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414 A UTE CARE HANDBOOK FOR PHYSICAl TIIERAPISTS
Thrombotic Thrombocytopenic Purpura
Thrombotic thrombocytopenic purpura (TIP) is the rapid accumulation of thrombi in small blood vessels. The etiology of TIP is unknown; however, it i associated with bacterial or viral infection ,
estrogen use, pregnancy, and autoimmune disorders, such as acquired
immunodeficiency syndrome."
Signs and symptoms of TIP may include the following:
•
Hemolytic anemia, thrombocytopenia
•
Fatigue and weakness
•
Fever
• Pallor, rash, petechiae
• Waxing and waning headache, confusion, altered consciousness
from lethargy to coma
o Abdominal pain
• Acute renal failure
Management of TIP may include any of the following: emergent
plasmaphoresis, plasma exchange, antiplatelet agents, corticosteroids,
immunosuppressive agents, or splenectomy if nOt refractory to initial
therapy or if the condition recurs.47.57
Management
The management of vascular disorders includes pharmacologic therapy and vascular surgical procedures. Hematologic disorders may be managed with pharmacologic therapy, as well as with nutritional
therapy and blood product transfusion.
Phanllac% gic Therapy
Common drug classifications for the management of vascular and
hematologic disorders include (I) anticoagulants (see Appendix
Table IV-4), (2) anti platelet agents (see Appendix Table IV-IO), and
(3) thrombolytic agents (see Appendix Table IV-29).
VASCULAR SYSTEM AND HEMATOLOGY
415
Allticoagulatioll Therapy
The standard INR goal for anticoagulation therapy with warfarin
(Coumadin) is 1.5-2.5 times a control value and is categorized by
condition or clinical state according to the following":
INR 2.0-3.0
o DVT
•
Pulmonary, systemic, or recurrent systemic embolism
• Valvular heart disease or after tissue heart valve replacement
° Atrial fibrillation
INR 2.5-3.5
• Recurrent systemic emboli while on warfarin.
• Recurrent myocardial infarction.
• Mechanical prosthetic heart valve replacement.
The physical therapist should understand some basic concepts of anticoagulation therapy to intervene safely and estimate length of stay.
° The physician will determine the PTflNR and PTT goal for each
patient. This goal is documented in the medical record. The patient
remains in a hospital setting until the goal is reached.
° The therapeuric effect of heparin is reached within minutes or hours,
whereas the effect of warfarin is reached in 3-5 days; thus, heparin is
usually prescribed before warfarin. Both drugs are given simultaneously
until the proper PTfINR is achieved, then heparin is discontinued.
° The terms subtherapeutic and supertherapeutic imply a coagulation level below or above the anticoagulation goal, respectively.
° A subtherapeutic PTflNR or PTT indicates a risk for thrombus formation, whereas a supertherapeutic level indicates a risk for hemorrhage.
° Supertherapeuric anticoagulation is rapidly reversed by vitamin
K or fresh-frozen plasma.
• Anticoagulant agents are temporarily discontinued before surgery to minimize bleeding intra- or postoperatively.
416 ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS
•
The physical therapist should always monitor the patient
who is taking anticoagulants for signs and symptoms of bleeding, as bleeding can occur even if the PTIINR is therapeutic."
N"tritiollai Therapy
Nutritional therapy is the treatment of choice for anemia caused
by vitamin and mineral deficiency. Appendix Table IV-2S describes
the indications and general side effects of the agents used to manage iron deficiency, vitamin B12, and folic acid anemias.
Blood Product Trallsfllsioll
Blood and blood products are transfused to replete blood volume,
maintain oxygen delivery to tissues, or maintain proper coagulation.62 Table 6-1S lists the most common transfusion products and the rationale for their use. Blood may be autologous (patient
donates own blood) or homologous (from a volunteer donor).
Before transfusing blood or blood products, the substance to be
given must be typed and crossed. This process ensures that the correct type of blood is given to a patient to avoid adverse reactions.
A variety of transfusion reactions can occur during or after the
administration of blood products. Transfusion reactions are either
immunologic (caused by the stimulation of antibodies in response
to antigens on the transfused cells) or non immunologic (caused by
the physical or chemical properties of the transfused cells).'3 Table
6-16 lists the signs and symptoms of various types of acute adverse
transfusion reactions. In addition to these reactions, complications
of blood transfusion include air embolism (if the blood is pumped
into the patient) or circulatory overload (from a rapid increase in
volume). Circulatory overload occurs when the rate of blood
(fluid) transfusion occurs faster than the circulation can accommodate. Signs and symptoms include tachycardia, cough, dyspnea, crackles, headache, hypertension, and distended neck veins. To
prevent circulatory overload during a transfusion, intravenous fluids may be stopped, or a diuretic (e.g., furosemide ILasixJ) may be given. Delayed adverse transfusion reactions include iron overload, graft-versus-host disease, hepatitis, human immunodeficiency virus-l infection, or delayed hemolytic reaction (approximately 7-14 days post transfusion)."