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Nikken business plan

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Asian Americans Are High Achievers Because They Work Harder. Asian Americans are academic high-achievers. Though they make up just 5 percent of the nikken business, U.S. population, Asian Americans represent 12 to 18 percent of the student body at Ivy League universities. Compared to white students they have higher grades and standardized test scores, and are more likely to essays, finish high school and attend college. Many theories exist as to why this is, but none has been widely accepted. Plan. Now, researchers, having analyzed longitudinal datasets, believe the council studies, recipe for Asian Americans#8217; educational advantage is simple: They exert greater academic effort than their white peers. Researchers began with data from two national, longitudinal surveys that followed students from kindergarten through high school.

In total over 4,000 white students and nearly 1,000 Asian American students were included. The data included GPA, standardized test scores, teacher reports, socio-demographic information and nikken, immigration status. Using the apa citation, data, they tested three popular theories to explain Asian Americans#8217; superior academic performance: socio-demographic characteristics, innate cognitive ability, and work ethic. They found that both socio-demographic characteristics and cognitive ability didn’t significantly contribute to the achievement gap. Plan. When students started kindergarten, for example, there was no discernible difference in the cognitive abilities of Asian Americans and white Americans. Essay. However, over business plan, time, the achievement gap grew. But why?

Researchers believe the gap grew due to differences in failure, tenacity. Business. Asian American students, according to survey responses, tended to believe intelligence is something that could be developed, whereas white students viewed cognitive abilities as inborn qualities. Asian American students also said their parents exerted more pressure on them to succeed than white Americans did. Researchers said Asian Americans’ cultural orientation and immigrant status are key drivers to a high-effort mentality. Asian Americans, they said, view education as a primary means for upward mobility. Researchers published their findings Monday in the journal Proceedings of the National Academy of Sciences.

But this high academic effort may come at a cost. Asian American students reported that they felt worse about themselves and ptlls, spent less time with friends than their white peers. However, researchers conceded they didn’t know what exactly caused Asians to harbor a less positive self-image and spend less time with friends. There#8217;s nothing new here. Business. Scientific American looked at this nearly forty years ago and reached the edexcel essays, same conclusion. We need to replicate studies, because one study or a few studies might not be enough to reach a solid conclusion. Nikken. That being said, I#8217;m a teacher, and the top university in my country teaches that difference in achievement in different races is mainly due to genetic differences#8230; So the #8220;news#8221; didn#8217;t reach everyone, and many still try to promote ancient, refuted and market failure, harmful ideas about the nature / nurture question. As I understand it, IQ before the age of 14 is relatively fluid, so kindergarten IQ wouldn#8217;t be a reliable measure of very much.

As if a study would prove one racial group has superior brain function. It#8217;s culture. The emphasis put on hard work and study. As opposed to video games and business plan, sneakers. Big surprise.

So I wonder why African Americans were not included in essays, the study. #8220;Compared to white students#8221;#8230; OMG, that#8217;s so racist! Everybody always picks on Whites! I#8217;m so tired of being discriminated against. I think I see a lawsuit coming on#8230;.. Oh please SHUT UP. Its the nikken business, truth. Paper Apa Citation. You cannot sue someone for telling the nikken business plan, truth of what they found in a study. DERRR.

And it is true by the way, Asians are academically high achievers#8230;(I am white by the way and cannot be offended by the truth! Americans can be academically very LAZY) DERRR. It#8217;s called sarcasm, Cowan. I was ribbing our non-pasty-white brethren for being so self-conscious and paper apa citation, defensive about nikken business plan, every little thing said about their race, color, religion, dress code or nose hairs. And I agree that offending red-necks is not an easy task.

Oh good- I got you:) You#8217;re going to ptlls course, see a lot more of that as the world become more inter racial and moves away from the ancient idea of white superiority(especially in america and Europe where whites are concentrated). Whites have been looking down on other races for ages now. Parents who #8220;don#8217;t want to push their kids#8221; are just saying with different words that they don#8217;t want to lead. Bunch of selfish cop outs running away from responsibility. Drives me nuts what#8217;s happened to the American white race. We were just like the Asians till we all got comfortable and nikken business plan, lazy. There#8217;s no excuse for the current situation. None at all.

Achivement should evalute how much an indivisual is able to live full balanced well life while enjoying the process of good thesis statements, self development. Many actually are erasing big part of their life aiming to business, live life when their body become too old. Essay On Christmas For Small Kids. Achievements that produce merly hardworking unbalanced society on nikken plan, the cost of what good thesis, having joy and satisfaction in life is deemed to business plan, create conflicts and collapse. I think that achievements should be redifined to create a sustainable world. I guess the title, #8221; Blacks don#8217;t work as hard as Asian#8221; wasn#8217;t politically correct enough? Didn#8217;t Jimmy the Greek get fired for saying that blacks were naturally born athletes? Why doesn#8217;t this study get hammered as racially insensitive? Because blacks are sensitive to the issue of race.

They are very vigalent of anything that can be seen asracist. That#8217;s why blacks can make jokes about whites all they want and crack it up, but as soon as a white drops a black joke the bullets come flying. This is very true! As a public school teacher it was obvious . In class the Asian kids were most attentive in class; ignored other kids#8217; bad behavior peer pressure, always did their homework, were rewarded by ptlls parents for good grades. Nikken. Some American other immigrant kids would say they were just smarter. I told them that they worked harder valued education more that that#8217;s the way kids used to be raised. Black families in what is a good thesis statements, my neighborhood raised their kids like that when I was growing up. Most went to college. Nikken Plan. I think what#8217;s the research paper, study shows is about reaping from what you sow. For us poorer country education is the only treasure that our parents can give. Plan. And as well the for european, only way to nikken business, better opportunity.

That#8217;s why we study hard. I#8217;m Asian. Not one article I have read today concerning the achievement gap has placed the blame on parental makeup of the homes. Another article stated that African Americans had the worst scores (30 points behind whites on math alone), followed by for european studies pre dissertation fellowship Hispanics with better cores but less than whites, followed by whites and business, the highest scores going to Asians. Take the divorce/ single parent rate and it follows the exact same trend! Two parent homes = more attention allowed per child to read with them and go over homework. Essay. As long as affirmative action stays off the books, the more likely Asians will start taking over all of the nikken plan, universities in this country by the end of this century. #8220;They found that both socio-demographic characteristics and cognitive. ability didn’t significantly contribute to the achievement gap.#8221; Actually, looking at thesis statements, the subgroup data provided by nikken PNAS, only East Asians had a cognitive advantage. The data showed a cognitive advantage of is a good statements, approximately 1/3, which is quite significant.

The rest of the Asians ( Southeast, Filipinos, and nikken plan, South) had no cognitive advantage. Sign up to essay market failure, get the latest science news delivered weekly right to your inbox!

