THROMBIN GENERATION IN NORMAL SUBJECTS AND CARDIAC PATIENTS

Early oral hydration: a novel regimen for management after elective cesarean section

OBJECTIVE

To compare early oral hydration versus the conventional intravenous fluid replacement after elective cesarean section.

METHODS

Two hundred women performed elective cesarean section were selected and randomized to: Regimen I (n = 100): early oral hydration (sips of fruit juices sweetened with honey once the women felt thirst immediately after the operation, then solid food 24 hours later, the amounts of juice or food were determined by the patient herself, i.e. she would regulate her physiological needs) versus regimen II (n = 100): conventional intravenous hydration (2-3 L of dextrose saline/24 hours and solid food thereafter). Biochemical, metabolic values, postoperative nausea and vomiting, propulsive bowel movements, tolerance of solid food, hospital stay and successful continuation of breast feeding were compared in both groups.

RESULTS

The two regimens were equally effective in maintaining fluid balance and normal plasma and urinary electrolytes without any observed differences in biochemical or metabolic values. The return of bowel sounds, first occurrence of flatus and tolerance of solid food were achieved in regimen I at time periods significantly shorter than those attained with regimen II (p < 0.0001). The incidence of nausea and vomiting, ileus and deep vein thrombosis was higher in regimen II than in regimen I but the difference is statistically insignificant (p > 0.05). Patients in regimen II were hospitalized for significantly longer times than those on regimen I (p < 0.0001). Successful continuation of breast feeding was significantly more in regimen I than in regimen II (p < 0.01).

CONCLUSION

Early oral hydration after elective cesarean section effectively maintained fluid balance and it was associated with rapid return of propulsive bowel movements, successful breast feeding, less side effects and shorter hospital stay than the conventional intravenous hydration. So, it should be used in most cases after elective cesarean section.

Untreated prostatic carcinoma is not associated with frequent thrombohemorrhagic disorders

We conducted an evaluation of the hemostatic integrity of patients with untreated cancer of the prostate. Of 60 patients analyzed retrospectively, only 1 had a mild case of disseminated intravascular coagulation, possibly associated with concomitant estrogen therapy, and in 1 patient mild deep vein thrombosis developed preoperatively, also possibly associated with multiple medications for concurrent disorders. Of 16 other patients prospectively evaluated on admission, only 1 had frankly abnormal levels of fibrinopeptide A unaccompanied by other coagulation abnormalities. Occasional individuals had minimal, negligible deviations of partial thromboplastin times, thrombin time, or antithrombin III values. In none of these patients did hemostatic complications develop during their hospital stay. These results demonstrate that although an occasional coagulation abnormality may occur in patients with cancer of the prostate (albeit with a lower incidence than in other neoplasms), this malignancy does not require increased precautions with respect to those given to the patient population at large.

Postoperative deep vein thrombosis caused by intravenous fluids during surgery

Using a new method of measuring whole blood clotting time, we have confirmed the findings of others, that blood clots faster when diluted with saline. A prospective trial was designed to test the hypothesis that intravenous saline peroperatively causes hypercoagulation and increases the risk of venous thrombosis. Sixty patients admitted for routine laparotomy were randomly allocated to either a group receiving intravenous fluids during or after operation (Wet), or a group receiving no intravenous fluids (Dry). The Wet patients became significantly more haemodilute and hypercoagulable than the Dry (P < 0.001), and these changes correlated. A postoperative deep vein thrombosis occurred in 30 per cent of the Wet patients, but in only 7 per cent of the Dry (P < 0.05). The need for intravenous fluids during uncomplicated surgery is probably unproved, and their greater use may have contributed to the increasing prevalence of venous thromboembolism.

Clotting predisposition in carcinoma of the prostate

To delineate factors that might increase the risk of thromboembolic events in patients on estrogen therapy for prostatic carcinoma a study was undertaken of various coagulation parameters. A correlation was demonstrated between advanced stages of prostatic carcinoma and depression of the serum antithrombin III activity. The addition of estrogen therapy resulted in further depression. Since low levels of serum antithrombin III activity have been associated with thrombosis this observation may have clinical relevance.

Detection and management of hypercoagulability

Patients at high risk of having thromboses can be identified not only on the basis of clinical criteria but also on the basis of laboratory studies. With use of a condensed coagulation profile consisting of six laboratory tests, the clinical impression of hypercoagulability can be confirmed in approximately 90 per cent of cases. Therapy directed to correct specific laboratory abnormalities may be more efficacious than nonspecific therapy.

Hypercoagulability in patients with peripheral vascular disease

Twenty-seven patients with peripheral vascular disease had studies of thrombin generation, antithrombin III -alues, factor VIII values, platelet adhesitivity, and activated partial thromboplastin time. Of the studies performed, the thrombin generation index, antithrombin III values, and, to a lesser extent, activated partial thromboplastin time were reliable in confirming clinically suspected hypercoagulability. When patients were placed into groups with and without operative complications, it was noted that the group with operative complications had higher average values of thrombin generation index and lower average values of antithrombin III and activated partial thromboplastin time than did the group without operative complications. It is thought that these tests may be useful in selecting those patients with a high risk of thrombotic complications from vascular surgery and who may benefit from anticoagulant management while undergoing necessary vascular reconstructive procedures.