiella infective endocarditis in Brazil: molecular evidence from excised valves from a cardiac surgery referral center in Rio de Janeiro, Brazil, 1998 to 2009. Increased risk for heart valve disease associated with antiphospholipid antibodies in patients with systemic lupus erythematosus: meta-analysis of echocardiographic studies. Spectrum of cardiac lesions in Behcet disease: a series of 52 patients and review of the literature. New criteria for diagnosis of infective endocarditis: utiliza- tion of speciﬁc echocardiographic ﬁndings. Development and assess- ment of a new early scoring system using non-speciﬁc clinical signs and biological results to identify children and adult patients with a high probability of infective endocarditis on admis- sion. Controlled evaluation of 5 versus 10 milliliters of blood cultured in aerobic BacT/Alert blood culture bottles. Recovery of clinically important microorganisms from the BacT/Alert blood culture system does not require testing for seven days. Modiﬁcation of the diagnostic criteria proposed by the Duke Endocarditis Service to permit improved diagnosis of Q fever endocar- ditis. Value of microimmunoﬂuorescence for diagnosis and follow-up of Bartonella endocarditis.
The guidelines allow a patient to eat a nonfat meal up to 618 hours before an elective procedure and support a fasting period for clear liquids of 2 hours for all patients buy top avana 80mg without a prescription. Coffee and tea drinkers should follow fasting guidelines but should be encouraged to drink coffee prior to their procedure because physical signs of caffeine withdrawal (headache) can occur generic top avana 80 mg online. To ensure patients are optimally medically managed before their outpatient surgery purchase top avana 80 mg without prescription, patients should have clear instructions concerning what chronic medications they should take before surgery and when (Table 31-4) generic 80mg top avana mastercard. Anxiety Reduction Most patients are anxious before scheduled surgery, and they are probably anxious long before they come to the outpatient area. Anxiety may begin as soon as the surgeon states the patient needs an operation and may not end even after discharge from the outpatient facility. Reasons for anxiety include concerns about family, worry about pain after the procedure, fear of complications, and lack of social support. Preoperative reassurance from nonanesthesia staff, use of booklets or audiovisual instruction with information about the procedure, or a preoperative visit by the anesthesiologist can all help reduce preoperative anxiety. However, not all outpatients are anxious and whether it is necessary to give every patient a preoperative drug to decrease anxiety is not clear. If in doubt about patient anxiety, ask the patient; do not assume every patient needs a drug to reduce anxiety. Certainly some of a child’s anxiety before surgery concerns separation from a parent or parents. A child is more likely to demonstrate problematic behavior from the time of separation from parents to induction of anesthesia if the procedure has not been explained preoperatively. Parents 2110 and children need to be involved in some preoperative discussions together so that the parents do not transmit their anxiety to the child. If the parents are calm and can effectively manage the physical transfer to a warm and playful anesthesiologist or nurse, premedication is not necessary. Whether having the parent present during induction reduces a child’s anxiety is unclear, though the practice of parental presence during anesthesia induction is widespread. Some parents can become upset when they see their anesthetized child, who appears to be dead, albeit breathing, and with a beating heart. Separation anxiety on the part of the parents is probably no different if the child is awake or asleep. Managing the Anesthetic: Premedication The outpatient is not that different from the inpatient undergoing surgery. In both, premedication is useful to control anxiety, postoperative pain, nausea and vomiting, and to reduce the risk of aspiration during induction of anesthesia. Because the outpatient is going home on the day of surgery, the drugs given before anesthesia should not hinder recovery. Most premedicants do not prolong recovery when given in appropriate doses for appropriate indications, although drug effects may be apparent even after discharge. Benzodiazepines Midazolam, a benzodiazepine, is currently the drug most commonly used to reduce preoperative anxiety and induce sedation. In adults, it can be used to control preoperative anxiety and, during a procedure alone or in combination with other drugs, for intravenous sedation. With19 this dose, most children can be effectively separated from their parents after 10 minutes and satisfactory sedation can be maintained for 45 minutes. Some children, particularly younger and more anxious children, even when they receive midazolam 0. Oral diazepam is useful to control anxiety in adult patients, either the day before surgery or the day of