Preparation for anaesthesia in small children follows the same pattern as for adults. Meticulous care is particularly necessary for infants because of reduced reserve in all systems. Adult anaesthetic apparatus is never suitable for children so preparation must include thorough checking of all equipment, especially for those anaesthetists less familiar with paediatric patients.
Physiological changes in clotting factors and venous flow during pregnancy increase the likelihood of deep venous thrombosis. Conditions that place the pregnant patient at a higher risk include a previous history of thromboembolic disease, and surgery or bed-rest for any reason during the pregnancy. In the high-risk patient, prophylactic therapy with low-dose heparin is advised beginning around the 34th week of pregnancy and continuing until 4–6 weeks after delivery. The clinical diagnosis of thrombophlebitis or pulmonary embolus is unreliable and should be confirmed objectively before therapy is started. The preferred method of therapy is full anticoagulation followed by subcutaneous heparin for the remainder of the pregnancy and the puerperium, although there is considerable controversy regarding long-term therapy. Fibrinolytic agents have no place in pregnancy and surgical therapy should be reserved for the severely ill patient.
Entry of amniotic fluid into the maternal circulation results in profound disturbances of cardiopulmonary function and the clotting mechanism. The rarity and unpredictability of the event makes prophylactic measures very difficult to apply and, despite many advances in resuscitation and systems support in the last few years, the mortality rate remains extremely high. It is impossible to disagree with the conclusions of the confidential enquiry into maternal deaths in England and Wales (Department of Health and Social Security, 1982) that ‘amniotic fluid embolism remains an unpredictable and largely unpreventable cause of maternal deaths’.
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