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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)."