surgery and before intravenous line insertion. Sleepiness associated with the effects of anxiolytics may delay or prevent the discharge of patients on the day of surgery, although more frequently patients are admitted because of the effects of the operation. With regard to anesthesia effects, patients more frequently stay in the facility not because they are too sleepy but because they are nauseous. In adults, particularly 2111 when midazolam is combined with fentanyl, patients can remain sleepy for up to 8 hours. Although children may be sleepier after oral midazolam, discharge times are not affected. A comparison of three doses of a commercially prepared oral midazolam syrup in children. Routine administration of supplemental oxygen with or without continuous monitoring of arterial oxygenation is recommended whenever benzodiazepines are given intravenously. This precaution is important not only when midazolam is given as a premedicant but also when it is used alone or with other drugs for conscious sedation. The potential for amnesia after premedication is another concern, especially for patients undergoing ambulatory surgery. For benzodiazepines, the effects on memory are separate from the effects on sedation. In addition, amnesia is not simply an effect of drug administration but, among other factors, it is also a function of stimulus intensity. Opioids and Nonsteroidal Analgesics Opioids can be administered preoperatively to sedate patients, control hypertension during tracheal intubation, and decrease pain before surgery. Treatment for shivering is usually instituted at the time of shivering, not in anticipation of the event. Other drugs, including clonidine, tramadol, and ketamine can also help control shivering. Opioid premedication prevents increases in systolic pressure in a dose- dependent fashion. After tracheal intubation, systolic, diastolic, and mean arterial blood pressures sometimes decrease below baseline values. The term “preventive analgesia” (as opposed to “preemptive analgesia”) is used to mean treatment of postoperative pain for a longer duration than the effect of the target drug (e. Laparoscopic cholecystectomy is less painful than open cholecystectomy, though patients undergoing the laparoscopic procedure also have postoperative pain. Children undergoing cleft-lip24 repair who received acetaminophen before surgery had similar pain relief postoperatively as compared to patients who received the acetaminophen intraoperatively. Ibuprofen or acetaminophen can be given orally25 preoperatively, or administered rectally to children around the time of induction. For patients seen for the first time in the preoperative holding area, midazolam 0. Except for obstetric cases, for which regional anesthesia may be safer than general anesthesia, all three types are otherwise equally safe. However, even for experienced anesthesiologists, there is a failure rate associated with regional anesthesia. For others, the preference of patients, surgeons, or anesthesiologists may determine selection. The cost of sedation is usually less than the cost of a general or regional anesthetic. In one study using New York’s ambulatory surgery databases, the authors analyzed patients undergoing inguinal hernia repair. They found that hospital cost was less if open inguinal hernia repair with local/regional anesthesia was used ($6,845) compared to general anesthesia ($7,839) and laparoscopic repair ($11,340). The different types27 of anesthesia and surgery, though, are not an option for all operations. Another study that compared groin hernia repair after either general, regional, or local infiltration, found that medical complications were more common, particularly in patients of 65+ years after regional versus general anesthesia and urologic complications were more common after regional versus local infiltration. In a retrospective study, authors compared spinal anesthesia to general anesthesia for patients undergoing hip or knee replacement procedures. They found that hospital treatment costs and length of stay were less for patients who received spinal anesthesia. In a review of peripheral regional anesthesia and outcome, the authors note that outcome studies of peripheral regional analgesia have yet to be published. However, postoperative mobilization and upper limb analgesia are generally better following regional anesthesia. Patients who receive spinal anesthesia for31 ambulatory surgery may take longer to be discharged if micturition is required, though discharge instructions do not necessarily have to require a patient to micturate prior to discharge. When applying studies of regional anesthesia to everyday practice, remember that the studies arise from centers where the authors are experienced in performing regional anesthesia and there are good systems to support the practice. Note also that anesthesiologists who are more experienced performing regional anesthesia are more likely to provide regional anesthesia.