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Beat the nikken business plan Applicant Tracking Systems (ATS): How to Survive Resume Reading Robots. By Resume Genius / September 29, 2014. Here’s an failure, experience you’ve probably had: You write a solid resume for the perfect position at nikken business, a big-name company, and essay for small send it off with an earnest cover letter. Unfortunately, besides an automated email reply, you hear absolutely nothing back. You feel crushed — you think some hiring manager on the other end actually read through the entirety of your resume and concluded that you weren’t qualified for the job. But here’s the twist — chances are, no human has even laid eyes on nikken plan your application. The truth? You were probably rejected by resume reading robot called an what good, Applicant Tracking System (ATS).

You were probably rejected by resume reading robot called an Applicant Tracking System (ATS). Welcome to business plan, the 21st century. Large and even medium sized firms are using ATS to deal with the hundreds, if not thousands of applicants who are applying to the same positions every day. This resume reading software allows these companies to to automate, streamline, and manage the hiring process. Why are companies allowing robots to make human resource decisions? Going through resumes to screen applicants is tedious work. But the ATS speeds up this process by identifying candidates whose resumes contain key experiences and skill sets that match the qualifications employers are seeking. According to a popular study conducted by search services provider Preptel, as many as 75% of the candidates don’t make it past the ATS screening. Research Apa Citation? It may seem brutal, but this screening process does the job of whittling down a cumbersome applicant pool into just a handful of applicants that the business plan human hiring managers can review more closely. Here’s the essay on christmas for small takeaway for nikken business plan, living in market the age of resume reading robots — a well-crafted, ATS friendly resume is absolutely critical to nikken business plan, a successful job hunt. Here’s the takeaway for living in the age of resume reading robots — a well-crafted, ATS friendly resume is absolutely critical to ptlls, a successful job hunt.

Qualified candidates that fail to nikken, make an ATS friendly resume will get rejected, period. Here are 4 reasons that even the most qualified candidates can fail to history essays, After combing the web and nikken consulting some of our in-house experts at Resume Genius, we zero in on the most common reasons why resumes of even the most qualified candidates fail to pass screening. Reason #1: The ATS can’t actually process your resume. Warning: The ATS will fail to read your artistic additions to market, your resume . Although a human hiring manager might appreciate a little flair, the resume robot will simply incinerate your resume without a second thought. It would be a shame for your resume to get screen out nikken business, because the market ATS is unable to nikken, read it. Basic rule of is a thumb: keep your fonts and formatting simple. Scrap inventive layouts, graphics, or artifacts that affect the readability of nikken your resume. Sometimes the ATS will use a built-in optical character recognition (OCR) software to processes your digital resume. What Thesis? It scans your file, converts it into a text format, then extracts your information and experiences from there.

While the plan ATS is getting better at reading PDF files, it’s still safer to essay on christmas for small, feed the system a Word or Text file. Do away with any adjusted spacing, newsletter formatting, lines. Nikken Business? Go with the clean, standard fonts like Arial, Verdana, and Times New Roman. Scrap inventive layouts, graphics, or artifacts that affect the readability of thesis statements your resume. Reason #2: The ATS doesn’t recognize the headings you used. Applicant Tracking System software is built to sort your experiences based on the resume’s section headings. Nikken? If you’ve written a different heading than normal — say “Major Abilities” instead of “Skills,” it will skip over that section if it is edexcel history essays unable to plan, determine what your heading stands for, the council pre dissertation CIO reports. People like to get creative with headings, thinking that it will help their resume stand out. Nikken Business Plan? Unfortunately, unconventional headings can actually hurt it.

Help the software do its job. Use the studies fellowship standard headings “Work Experience”, “Skills”, “Publications” so you don’t stand the risk of the nikken business resume bot placing your qualifications under the wrong categories, or misreading your headings altogether. Reason #3: Your resume lacks targeted keywords. By now, you’ve formatted your resume properly, and used normal headings. Here’s the meat of how an essays, ATS actually reads your resume.

It’s looking for nikken plan, targeted keywords. First, the hiring manager will input certain keywords and key phrases into the software, each relevant to the role they need filled. For example, an software company hiring manager might use these keywords: Next, the ATS software will read through each resume, and determine whether the it has enough keywords and failure key phrases to pass through the screening. If the nikken business percentage is high enough, your resume will successfully be reviewed by an actual human. Your ability to use the right keywords depends on two things: Do you actually have the relevant skills, abilities, education, and market work experiences? If you do have all or some from nikken plan, #1, doing good research and paper apa citation giving your resume a hard look-over will get you through the ATS. The best place to begin is to nikken, read the hiring manager’s very own job description. From that job description, you can see what keywords and key phrases they emphasize a potential applicant should have. Essays? If they include them in the job description, it’s highly likely they’ve also input them into nikken, the ATS.

The image below contains a real example of is a a librarian job description, and the image next to it reflects what we believe are important keywords a librarian applicant should include on plan their resumes: Normal Job Description. Job Description with ATS Keywords Highlighted. GREEN HIGHLIGHT: Keywords that are CRITICAL to getting past the ATS. YELLOW HIGHLIGHT: Keywords that will please the human hiring manager, or are ATS keywords of lower importance. The job post gives you good clues about keywords and experiences employers are seeking. It’ll serve you well to market failure, read those job descriptions closely, and nikken business identify important competencies and skill sets. Place emphasis on research these matched experiences in your resume. It’s also helpful include both specific and general keywords in the mix.

ATS uses all of business these keywords into certain job functions. For your previous position as “team leader”, include job-specific buzzwords such as “coordinate”, “manage”, but having the general keyword “project coordinator”, “project manager” will help to strengthen your resume. Be sure to what statements, try out our ATS-friendly resume building software that comes with over 50,000 professionally-written phrases and job-specific keywords. Reason #4: Your resume has too many nonspecific keywords. Some have suggested “hacking” the resume bot by nikken plan, submitting two or three-page long resumes that exhaust all keywords that are relevant to the job. That’s not a good idea — even if it did work (it doesn’t), it certainly won’t impress the essay market human hiring manager.

you can’t stuff your resume with an business plan, exhaustive list of history experiences and plan hope to for small kids, game the system into thinking you’re a perfect match. According to nikken plan, a report from The Ladders, ATS software ranks your candidacy based on how specifically your resume matches keywords and phrases in essays a job description. Some software even looks for how uniquely the work experiences you listed match the job requirements. Here’s the rub — you can’t stuff your resume with an business plan, exhaustive list of experiences and council for european studies hope to game the system into nikken plan, thinking you’re a perfect match. Having off-target keywords can score your resume down on relevancy. Use the instruction from #3 to research relevant keywords and ensure that your resume is concise and targeted. To the greatest extent possible, your resume should uniquely match the requirements in on christmas the job description. To sum it up: the nikken business bots are getting better at council for european studies pre dissertation fellowship, contextualizing resumes, and recruiters are always aiming to interview candidates whose experiences adhere the nikken business plan most closely to positions they’re seeking to fill. Edexcel Essays? Therefore, having targeted, job-specific keywords throughout your resume is more important than ever.

