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The choice of prosthetic valve depends on a variety of considerations, such as assessing the expected survival of the patient versus the durability of the valve and the safety of warfarin for the patient Bioprosthetic valves usually have a life expectancy of 10 15 years, but less in young patients and those on dialysis The lifespan of bovine pericardial valves is somewhat longer than porcine valves, and these are becoming the favorite bioprostheses Bioprosthetic valves, homografts, and the Ross procedure do not require anticoagulation with warfarin Mechanical valves have a much longer lifespan, but all require use of warfarin (and frequently aspirin as an adjunct) The long-term risk of warfarin depends on patient compliance and whether there is coexisting disease that may predispose to bleeding Mechanical mitral valve prostheses pose a greater risk for thrombosis than mechanical aortic valves For that reason, the INR should be kept between 25 and 35 for mechanical mitral prosthetic valves but can be kept between 20 and 25 for mechanical aortic prosthetic valves Enteric-coated aspirin 81 mg once daily is given to patients with both types of mechanical valves, but appears to be more important for mitral valve prostheses Warfarin causes fetal skeletal abnormalities in about 2% of women who become pregnant while taking warfarin, so every effort is made to defer valve replacement in women until after childbearing age However, if a woman with a mechanical valve becomes pregnant while taking warfarin, the risk of stopping warfarin is higher for the mother than the risk of continuing warfarin for the fetus The risk of warfarin to the fetal skeleton is greatest during the first trimester, so if pregnancy is planned in a woman with a mechanical valve, unfractionated heparin is often used temporarily during the first trimester After the first trimester, warfarin use is safe again until 2 weeks before planned delivery, when the patient should be switched back to unfractionated heparin Lowmolecular-weight heparin has not been shown to be effective and should not be substituted for unfractionated heparin in the pregnant patient with a mechanical heart valve When patients with mechanical valves must undergo noncardiac surgery, the risk of thrombosis from stopping warfarin versus the risk of excessive bleeding from continuing warfarin must be weighed In general, for bileaflet aortic mechanical valves, warfarin can be stopped 3 4 days ahead of the surgical procedure and resumed the night of the procedure without bridging by use of unfractionated or low-molecular-weight.

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bin by regenerating 2,3-diphosphoglycerate However, three randomized studies in which phosphate was replaced in only half of a group of patients with diabetic ketoacidosis did not show any apparent clinical benefit from phosphate administration Moreover, attempts to use the phosphate salt of potassium as the sole means of replacing potassium have led to a number of reported cases of severe hypocalcemia with tetany To minimize the risk of inducing tetany from toorapid replacement of phosphate, the average deficit of 40 50 mmol of phosphate should be replaced intravenously at a rate no greater than 3 4 mmol/h in a 60 70-kg person A stock solution (Abbott) provides a mixture of 112 g KH2PO4 and 118 g K2HPO4 in a 5-mL single-dose vial (this equals 22 mmol of potassium and 15 mmol of phosphate) One-half of this vial (25 mL) should be added to 1 L of either 045% saline or 5% dextrose in water Two liters of this solution, infused at a rate of 400 mL/h, will correct the phosphate deficit at the optimal rate of 3 mmol/h while providing 44 mEq of potassium per hour (Additional potassium should be administered as potassium chloride to provide a total of 10 30 mEq of potassium per hour, as noted above) If the serum phosphate remains below 25 mg/dL after this infusion, a repeat 5-hour infusion can be given 7 Hyperchloremic acidosis during therapy Because of the considerable loss of keto acids in the urine during the initial phase of therapy, substrate for subsequent regeneration of bicarbonate is lost and correction of the total bicarbonate deficit is hampered A portion of the bicarbonate deficit is replaced with chloride ions infused in large amounts as saline to correct the dehydration In most patients, as the ketoacidosis clears during insulin replacement, a hyperchloremic, lowbicarbonate pattern emerges with a normal anion gap This is a relatively benign condition that reverses itself over the subsequent 12 24 hours once intravenous saline is no longer being administered 8 Treatment of associated infection Antibiotics are prescribed as indicated Cholecystitis and pyelonephritis may be particularly severe in these patients.

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