Although the goals of the visit are no different than for any other patient purchase 80 mg top avana, there are issues more common among the elderly population that should be raised top avana 80mg otc. For example purchase top avana 80 mg with visa, will the patient’s living situation provide the support necessary for a successful recovery? Furthermore purchase genuine top avana, elderly patients may require a long time to return to their preoperative level of function, assuming full recovery is even possible. Older patients often recognize that the end of their lives is no longer the theoretical consideration of youth, so they are more likely to have living wills, health-care proxies, and health-care directives in place at the time of surgery. A retrospective cohort survey of elderly Medicare beneficiaries found that almost a third undergo surgery in their last year of life and that over 18% undergo surgery 2248 in the last month of their lives. The older patient’s expectations from67 surgery may be much different than that of their younger counterparts, and medical practitioners must be careful not to judge a patient’s decision-making based on the practitioner’s values or expectations. The prospect of functional impairment may be more worrisome to the older patient than even death. Such personal values are particularly important when questions of competence arise and the physician could be tempted to question competence if the patient’s decision does not coincide with the opinion of the physician. If health-care directives prohibit various life-sustaining or resuscitative procedures, the patient/proxy and anesthesiologist must come to a mutual understanding of what will or will not be performed if an untoward event occurs in the perioperative period. As much as 30% of ambulatory older adults require medical care for adverse drug events, and upward of 30% of hospitalizations in the elderly are related to drug effects. In fact, one of the major goals of geriatric consult services69 to surgical patients is to pare down those medications whenever possible. The anesthesiologist can help by alerting the primary care team to this issue and suggest a geriatric consult. In the very old, dehydration, elder abuse, and malnutrition are all more common than generally appreciated. In the case of malnutrition, the deficit may be limited to isolated deficiencies such as vitamin D or B , or it may be more global and include inadequate caloric12 intake from poor oral hygiene or the “anorexia of aging,” in which neuroendocrine changes lead to early satiety and diminished sense of taste. In fact, the Veterans Affairs National Surgical Quality Improvement Program found albumin to be as sensitive an index for mortality or morbidity as any other single indicator, including the American Society of Anesthesiologists status. Integration of the patient’s medical status, the impact of surgery, and the patient’s goals require a comprehensive approach that encompasses both preoperative optimization and potentially prolonged postoperative recovery. In the preoperative period coordination of care, cost-effective73 testing and consultation and development of discharge and transition plans 2249 are started immediately leading to identification of patients who need specialized care and interventions to optimize preoperative status and improve the likelihood of maintained, if not improved, functional status after surgery. Intraoperative Management There are no magic bullets for the induction of general anesthesia in older patients. The effects of a bolus induction dose on a single patient are highly variable, so admittedly there is a certain amount of guesswork. In general, smaller doses are needed in comparison with young adults, and the efficacy of using a lesser amount becomes more apparent if more time is allowed for the drug to achieve its peak target organ (brain) effect. A given blood level of propofol causes a greater decrease in brain activity in an older patient, but the decrease in blood pressure is even more dramatic in comparison to the decrease observed in young adults. Many74 strategies can be used to minimize the decrease in blood pressure, but most attempt to reduce the amount of propofol with the use of adjuncts such as opioids, or combining small doses of propofol with etomidate. Etomidate has been43 observed to produce less hypotension than propofol in older patients. It can be argued that an excessive hypertensive response to intubation may be more harmful than a brief period of hypotension. One must expect that significant changes in blood pressure, up or down, will occur, and the sooner the practitioner recognizes those changes, the quicker the aberration can be treated. Cycling the blood pressure cuff every minute should alert the practitioner to these changes sooner than would less frequent cycling. Although swings in blood pressure may not be desirable, there is little evidence that even major, but brief, changes in blood pressure lead to adverse outcomes. Whether general or neuraxial anesthesia is used, the maintenance phase of anesthesia will commonly result in a significant