Reason #5: Your resume lacks industry and company jargon or abbreviations. Experts suggest that adopting industry jargon or even including a company’s corporate lingo within your resume is a smart choice. If you think about it, it’s only business, logical for the hiring manager to essay kids, input industry jargon and abbreviations into an ATS. Therefore, you will need to optimize your resume to include these terms wherever possible. Fortunately, this is very simple to do. Weave relevant jargon and terminology into nikken business, your resume, and spell out the abbreviations and acronyms. DO NOT ever simply include an edexcel history essays, acronym or abbreviation by itself on a resume. You should always spell them out nikken, completely, followed by their abbreviation or acronym. Acronyms with Spelled out Examples. Federal Bureau of Investigation (FBI) agent with 10+ years of experience. Optimized and purchased Pay Per Click (PPC) ads for a major software company Maintained plant operation’s perfect record of zero Operation Safety Health Administration (OSHA) recordables.

If you’re unfamiliar with a certain industry’s lingo, you can research jargon and abbreviations specific to the field, sector, or industry in which you’re seeking employment. To sum it up: a resume with clean formatting and clear, targeted language gets you through ATS screening. Once you land that interview, however, it would be advisable to have a more descriptive and eye-pleasing version of your resume ready for your human recruiters. Thanks… this really was useful. Thanks for your comment Rasana!

Glad we could help! Feel free to ask us any questions. I have found that in order to get your resume even considered, you must really target each position for the relevant key words. Also, do the essay same for your cover letter or add those that were missed in the resume. You are absolutely correct about targeting each position for relevant key words. One of the best places to pinpoint relevant key words is in the position’s job description. Great comment Jamie! I’ve been reading articles on nikken plan cracking the essay failure ATS for a couple months now, just confounded at business, what I was doing wrong, or what I could do differently. this article has been more helpful than ALL the others! Thanks for what statements, that. Bookmarked! Thanks for your comment Pert!

Glad that you found our article useful. Good luck on the job hunt! This is very useful information, thanks for sharing. Glad you found it helpful. Be sure to share it with your friends and get the business word out. Thanks for the comment.

High Quality Candidates: If a company doesn’t care enough about you and your far superior talents, capabilities and experience that they throw an ATS software program in your way DON’T reward them with an application! ATS software and all similar crap will be avoided by research paper apa citation, companies IF there’s a large enough movement among the highly qualified and most talented employee pool. Concentrate on those companies that treat you like a real human and avoid the plan automated people processors whenever possible! Companies will catch on to the detrimental nature of thesis this “time and cost saving software” and realize it’s costing them everything! Many already have. Imagine, as with myself, you work in a totally “visual” industry where picture representations of your work tell virtually your whole story! Applying for a graphic design, art director or illustrator job has been rendered orders of magnitude more difficult with the advent of ATS processing! The situation is about as insane as trying to get a singing job with no recordings of your voice being allowed and no chance for a personal audition! Companies with H.R. people who have virtually no expertise in the commercial art field are already at a huge disadvantage in making any kind of nikken business qualified decisions regarding such applicants.

Add to that a totally intrusive, opaque and “dumb” software program placed strategically as a final barrier to any chance of actually communicating your amazing talents and, well, you have the “perfect storm” of employment failure – both for the employer and is a good thesis potential employee. Agreed. However, my line of plan work is not with the smaller companies that seem to actually read a resume but within the larger corporations and is a statements they ALL use ATS! Buzz words (key words) are definitely the nikken business plan secret and one must learn this and use the job description in the posting and customize the resume accordingly or else be among the roughly 75% that are automatically not reviewed and receive the proverbial computerized canned rejection letter from edexcel essays, a “do not reply” to email address! Definitely, if your are in nikken business the design and arts profession, ATS is research paper apa citation surely the Antichrist! Preach!! I 1000% get what you’re saying!! I’ve been in the advertising industry for 25 years, 13 years on nikken business staff, and the last 12 years as a freelancer. How in the world do you include 12 years of significant freelance work with several different clients on a multitude of different accounts with all kinds of varying calendar timing through an ATS and expect it to spit out anything resembling a solid, successful overall career?? Despite the fact that so many highly qualified candidates are finding the ATS to be their ultimate challenge in the job search, the “sheeple” continue to essay, just follow the guidelines to gaming the system via keyword dumping rather than avoiding companies who rely on filtering human beings through their ATS.

Unfortunately for the likes of nikken business plan you and on christmas for small me, we don’t really have the nikken business luxury to NOT play along at is a, least a little bit or get utterly left behind, but I agree completely that if more people just stop playing along, companies will finally get exactly what you said: it’s costing them everything! That’s easy to say if you have a job. But if you are unemployed, you have little choice. This software should be outlawed. No wonder the nitwits in HR claim they ‘can’t find qualified people’, their ATS screened them out beforehand. Woww. Having the right information at the tip of your finger can actually ease the endless pain of job seeking and plan resume submission without consideration. Thanks, your article is encompassing and indeed rich.

Keep it up. Glad we could help! Thanks for you comment. While I found this article very helpful as a job seeker, it is a sad commentary on the state of corporate hiring today. We are being dehumanized and reduced to automatons in the new world order system. This article is so very.

useful. It really helped me a lot to research, understand what I was doing wrong. Just few. questions: 1) do you advise to mold my resume to match every single job I am. applying to? 2) In situations where one does not possess all of the required. skills of a job posting, but one knows it will not take long to nikken business, acquire them; how. do you suggest one should handle such situation?

Ignore the course job post, and move. to the next one? Any advice is business plan greatly appreciated. Yes, your resume should always be tailored to the specific job post. As far as skills go, check out this page for more advice: https://resumegenius.com/resume/skills-section-writing-guide. Thanks for you comment. Dude seriously?? and here I thought even after knowing whatever was the studies pre dissertation fellowship demand of our beloved employer I wasn’t getting hired because I had no skill. On top of that I didn’t even know ATS existed, I always thought living human beings reject me :p. Bravo…. and plan lamentation. In these days of big data, it’s laughable that job matching is still such an research paper apa citation, outrageously resource wasting game of hide and seek. Resumes and job postings are still crafted as for plan, a single pieces of essays paper formatted to communicate all pertinent information in nikken plan the 10 or so seconds of what good statements attention that conventional wisdom says they may receive.

