Prevention of Venous Thromboembolism : The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

https://www.chpso.org/sites/main/files/file-attachments/chest-2008-geerts-381s-453s.pdf

Prevention of Venous Thromboembolism* American College of Chest Physicians Evidence- Based Clinical Practice Guidelines (8th Edition)

https://rapm.bmj.com/content/rapm/43/3/263.full.pdf

Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition).

Maternal hemorrhage, defined as a cumulative blood loss of greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process, remains the leading cause of maternal mortality worldwide (1). Additional important secondary sequelae from hemorrhage exist and include adult respiratory distress syndrome, shock, disseminated intravascular coagulation, acute renal failure, loss of fertility, and pituitary necrosis (Sheehan syndrome).Hemorrhage that leads to blood transfusion is the leading cause of severe maternal morbidity in the United States closely followed by disseminated intravascular coagulation (2). In the United States, the rate of postpartum hemorrhage increased 26% between 1994 and 2006 primarily because of increased rates of atony (3). In contrast, maternal mortality from postpartum obstetric hemorrhage has decreased since the late 1980s and accounted for slightly more than 10% of maternal mortalities (approximately 1.7 deaths per 100,000 live births) in 2009 (2, 4). This observed decrease in mortality is associated with increasing rates of transfusion and peripartum hysterectomy (2-4).The purpose of this Practice Bulletin is to discuss the risk factors for postpartum hemorrhage as well as its evaluation, prevention, and management. In addition, this document will encourage obstetrician-gynecologists and other obstetric care providers to play key roles in implementing standardized bundles of care (eg, policies, guidelines, and algorithms) for the management of postpartum hemorrhage.

ACOG practice bulletin: Clinical management guidelines for obstetrician-gynecologists

https://www.thelancet.com/pdfs/journals/lanres/PIIS2213-2600(14)70061-X.pdf

Assessment of the worldwide burden of critical illness: The Intensive Care Over Nations (ICON) audit

Background: Central neuraxial blockades find widespread applications. Severe complications are believed to be extremely rare, but the incidence is probably underestimated. Methods: A retrospective study of severe neurologic complications after central neuraxial blockades in Sweden 1990 ‐1999 was performed. Information was obtained from a postal survey and administrative files in the health care system. During the study period approximately 1,260,000 spinal blockades and 450,000 epidural blockades were administered, including 200,000 epidural blockades for pain relief in labor. Results: The 127 complications found included spinal hematoma (33), cauda equina syndrome (32), meningitis (29), epidural abscess (13), and miscellaneous (20). Permanent neurologic damage was observed in 85 patients. Incidence of complications after spinal blockade was within 1:20‐30,000 in all patient groups. Incidence after obstetric epidural blockade was 1:25,000; in the remaining patients it was 1:3600 (P < 0.0001). Spinal hematoma after obstetric epidural blockade carried the incidence 1:200,000, significantly lower than the incidence 1:3,600 females subject to knee arthroplasty (P < 0.0001). Conclusions: More complications than expected were found, probably as a result of the comprehensive study design. Half of the complications were retrieved exclusively from administrative files. Complications occur significantly more often after epidural blockade than after spinal blockade, and the complications are different. Obstetric patients carry significantly lower incidence of complications. Osteoporosis is proposed as a previously neglected risk factor. Close surveillance after central neuraxial blockade is mandatory for safe practice. CENTRAL neuraxial blockades (CNB) find widespread application in anesthesia as well as in postoperative and labor analgesia. Recent studies also suggest a reduction in postoperative mortality when CNB are used in major surgery. 1 The use of CNB will probably increase in the future, as serious complications have been reported to be extremely rare. 2 Studies are scarce, and their results difficult to compare. 3– 8 Many complications are known through case reports, and these rare events might not be evenly distributed within the patient population. Because the enormous number of patients needed to perform prospective studies exceeds feasibility, it is important that retrospective studies try to minimize the inherent weakness of such study designs. Underreporting is common in retrospective studies, causing underestimation of risk. In recent years, interest has focused on spinal hematoma after administration of low molecular weight heparin (LMWH). 9 –12 To investigate the incidence of serious neurologic complications after CNB in Sweden from 1990 to 1999, all available sources of information were searched. The aim was also to identify subgroups of patients with higher or lower prevalence of risk factors.

Severe Neurological Complications After Central Neuraxial Blockades in Sweden 1990-1999:

Lack of analgesic effect of systemically administered morphine or pethidine on labour pain

The cardiovascular effects of adenosine-induced controlled hypotension were studied in 10 patients undergoing cerebral aneurysm surgery. Adenosine and its metabolites were measured in arterial plasma using high-pressure liquid chromatography. Whole body and cerebral arteriovenous oxygen content diff

Controlled Hypotension with Adenosine in Cerebral Aneurysm Surgery

Lung function was measured at 30 minutes and again at 2 hours after birth in 12 infants delivered vaginally, in 15 infants delivered by elective caesarean section under general anaesthesia (GA), and in 15 delivered under epidural anesthesia (EDA). Umbilical arterial blood was analysed for pH and for concentrations of catecholamines and cortisol. No important differences in gestational age, birthweight, Apgar scores, or haematocrit were found among the three groups. Tidal volume and minute ventilation measured 30 minutes after birth were lower in infants delivered by caesarean section than in those delivered vaginally and at 2 hours the tidal volume was still lower in the babies delivered by caesarean section than in those delivered vaginally. Dynamic compliance was lower at 30 minutes in the group that had a caesarean section than in the vaginal group, and this difference was significant at two hours. Tidal volume, minute ventilation, and dynamic compliance in the GA and EDA groups did not differ. The catecholamine and cortisol concentrations at birth were higher in the vaginal group than in the group delivered by caesarean section. Two hours after birth there was a significant correlation (r = 0.84) between the catecholamine concentrations of the infants born vaginally and lung compliance. The lower dynamic lung compliance in infants delivered by elective caesarean section might be explained by delayed absorption of liquid in the lung due to lack of catecholamine surge.

https://adc.bmj.com/content/archdischild/58/4/262.full.pdf

Catecholamine surge and lung function after delivery.

Background: While there is a need for good quality care for patients with serious reversible disease in all countries in the world, Emergency and Critical Care tends to be one of the weakest parts of health systems in low-income countries. We assessed the structure and availability of resources for Emergency and Critical Care in Tanzania in order to identify the priorities for improving care in this neglected specialty. Methods: Ten hospitals in four regions of Tanzania were assessed using a structured data collection tool. Quality was evaluated with standards developed from the literature and expert opinion. Results: Important deficits were identified in infrastructure, routines and training. Only 30% of the hospitals had an emergency room for adult and paediatric patients. None of the seven district and regional hospitals had a triage area or intensive care unit for adults. Only 40% of the hospitals had formal systems for adult triage and in less than one third were critically ill patients seen by clinicians more than once daily. In 80% of the hospitals there were no staff trained in adult triage or critical care. In contrast, a majority of equipment and drugs necessary for emergency and critical care were available in the hospitals (median 90% and 100% respectively. The referral/private hospitals tended to have a greater overall availability of resources (median 89.7%) than district/regional hospitals (median 70.6). Conclusions: Many of the structures necessary for Emergency and Critical Care are lacking in hospitals in Tanzania. Particular weaknesses are infrastructure, routines and training, whereas the availability of drugs and equipment is generally good. Policies to improve hospital systems for the care of emergency and critically ill patients should be prioritised.

/pdf/emergency-and-critical-care-services-in-tanzania-a-survey-of-59r12a8v6p.pdf

Emergency and critical care services in Tanzania: a survey of ten hospitals.

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