decrease in systemic blood pressure, more so than typically occurs in younger patients. Although76 decreases in both systemic vascular resistance and cardiac output likely occur, the decrease in vascular resistance is probably the largest contributor, although this observation has really been confirmed only during spinal anesthesia. However, the afterload reduction from the decrease in blood pressure presumably allowed the ejection fraction to increase, thereby ameliorating the effect the decrease in 2250 end-diastolic volume had on stroke volume. Because vascular resistance contributes significantly to the decrease in blood pressure during anesthesia, it has been argued that the use of α-agonists is an appropriate therapy and may be more effective than volume alone. Although no one would advocate vasoconstriction as a treatment for hypovolemia (except as a stopgap measure), the ventricle can only get so big; therefore, it is impossible for volume administration alone to raise cardiac output enough to compensate for a large decrease in vascular resistance. Furthermore, when sympathetic nervous system activity returns postoperatively, blood will shift from the periphery to the central circulation. Excess peripheral volume now becomes excess central volume and could push an elderly heart into diastolic heart failure. In short, volume administration to an older patient may be problematic, with a very fine line between too much and too little, and what was “just right” in a deeply anesthetized state may become “too much” later on. Figure 34-8 The response to total sympathectomy from spinal anesthesia as illustrated in older men with cardiac disease. Hemodynamic response and change in organ blood volume during spinal anesthesia in elderly men with cardiac disease. An endotracheal tube will likely have more adverse effects than a laryngeal mask on mucociliary clearance and possibly on swallowing. The advantage of an endotracheal tube is in the ability to guarantee control of ventilation and thereby greater ability to prevent hypercarbia and intraoperative atelectasis. If positive-pressure ventilation is utilized, one important goal is to have the lung volume exceed closing capacity during the respiratory cycle in order to prevent atelectasis. Initial studies found that the low tidal volume strategy tended to be associated with lower levels of inflammatory markers. Another aspect of anesthetic management that is likely deleterious to the aging pulmonary system is the presence of residual neuromuscular blockade. Initially observed with pancuronium, intermediate acting neuromuscular blocking agents have also been implicated and the phenomenon is associated with adverse respiratory events such as hypoxia and airway obstruction. Nevertheless, at least one study has shown that older patients81 (average age 75) are at almost double the risk of residual neuromuscular blockage and adverse respiratory events in comparison to middle-aged adults. This observation argues for very careful use of nondepolarizing83 muscle relaxants in older patients. Postoperative Care The goals of emergence and the immediate postoperative period are no different for an elderly than a young patient; they are just more difficult to achieve. Analgesia is a major goal, and it should be stated up front that there is no evidence that pain is any less severe or any less detrimental in an older patient than in young patients. Less drug may be required (or not), but given that the standard approach to analgesia is to titrate to the desired effect, the 2252 outcome should be good pain relief for patients of any age. However, there are impediments to achieving adequate analgesia in an older patient. Older patients have more difficulty with visual analog scoring systems than verbal or numeric systems. If the patient is cognitively impaired, communication of pain is further impaired; indeed, demented patients often experience severe pain after hip surgery, but even mild cognitive impairment can lead to problems with pain assessment or with use of a patient-controlled analgesia machine. Failure to achieve adequate levels of analgesia is associated with numerous adverse outcomes, including sleep deprivation, respiratory impairment, ileus, suboptimal mobilization, insulin resistance, tachycardia, and hypertension. The apparent paradox of adequate analgesia is that opioids are the mainstay of postoperative analgesia, and opioids are capable of producing many of those same adverse outcomes. Therefore, as with all medical care of elderly patients, good judgment, caution, and frequent monitoring of analgesia and adverse effects are essential. Adjunctive medications such as nonsteroidal anti-inflammatory drugs have been shown to reduce opioid requirements and some of the opioid adverse effects, but often carry their own risks such as renal damage or gastrointestinal toxicity. Epidural analgesia is well known to provide84 analgesia that is superior to intravenous therapy, a finding that has been specifically replicated in the elderly. Although many aspects