While an ATS attempts to tweak that Cretaceous period bottleneck, clearly there’s something missing. I’m considering starting a company that would provide the nikken plan mirror analog of an ATS to job seekers for free, with the ultimate goal of steering development of the market failure cooperative, common have/need data platform that would evolve once the inevitable war between the two systems runs its course (I’d rather just skip to the common platform, but sometimes you’ve got to kick the mule). Who’s with me? How should I handle the resume I post on job boards (e.g. Monster, Dice)? That resume can’t be tailored to a specific job description. Should I use keywords common to many of the job descriptions for my target position? And then use a customized resume when I apply for a specific job? BINGO! Sounds like you know what you’re doing.

Best of nikken luck! Thanks for market failure, your help and for the great article. Cheers! Thanks for the comment! You bring up a good point — it’s important to create a resume that both gets through the ATS and appeals to plan, hiring managers once it lands in their hands. Share Beat the Applicant Tracking Systems (ATS): How to Survive Resume Reading Robots Our code geeks and HR experts are proud to introduce our new Free Resume Builder software to help you land more interviews in today’s competitive job market. We provide HR-approved resume templates, built-in job description bullet point phrases to choose from, and easy export to MS Word and PDF.

Get awesome job opportunities sent directly to ptlls course essays, your inbox. By clicking Send Me Job Alerts, I agree to the Resume Genius Terms of Use and Privacy Policy. Play the One-Minute Game That’ll Show You How to Improve Your Resume. Think you can judge the quality of a resume within 6 seconds? The answer may surprise you. Put your skills to nikken plan, the test, and learn how to apa citation, make your resume 6 second worthy!

3 Reasons Why I Wouldn't Hire Tom Brady. Tom Brady’s resume is a couple yards short of a touchdown. There are tons of errors throughout. Nikken Business? See why. How to Modify and Maximize your Resume Template.

Need a resume template? Feel free to download one, but be sure to make small modifications to unlock your. Would You Rather Work for a Man or a Woman? Do people still care whether they work for a man or woman, or do most people simply look for a nice job. 5 Ridiculous Excuses To Calling Out Of Work That Were Surprisingly Successful. Every office is bound to have that one person that abuses the call-out policy.

These people go above and. Resume Genius' builder, resources, advice and career tips are regularly featured on some of the world's leading online and offline publications including: Our code geeks and HR experts are proud to introduce our new Free Resume Builder software to help you land more interviews in today's competitive job market. HR-proven resume templates, built-in job description bullet point phrases to choose from, and easily export to MS Word and PDF.

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The Nikken Business Plan — The …

10 at-home workouts to build muscle in plan, under 20 minutes. You put in long hours at research apa citation, work, or maybe even work overnight shifts. You’re tight on money. You want to spend downtime with friends. A hurricane or polar vortex has you barricaded in nikken, your home. Whatever the essay on christmas kids reason, there are times when you just can’t make it to the gym. Plan! We’ve all been there. Is A Good Statements! And so long as you don’t use that as an excuse to skip workouts, you’re golden. There’s no reason you can’t build muscle, strength, and size at home. It won’t take all day, either. Training with minimal equipment, or even your bodyweight, is enough to get you in the shape you want.

Los Angeles-based personal trainers Ben Bruno and Anthony Yeung designed 10 time-crunch workouts using just your bodyweight and nikken plan dumbbells. These exercises will shred you to pieces. The best part of all? You don’t even need to research leave your home. The post-workout smoothie and shower are just steps away. The first five workouts are courtesy of Yeung. The last five workouts are courtesy of Bruno. Perform all A exercises, then all B exercises, then all C exercises. A1) Feet-Elevated Pike Pushup. Rest: 60 seconds. Get into a pike position—arms straight and nikken business legs straight with your hips high in the air—with your feet on a sturdy elevates surface like a box.

Slowly lower yourself and drive back up. A2) Alternating Split Squat Jump. Reps: 10 (each leg) Rest: 60 seconds. Ptlls Essays! Start in a split stance. Squat down and explode into the air, switch legs, and nikken business plan land in the opposite ptlls, stance. Alternate quickly and plan jump as high as you can each time. B1) Spiderman Crawl. Rest: 30 seconds. Start in a pushup position. Crawl forward by essay failure, taking a large step with your right arm and left leg at the same time—get low to business plan the ground and swing your left knee so that it almost touches your right elbow.

Alternate sides and keep your body low to the ground. To increase the difficulty, crawl backwards. B2) Spiderman Pushups. Rest: 30 seconds. Start in a pushup position. As you lower yourself, pull one knee toward that same-side’s elbow. Failure! As you rise, bring your leg back. Repeat on the other side and continue alternating.

B3) Single-Leg Box Squats. Start by nikken business plan, facing away from a bench or box. Lift one leg, sit back onto the bench and come up without putting your other leg down. To make it harder, lower the bench. C1) Alternating Side Plank. Reps: 5 (each side) Rest: 30 seconds. Essay! Lie on your side and place your forearm on the ground, perpendicular to your body. Keep your body straight, your glutes squeezed, and plan your shoulders pulled back. Don’t let your hips sag.

Twist your body toward the ground, switch arms, and do a side plank facing the other way. Do all “A” exercises then all “B” exercises. Paper! For example, you’ll do A1 (siff squat) then A2 (prisoner hold jump squats and then start over nikken business plan, with the siff squat for the second set. What Good Statements! Do the nikken same for essay on christmas for small the “B” and C exercises. Stand shoulder-width apart with your feet slightly turned out. Get onto the balls of your feet and stay there throughout. Squat down, sitting back and spreading your knees apart. Once you descend below parallel, drive back up. A2) Prisoner Hold Jump Squats, Rest: 60 seconds. Stand shoulder-width apart with your feet slightly turned out. Business! Places your hands behind your head.

Squat down, sitting back and spreading your knees apart. Keep your weight on your heels. Once you descend below parallel, explode up and jump as high as you can. B1) Feet-Elevated Pike Pushups. Rest: 60 seconds. Essay For Small Kids! Get into a pike position — arms straight and legs straight with your hips high in the air — with your feet on a bench or small box. Nikken Business! Slowly lower yourself and drive back up. B2) Alternating Split Squat Jumps. Is A Thesis! Rest: 60 seconds. Start in a split stance. Business! Squat down and studies explode into the air, switching legs, and plan landing in the opposite stance.

Alternate quickly and jump as high as you can each time. C1) Salute Planks. Reps: 5 (each arm) Rest: 30 seconds. Get into a plank position. Bring one hand to your forehead in a salute position and research paper hold for nikken business plan 3 seconds before switching arms. Prevent your hips from what twisting as you salute. Rest: 30 seconds. Get into a plank position with only your feet on Valslides. Business Plan! Squeeze your glutes and tighten your core. Then, push your body backward with your forearms as far as you can. Pull yourself back to the starting position and repeat.

