Volume restoration management

In severe anaphylaxis, hypotension is due to vasodilation and loss of circulating volume through leaky capillaries. Colloid is more effective at restoring blood volume than crystalloid and 1-21 of plasma substitute should be infused rapidly. Oxygen and artificial ventilation may be necessary. Advice on the management of anaphylactic shock may be altered from time to time check the UK Resuscitation Council website (www.resus.org.uk) for current information. 

In the urgent/emergent situation, restoration of the patient s volume status is the most important outcome. Toxic patients (fever, dehydration, hematochezia, or hypotension) require hospitalization, intravenous fluids and electrolyte administration, and empiric antibiotic therapy while awaiting culture and sensitivity results. With timely management, these patients usually recover within a few days. 

Patients with diastolic heart failure are typically dependent upon preload to maintain adequate cardiac output. While patients with symptomatic volume overload will benefit from careful modulation of intravascular volume, volume reduction should be accomplished gradually and treatment goals reassessed frequently. In addition to cautious volume management, it is important to maintain synchronous atrial contraction in such patients, which maintains adequate left ventricular filling during the latter phase of diastole. Cardiac function is often severely impaired if patients with diastolic heart failure develop atrial fibrillation, particularly in the context of sub-optimal ventricular rate control. Meticulous control of the ventricular rate with drugs that slow AV conduction is mandatory (see Chapter 34) and restoration of sinus rhythm should be considered. It is also important to evaluate and treat conditions that are associated with dynamic abnormalities of diastolic function, such as myocardial ischemia and poorly controlled systemic hypertension. 

Early diagnosis of PPH is crucial for initiating appropriate management as early as possible. Management includes restoration of the blood volume and identification of the underlying cause. Delay and inappropriate management are the leading causes of maternal death after delivery. 

The laboratory should be considered an important member of the preservation team. Retaining a laboratory that performs only routine examinations and has no real experience in historical materials analysis is equivalent to hiring a masonry contractor that only repoints Type N portland-lime mortars and has no experience in placing restoration materials. A brief discussion of the project with the laboratory manager will often reveal volumes about the skill of that laboratory in reverse engineering historical materials. When an experienced laboratory is found, the forensic work should be performed as early as possible as the analyses described above will require several weeks for completion. 

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