of postoperative care are more likely to be the purview of the surgeon or the internist, there are some things that the anesthesiologist could and probably should be watchful for when performing a postoperative visit on an older patient. If a patient had a surgery with major fluid requirements, it is important to look for signs of fluid overload, including rales, dyspnea, tachypnea, and orthopnea, particularly around postoperative day 2 when third space fluid tends to mobilize. A timely administration of a diuretic may prevent the development of overt pulmonary edema and the accompanying escalation of therapy and risk. Feel the pulse: atrial fibrillation is often intermittent and the more often someone looks for it, the more likely it will be detected.
The risk of severe hemorrhage after attempted removal of the placenta is greatly increased in patients who have undergone prior uterine surgery generic 80mg top avana otc, including cesarean delivery order genuine top avana online. This is related to a higher incidence of placenta accreta order 80mg top avana with visa, which results from the penetration of myometrium by placental villi order top avana online pills. The risk of placenta accreta in women with previa increases from 3% in primary cesarean section to 61% in quaternary section. When placenta accreta is suspected or known, delivery is usually scheduled at 36 to 37 weeks of gestation via cesarean hysterectomy. Some institutions may use occlusive balloon catheters placed in the internal iliac arteries prior to surgical delivery. In the face of bleeding with either placenta previa or accreta, when maintenance of fertility is desired, arterial embolization or ligation, uterine compression sutures, and/or methotrexate therapy may be attempted to avoid hysterectomy. Complications include Couvelaire uterus (when extravasated blood dissects between the myometrial fibers), renal failure, disseminated intravascular coagulation, and anterior pituitary necrosis (Sheehan syndrome). The diagnosis of abruptio placentae is based on the presence of uterine tenderness and hypertonus as well as vaginal bleeding of dark, clotted blood. Bleeding may be concealed if the placental margins have remained attached to the uterine wall. If the blood loss is severe (>2 L), there may be changes in the maternal blood pressure and pulse rate, indicative of hypovolemia. Fetal movement may increase during acute hypoxia or decrease if hypoxia is gradual. Management of abruption depends on presentation, gestational age, and the degree of compromise. Management of milder cases of abruption includes artificial rupture of 2881 amniotic membranes and oxytocin augmentation of labor, if required. In the presence of nonreassuring fetal status, an emergency cesarean delivery may be performed. If fetal death has occurred, usually with severe abruption, vaginal delivery is reasonable if the mother is stable. Postpartum hemorrhage is usually defined as blood loss greater than 500 mL after vaginal delivery or greater than 1,000 mL after cesarean section. The incidence of postpartum hemorrhage is increasing in the United States, mainly due to an increase in uterine atony. Treatment of postpartum hemorrhage may require aggressive uterotonic therapy for atony, intrauterine balloon tamponade or evacuation of the uterus for retained products of conception (Table 41-2). If there is a need for dilation and curettage, the anesthesiologist may be asked to provide uterine relaxation. This can be accomplished with volatile agents if the patient is under general anesthesia or with intravenous nitroglycerin if regional anesthesia or general anesthesia is used. The anesthesiologist’s role in management of obstetric hemorrhage includes both maternal resuscitation and provision of anesthesia for cesarean delivery, cesarean hysterectomy, or dilation and curettage. The choice of anesthetic technique depends on the anticipated duration of surgery, maternal condition and volume status, the potential for coagulopathy, and urgency of the procedure. General anesthesia is indicated in the presence of uncontrolled hemorrhage and/or severe coagulation abnormalities. Neuraxial anesthesia, usually continuous epidural anesthesia, has been successfully used for hysterectomy in planned, controlled situations. A saddle block is an option for anesthesia when dilation and curettage for treatment of postpartum hemorrhage is indicated and the patient is hemodynamically stable. All of these tasks may be challenging in the parturient and consideration should be given to performing them in advance of hemorrhage when hemorrhage is anticipated. Prompt transfusion of blood component therapy is crucial for replacement of blood loss, maintenance of tissue oxygenation, and correction of coagulopathy. In recent years, transfusion rates for postpartum hemorrhage have increased 92% in the United States. Early administration of platelets and cryoprecipitate has also become common in hemostatic resuscitation protocols for major traumatic hemorrhage, and crystalloid and colloid