The farther back you push, the harder you hit your core. Perform all A exercises, then all B exercises, then all C exercises. Council For European Studies Fellowship! Rest: 60 seconds. Grab a pullup bar and lift your legs in front of you so your body forms an L. Hold this position and nikken plan perform your pullups. A2) Feet-Elevated Pushups. Rest: 60 seconds. Council Studies Pre Dissertation! Perform a regular pushup with your feet on a small box or bench. B1) Skater Squat.

Rest: 60 seconds. Nikken! Start from a stand and bend one foot behind you. Then, squat down while trying to touch the edexcel history knee of the bent leg onto the ground behind you. Let your lean your torso and reach your arms forward as you descent. B2) Single-Leg Box Squats. Rest: 60 seconds. Start by facing away from a bench or box. Lift one leg, sit back onto the bench and come up without putting your other leg down. To make it harder, lower the bench. B3) Valslide Lateral Squat. Nikken Business! Reps: (10 each leg) Rest: 60 seconds.

Place one foot on ptlls essays, a Valslide. Squat and push your sliding leg directly out to the side while squatting down on nikken business plan, your stationary leg. Market Failure! On your stationary leg, focus on sitting backward with your weight on nikken plan, your heel, keeping your chest tall, and keeping a neutral arch in your lower back. Rest: 30 seconds. Start in a pushup position. Do one pushup and as you rise, explosively pull your knees toward your chest and essay for small place your feet underneath your chest. Then, jump as high as you can. Once you’re land, put your hands on the ground and kick your legs behind to return into a pushup position. Repeat as fast as you can.

Perform all A exercises, then all B exercises, then all C exercises. A1) Wide-Grip Pullups. Reps: Until Failure. Rest: 90 seconds. Business Plan! Hang from a pull bar with an overhand grip, hands wider than shoulder-width apart. Squeeze your shoulder blades together and council studies fellowship pull yourself up until your chin is over the bar. B1) Single-Leg Box Squats.

Rest: 60 seconds. Start by facing away from a bench or box. Lift one leg, sit back onto the bench and come up without putting your other leg down. To make it harder, lower the bench. B2) Hip/Thigh Extension. Rest: 60 seconds. Lie on business plan, your back and bend one knee so that it makes a 90-degree angle and stick the other leg straight out. Research! With your bent leg, squeeze your glute, push through your heel, push your hips up, and keep your hips level as you rise.

Keep your straight leg extended throughout the exercise and keep it inline with your torso. Plan! B3) Pushup + Overhead Reach. Reps: 6 (each side) Place one palm on a slideboard or Valslide. From the for european pre dissertation fellowship pushup position, descend into a pushup while simultaneously reaching forward with the hand on the sliding surface. When you’re at the bottom of the pushup, your sliding arm should be locked out. C1) Forward Crawl. Duration: 30 seconds crawling. Rest: 30 seconds.

Start on all fours, with your shoulders directly above your hands, your hips above your knees, and nikken plan your knees an inch above the ground. Crawl forward by taking a tiny step with your right arm and for european pre dissertation left leg at the same time, and nikken business then another step with your left arm and for european studies fellowship right leg. Nikken Business Plan! Alternate while keeping your hips low and your head up. To increase the difficulty, crawl backwards or laterally. Workout 5: Chinup and valslide Workout. Perform all A exercises, then all B exercises, then all C exercises.

A1) Valslide Leg Curl. Rest: 60 seconds. Lie on your back with your feet on Valslides. Start by squeezing your glutes and extending your hips. What Thesis! Then, curl your feet underneath your knees while keeping your hips extended and maintaining a straight line from your shoulders to your knees. Remember: every inch you curl your feet is another inch your hips need to rise. Business! B1) Feet-Elevated Pushups. Rest: 60 seconds. Perform a regular pushup with your feet on a small box or bench. Rest: 60 seconds. Grab a pullup bar shoulder-width apart with a supinated grip.

Squeeze your shoulder blades together and pull your chest to the bar. C1) Alligator Drags. Rest: 30 seconds. Place both feet on ptlls course, a slideboard or on business plan, separate Valslides. Get into pushup position with your glutes squeezed and what good thesis core tight. While keeping your arms straight, march forward with your arms while dragging your legs behind you. Nikken! Keep your legs straight. Workout 6: Full-body bodyweight workout (with warmup) The Warmup (Will make total workout time greater than 20 minutes) Do all three exercises in a row and then repeat the circuit again for a total of for european pre dissertation fellowship six sets. Business Plan! 2. Alternating Lunges (with hands behind head) Reps: 10 (each leg) 3. Ptlls Essays! Lateral Lunges (hands in front) Reps: 10 (each leg) Do all “A” exercises then all “B” exercises. For example, you’ll do A1 (glute bridge march) then A2 (pushups), then A3 (split squats) and then start over with glute bridge marches for the second set.

Do the same for the “B” exercises. Plan! Reps: 10 (each leg) Reps: As many as possible (AMRAP) A3. Bulgarian Split Squat (foot on chair, box, or bench) Reps: 12 (Per Leg) B3. Straight Leg Situp (reach for ceiling) Do all “A” exercises then all “B” exercises. For example, you’ll do A1 then A2, then A3 and then start over with A1 for the second set. Do the same for the “B” exercises.

A1. Bulgarian Split Squat. Reps: 6 (each leg) A2. Single Arm Dumbbell Floor Press. Essay Kids! Reps: 8 (each arm) Use a neutral grip and business touch the dumbbell to your armpit on each rep. A3. Course! Chest Supported Dumbbell Row. Set bench to approximately 35 degree angle, stand with toes on floor and nikken business plan body facing bench. Good Thesis Statements! Row dumbbells to touch shirt, pause, then lower back down until arms are extended. If you don’t have a bench, do standing bentover dumbbell rows.

B1. Nikken! Goblet Squat. B2. Pushups with hands on dumbbells. B3. Bent Over Reverse Fly. On Christmas For Small Kids! Do all “A” exercises then all “B” exercises. For example, you’ll do A1 then A2, then A3 and then start over with A1 for the second set. Do the same for the “B” exercises. B3. Sliding Mountain Climbers.

Reps: 15 (each leg) Repeat this circuit as many times as possible in 20 minutes. A2. Straight Leg Situps. Duration: 30 seconds. Do all “A” exercises then all “B” exercises, then all C exercises. A1. Bulgarian Split Squat Jumps. Reps: 6 (each leg) B1. Bulgarian Split Squat Countdowns.

B2. Straight Leg Situps. C2. Plan! Straight Leg Reverse Crunch. *Do 6 reps, then do a 6-second iso hold with your rear knee just off the floor. Go straight into 5 reps followed by a 5-second iso hold, then 4, etc, all the way down to 1 rep. 21 reps and 21 seconds of holds. Copyright © 2017 Weider Publications, LLC, a subsidiary of fellowship American Media, Inc.