administration is minimized in favor of blood products (see Chapter 53). Hypothermia, metabolic acidosis, and coagulopathy commonly occur in traumatic and obstetric hemorrhage. Because of these commonalities, it has become common to extend these successful transfusion practices from the trauma literature to obstetric practice. Transfusion of cryoprecipitate or better, fibrinogen concentrate, should be incorporated early in obstetric hemorrhage because decreased fibrinogen levels strongly correlate with increased severity of postpartum hemorrhage. Other options are available to decrease transfusion requirements and reduce blood loss. Intraoperative cell salvage, formerly shunned because of concerns about the risk of amniotic fluid contamination of red cells, has been implemented safely during cesarean section in many centers. The antifibrinolytic drug tranexamic acid has been shown to decrease bleeding in both elective cesarean section and postpartum hemorrhage and is recommended for early use in resuscitation by a European task force131; however, further studies are needed to confirm its safety. Medical and surgical advancements have changed the types of cardiac problems seen in pregnancy. Patients with congenital heart disease are reaching childbearing age, and the number of patients with rheumatic heart disease has declined. Older parturients may present with aortic stenosis and insufficiency associated with a bicuspid aortic valve. The increase in maternal blood volume, which occurs at 20 to 24 weeks of gestation, may also precipitate cardiac decompensation. During labor, cardiac output increases progressively above antepartum levels; with each uterine contraction, approximately 200 mL of blood moves into the central circulation. Consequently, stroke volume, cardiac output, and left ventricular work increase, and each contraction consistently increases cardiac output by 10% to 25% above that of uterine diastole. The greatest change occurs immediately after delivery of the placenta, when cardiac output increases to an average of 80% above prepartum values; in some patients, it may increase 2884 by as much as 150%. Evaluation of pre-existing heart disease is crucial and a multidisciplinary approach is necessary when managing patients with complicated cardiac disease during pregnancy and parturition. Labored breathing and venous stasis from aortocaval compression may mimic pulmonary and peripheral edema associated with congestive heart failure. Finally, elevation of the diaphragm causes the heart to rotate, signs of which may be mistaken for cardiac hypertrophy. For the anesthesiologist, it is particularly important to understand how the hemodynamic consequences of different anesthetic techniques might adversely affect mothers with specific cardiac lesions. Exceptions are patients with pulmonary hypertension, right-to-left shunts, or coarctation of the aorta. Because hemodynamic changes observed during labor and delivery persist into the postpartum period, if used, invasive monitoring should continue for 24 to 48 hours postpartum. Congenital Heart Disease Many patients with successful surgical repair of congenital heart defects are asymptomatic with minimal cardiac findings. Patients with uncorrected or partially corrected lesions may have serious cardiac decompensation with pregnancy. This includes patients with corrected tetralogy of Fallot who may have recurrence of a small ventricular septal defect or develop outflow obstruction. Neuraxial labor analgesia is recommended to minimize hemodynamic changes associated with pain. Patients with corrected ventricular septal defects or atrial septal defects require no special care, nor do those with small asymptomatic atrial septal defects or ventricular septal defects. Large ventricular septal defects or atrial septal defects are associated with pulmonary hypertension. Eisenmenger syndrome occurs when uncorrected left-to-right shunt results in pulmonary hypertension, which, when severe, reverses flow to a right-to- 2885 left shunt. Pregnancy is not well tolerated and mortality can approach 30%, most commonly from embolic phenomena. Implementing labor analgesia that does not lead to deleterious hemodynamic changes is a challenge; opioid-based neuraxial techniques (e. Cesarean delivery is most often accomplished under general anesthesia in women with Eisenmenger syndrome. It should be recognized that arm-to- brain circulation times are rapid owing to right-to-left intracardiac shunts; drugs given intravenously have a rapid onset of action. In contrast to parenteral drugs, the rate of rise of arterial concentrations of inhaled drugs is slow because of decreased pulmonary blood flow. The myocardial depressant and vasodilating actions of volatile drugs may be hazardous in patients with Eisenmenger syndrome, and nitrous oxide, which may increase pulmonary vascular resistance, should be avoided. Valvular Heart Disease The decrease in incidence of rheumatic heart disease in the developed world has resulted in fewer parturients with valvular heart disease.