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cardiac case study Anesthesiology: Problem-Oriented Patient Management. CASE 15: Cardiac Tamponade. Manuel L. Fontes. Quick Links to Sections in nikken this Chapter. Related Links in other Resources. Four days following two-vessel coronary artery bypass graft (CABG) procedure and studies fellowship, replacement of a mitral valve, this 69-year-old woman presented with a chief complaint of shortness of breath, inability to lie supine, oliguria, and overt weakness.

On examination, she appeared anxious and diaphoretic with the following vital signs: respiratory rate 38 breaths/minute, heart rate (HR) 120 beats/minute [normal sinus rhythm (NSR)], and systemic blood pressure 115/66 mm Hg. A pulmonary artery catheter (PAC) was placed and revealed: pulmonary artery (PA) pressures, 55/15 mm Hg; pulmonary artery occlusion pressure (PAOP), 14 mm Hg; central venous pressure (CVP), 23 mm Hg; and a cardiac output (CO) of nikken business plan, 2.7 L/minute. Both the ptlls course, prothrombin and plan, the partial thromboplastin times were elevated. Medical Disease and Differential Diagnosis What is the differential diagnosis of low cardiac output (CO) postoperatively? A. Medical Disease and Differential Diagnosis. A.1. What is the differential diagnosis of low cardiac output (CO) postoperatively? CO is determined by the product of stroke volume (SV) and heart rate (HR) during 1 minute (CO = HR x SV). Essays. Thus, a low output state can occur when SV and/or HR decrease.

Tachyarrhythmias of either ventricular or atrial origin can also cause a low output state (i.e., atrial fibrillation). To more accurately determine the nikken business, etiology of a reduced SV, it is necessary to explore whether there has been a change in for european the preload, the afterload, and/or the contractile state. Either too much preload (ventricular overdistention) or too little preload can lower the CO. Similarly, a significant reduction in afterload (vasodilators, anesthetics, sympatholysis) or an increase in afterload (arterial resistance) can diminish SV. Nikken Business Plan. The latter, however, is only seen in patients with severe ventricular dysfunction whereby the heart can no longer compensate for increases in afterload. Myocardial contractility can be compromised by either direct causes (myocardial ischemia, myocardial infarction, myocardial stunning, or myocardial hibernation) and/or by on christmas kids indirect causes (mechanical factors as in cardiac tamponade; pharmacologic agents; and by toxins, namely, inflammatory cytokines and bacterial endotoxins). A combination of hemodynamic disturbances can coexist in the same patient. For example, a patient can have both a decrease in plan contractility and a reduced preload to account for edexcel history, the low output state. Correcting one problem alone may not produce the optimal hemodynamic condition.

Fontes ML. Hines RH. Nikken Plan. Pharmacologic treatment of what statements, perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Nikken Business. Philadelphia: Grune Stratton, 1999:1155–1191. A.2. Research Paper Apa Citation. What is cardiac tamponade? Enumerate the common etiologies of cardiac tamponade. Cardiac tamponade is defined as significant compression of the heart by accumulating pericardial contents. These include blood and clots (postcardiotomy, chamber perforation, dissecting aortic aneurysm, trauma, anticoagulant therapy), exudative effusions (malignant states, infective pericarditis, idiopathic pericarditis), nonexudative effusions (uremia, systemic lupus erythematous, rheumatoid arthritis, idiopathic, radiation), and plan, air. How significant cardiac tamponade is depends on whether the definition is clinical versus physiologic.

That is, tamponade is a pathophysiologic continuum that on one extreme may be clinically insignificant whereas on another extreme presents as a life-threatening condition requiring emergent surgical attention. Market. Clinical tamponade is frequently associated with marked increase in nikken plan pericardial pressure relative to essays, intracardiac pressures (atrial and ventricular) such that SV progressively declines resulting in systemic hypotension and in cardiogenic shock. Braunwald E, Heart disease: a textbook of nikken business plan, cardiovascular medicine 6th ed. Philadelphia: WB Saunders, 2001:1498. Fowler NO. Gabel M. Buncher CR. Cardiac tamponade: a comparison of right heart versus left heart compression. JACC 1988:12:187.

Kaplan JA, Cardiac anesthesia 3rd ed. Essay Kids. Philadelphia: WB Saunders, 1999:847. Spodlick D. Pathophysiology of business plan, cardiac tamponade. Chest 1998:113:1372–1378. A.3. What is the difference between acute and delayed cardiac tamponade? In the setting of cardiac surgery, cardiac tamponade can occur acutely over minutes, hours, or after a few days postoperatively. The reported incidence of acute cardiac tamponade is 0.5#37; to 5.8#37;.

The typical patient has significant chest tube output (more than 200 mL/hour) in the immediate postoperative period associated with or without hemodynamic signs of inadequate CO. Alternatively, the chest tubes may become clogged by blood clots impeding mediastinal drainage. Essay Kids. Delayed tamponade has been arbitrarily defined as cardiac tamponade occurring greater than 5 to 7 days after pericardiotomy. Nikken Business. The incidence is 0.3#37; to 2.6#37; and is often misdiagnosed because of a low index of suspicion and because the clinical signs and symptoms can be comparable to those of congestive heart failure, pulmonary embolism, and generalized fatigue (i.e., failure to thrive postoperatively). The most common culprit in delayed cardiac tamponade is anticoagulant therapy with coumadin, heparin, and/or platelet inhibiting agents.

Effusion after cardiac surgery is common. Using echocardiography, Weitzman et al. evaluated consecutive patients postoperatively and demonstrated that 103/122 (84#37;) had pericardial effusions. Generally, effusions reach their maximum size by ptlls essays the tenth postoperative day and regress spontaneously thereafter. D'Cruz IA. Nikken Plan. Overton DH. Pai GH. Pericardial complications of cardiac surgery: emphasis on essay failure, the diagnostic role of echocardiography.

J Card Surg 1992:7:257–268. Nelson RM. Nikken Business Plan. Jeson CB. Paper. Smoot WM. Pericardial tamponade following open-heart surgery. J Thorac Cardiovasc Surg 1969:58:510–516. Weitzman LB. Tinker WC. Business. Kronzon I, et al.The incidence and natural history of essay on christmas kids, pericardial effusions after cardiac surgery: an nikken plan, echocardiographic study.

Circulation 1984:69:506. A.4. How is the diagnosis of postcardiotomy cardiac tamponade made? The diagnosis of cardiac tamponade following cardiac surgery is often difficult and requires a high degree of clinical suspicion, proficient knowledge of pulmonary artery catheter (PAC) derived measures, physical examination, and diagnostic tools such as echocardiography and chest x-ray film. Often, the diagnosis is made in the operating room whereby evacuation of clot and blood from the mediastinum is associated with drastic improvement in hemodynamics. Relying on one modality alone for diagnosis can lead to essays, inaccurate management decisions and increase patient morbidity. For example, the PAC is an business, important device for monitoring cardiac function; however, its measures can be misleading postcardiotomy unless the clinician is cognizant of such limitations.

The classical teaching of equalization of diastolic blood pressures in cardiac tamponade [central venous pressure (CVP) = pulmonary artery diastolic pressure (PAD) = pulmonary artery occlusion pressure (PAOP)] is infrequently observed postoperatively because the pericardium is left open. As such, blood or clot or both do not distribute around the heart homogeneously to produce equalization of pericardial diastolic pressures. Generally, the CVP is elevated but the research paper apa citation, PAD and the PAOP can be normal, elevated, or, in some cases, reduced. With significant compression of the right heart, reduced blood flow to the pulmonary artery (PA) and to business, the left heart can yield lower pressures that would be inconsistent with classical tamponade physiology. Russo and colleagues found that only 33#37; of essay market failure, patients with the diagnosis of cardiac tamponade had right heart catheterization findings that reflected equalization of nikken, diastolic blood pressures. Overall, 90#37; of patients with postcardiotomy cardiac tamponade had either atypical clinical, hemodynamic, and/or echocardiographic findings. Ptlls Course Essays. Therefore, the diagnosis of postoperative cardiac tamponade should be considered whenever hemodynamic deterioration is encountered, particularly when reduction in CO or blood pressure or both are not readily responsive to conventional management. Nikken Business Plan. Furthermore, in delayed tamponade the complaints tend to be vague and less hemodynamic data is available (i.e., PAC) to allow prompt diagnosis of tamponade.

Whenever, the patient is not progressing as expected postoperatively with some signs of end-organ dysfunction [fall in urine output and or increase blood urea nitrogen (BUN) and essays, creatinine], an echocardiogram should be obtained to nikken business plan, rule out cardiac tamponade. Russo A. O'Connor W. Waxman H. For European Fellowship. Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery. Chest 1993:104:71–78. Spodlick D. Pathophysiology of cardiac tamponade. Chest 1998:113:1372–1378. A.5. What is regional cardiac tamponade? Regional cardiac tamponade occurs when one or more cardiac chambers become compressed by blood or blood clot or both compromising forward flow.

Postcardiotomy, diastolic regional collapse of the right atrium or the right ventricle is the most common echocardiographic finding in nikken plan early cardiac tamponade. Postoperative right atrial hematoma often become localized to the anterior and lateral walls, whereas left atrial clots are more commonly found behind the left atrium where they become encysted in the posterior space in essays the oblique sinus. Selective hematoma compression of the business plan, right heart becomes less prominent in delayed tamponade as the right heart becomes adherent or tethered to the anterior chest wall. Essay On Christmas Kids. As discussed in the previous answer, the diagnosis of tamponade is often misdiagnosed because classical features of tamponade are often absent because of uneven distribution of nikken, blood and blood clots around the heart. The clinical presentation may be mistaken for congestive heart failure, acute left or right ventricular infarction, septic shock, or pulmonary embolism. Chuttani K. Pandian NG. Mohanty PK, et al.Left ventricular diastolic collapse. An echocardiographic sign of regional cardiac tamponade. Circulation 1991:83:1999–2006. Fowler NO. Apa Citation. Gabel M. Regional cardiac tamponade: a hemodynamic study.

J Am Coll Cardiol 1987:10:164–169. Hutchins GM. Isolated right atrial tamponade caused by hematoma complicating coronary artery bypass graft surgery [Letter]. Arch Pathol Lab Med 1980:104:612–614. Jadhav P. Asirvatham S. Nikken Business Plan. Craven P, et al.Unusual presentation of council, late regional cardiac tamponade after aortic surgery.

Am J Cardiac Imaging 1996:10:204–206. Kochar GS. Jocab LE. Holter MN. Right atrial impression in postoperative patients: detection by business transesophageal cardiography.

J Am Coll Cardiol 1990:16:511–516. Russo A. Essay On Christmas. O'Connor W. Nikken Business Plan. Waxman H. Failure. Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery. Plan. Chest 1993:104:71–78. Sandifer DP. Essay Kids. Gonzalez JL.

Refractory postoperative hypoxemia associated with regional cardiac tamponade and patent foramen ovale. Crit Care Med 1997:25:1608–1611. A.6. What is pulsus paradoxus? What is Kussmaul's sign?

Normally, there is an inspiratory fall of less than 10 mm Hg in the arterial systolic pressure and nikken business, an accompanying inspiratory fall in essay the venous pressure. However, a paradoxical pulse differs from the normal situation in two aspects: (a) the inspiratory fall of the arterial pressure exceeds 10 mm Hg and (b) the inspiratory venous pressure remains steady or increases (Kussmaul's sign). Echocardiographic studies of patients with cardiac tamponade by D'Cruz et al. described phasic respiratory changes whereby both left ventricular and mitral valve excursion decreased during inspiration. In contrast, right ventricular dimensions increased in association with a shifting of the interventricular septum toward the left ventricle. Nikken Business. Of importance, pulsus paradoxus is not unique to cardiac tamponade.

The phasic respiratory changes in good thesis statements ventricular dimensions with exaggerated decrease in systemic systolic arterial pressure during inspiration can be present in a variety of plan, clinical conditions whereby intrapleural pressure is significantly diminished. That is, the magnitude of what is a, paradoxical pulse is directly proportional to the inspiratory decrease of left ventricular dimension, diastolic volume, and SV. This physiologic process is often present in respiratory distress, airway obstruction, chronic obstructive pulmonary disease (COPD), and pulmonary embolism. Although a prominent feature of cardiac tamponade, pulsus paradoxus may not be present at all in patients with chest wall trauma, neuromuscular disease, and pneumothorax because they cannot produce sufficient negative intrapleural pressure during inspiration to produce the typical changes in chamber dimension and nikken plan, fall in left ventricular SV. Statements. Similarly, those who are receiving positive pressure mechanical ventilation (early postoperative period) and nikken business plan, patients with severe aortic regurgitation do not exhibit pulsus paradoxus. D'Cruz IA. Council Pre Dissertation. Overton DH. Pai GH. Pericardial complications of cardiac surgery: emphasis on the diagnostic role of echocardiography.

J Card Surg 1992:7:257–268. Frey B. Freezer N. Diagnostic value and pathophysiologic basis of pulsus paradoxus in infants and children with respiratory disease. Pediatr Pulmonol 2001:31:138–143. Jay GD. Onuma K. Davis R, et al.Analysis of nikken business, physician ability in the measurement of pulsus paradoxus by sphygmomanometry. Chest 2000:118:348–352. McGregor M. Pulsus paradoxus. N Engl J Med 1979:301:480.

Tsang TS. Barnes ME. Hayes SN, et al.Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979#150;1998. Chest 1999:116:322–331. A.7. Describe ventricular interaction in cardiac tamponade.

Ventricular interaction is extremely important for maintenance of paper apa citation, adequate cardiac performance. Under normal conditions, the average SV of the right ventricle equals the SV of the left ventricle; however, cyclical respiratory differences in left and business, right ventricular SV do occur. During the inspiratory cycle, negative intrapleural pressure is generated facilitating venous return to on christmas kids, the right heart, whereas venous return to the left heart is diminished for the following reasons: (a) lung expansion increases its reservoir for blood and (b) the increase in right ventricular filling causes the nikken, interventricular septum to bulge leftwardly reducing left ventricular dimension and altering its compliance and filling (ventricular interaction). Edexcel. During exhalation, the reverse process occurs. In the nikken business plan, case of cardiac tamponade, ventricular interaction also involves the interventricular septum but it can involve other chamber and processes depending on the etiology of the tamponade (fluid vs. Essay. clot, regional vs. global tamponade). Fundamentally, as intrapericardial content increases, it will reach a point whereby the parietal pericardium cannot stretch commensurate with the rising pressure. Because of the fixed space within the pericardium, cardiac chamber dimensions become smaller. First, the thin-walled and more compliant atriums progressively get compressed followed by the right ventricle and lastly the business, left ventricle.

Overall, the physiology of ventricular interaction in on christmas for small kids clinical cardiac tamponade becomes complex as the pressure-volume relationship of mediastinal and chest structure alters with each heartbeat and from respiratory and neuroendocrine influences. Spodlick D. Pathophysiology of cardiac tamponade. Chest 1998:113:1372–1378. A.8. How is coronary blood flow affected in cardiac tamponade? In the absence of coronary artery disease, coronary blood flow is nikken plan reduced in paper apa citation cardiac tamponade but this reduction is not sufficient to add an ischemic injury to the myocardium because there is a proportionate decrease in (a) ventricular preload (underfilled) and (b) ventricular afterload (underafterloaded). Consequently, both myocardial work and oxygen consumption are reduced. Business Plan. In contrast, patients with coronary artery disease may be at essay on christmas, increased risk for myocardial ischemia or infarction or both. Reddy PS.

Curtiss EL. Otoole JD, et al.Cardiac tamponade; hemodynamic observation in man. Circulation 1978:58:265–272. Spodlick DH. Threshold of pericardial constraint: the nikken plan, pericardial reserve volume and ptlls course, auxiliary pericardial functions.

J Am Coll Cardiol 1985:6:296–299. A.9. What are the electrocardiographic abnormalities associated with cardiac tamponade? Electrocardiographic changes may occur in the settling of cardiac tamponade. These include nonspecific ST-T wave abnormalities, low voltage QRS complex, signs of myocardial ischemia and nikken business, pericarditis, and electrical alternans ( Fig. 15.1A ). The latter is seen in patients with large effusions and is characterized by interbeat shifts in council fellowship electrical axis. This beat-to-beat alteration may be due to nikken business plan, increased distance between the council for european studies pre dissertation, heart and the chest wall resulting in a pendulum like motion of the heart. However, it has been shown that with minimal amount of pericardial fluid removal, the presence of electrical alternans can be abolished while the pericardial space remains enlarged. Thus, the electrocardiographic change of electrical alternans may reflect a hemodynamic pathology rather than an anatomic abnormality.

This finding, although sensitive for cardiac tamponade, is not very specific (very few patients with tamponade present with electrical alternans). Figure 15.1. Depiction of electrical alternans in a patient with cardiac tamponade. The images demonstrate significant pericardial effusions (PE) obtained during transthoracic echocardiography. Note the image of the left ventricle (LV) during systole and diastole. (From Longo MJ, Jaffe CC. Images in clinical medicine. Business Plan. Electrical alternans. N Engl J Med 1999;341:2060, with permission.) Figure 15.1. Depiction of electrical alternans in a patient with cardiac tamponade. The images demonstrate significant pericardial effusions (PE) obtained during transthoracic echocardiography.

Note the image of the market, left ventricle (LV) during systole and business, diastole. (From Longo MJ, Jaffe CC. Good Thesis. Images in business plan clinical medicine. Essay Kids. Electrical alternans. N Engl J Med 1999;341:2060, with permission.) Fox JJ. McHarg JL. Gilmour RF Jr. Ionic mechanism of electrical alternans. Am J Physiol Heart Circ Physiol 2002:282:H516–530.

Kosta E. Kronzon I. Electrical alternans in cardiac tamponade. Echocardiography 2000:17:(6 Pt 1)575–576. Kronzon I. Cohen M. Winer H. Contribution of echocardiography to nikken plan, the understanding of the pathophysiology of cardiac tamponade. For European. J Am Coll Cardiol 1983:1:1180–1182. Longo MJ. Jaffe CC. Images in nikken clinical medicine. Electrical alternans. N Engl J Med 1999:341:2060. A.10. What roentgenographic and echocardiographic findings are noted in cardiac tamponade?

On standard anterior-posterior chest roentgenography, the cardiac silhouette may appear normal in size or extremely enlarged depending on the acuity and essay on christmas kids, chronicity of the tamponade process. Normally, the pericardial fluid amounts to 15 to 25 mL. Acute tamponade physiology can arise with as little as 150 mL of effusion, whereas chronic effusions may exceed 1,000 mL before clinical signs and symptoms of cardiac tamponade manifest. On chest x-ray film, the cardiac silhouette will appear widened with or without features such as obscuring of the pulmonary vessels at business, the hilum and a globular or water bottle configuration of the essays, heart. Transthoracic or transesophageal echocardiography can differentiate between cardiac dysfunction arising from direct myocardial injury versus cardiac dysfunction associated with mechanical processes.

Pericardial effusions can be readily seen and semiquantitated. Likewise, pericardial blood clots can be demonstrated to compress the plan, respective chamber. Essay Market. Additional echocardiographic signs observed in tamponade include (a) diminished left ventricular dimension and nikken, mitral valve excursion during inspiration, (b) shifting of the interventricular septum toward the left ventricle, (c) changes in transvalvular (mitral and what is a good thesis, aortic) flow characteristics seen by Doppler techniques, (d) diastolic posterior motion of the business plan, right ventricular wall, and (e) in some cases, a systolic notch on the right ventricular epicardium ( Fig. 15.1B and C ). Although many of the findings of council studies pre dissertation fellowship, both x-ray film and echocardiogram can be suggestive of cardiac tamponade, no one sign is 100#37; sensitive and specific. Braunwald E, Heart disease: a textbook of business, cardiovascular medicine 6th ed. Philadelphia: WB Saunders, 2001:1490. Kaplan JA, Cardiac anesthesia 4th ed. Philadelphia: WB Saunders, 1999:932, 1250.

Singh SM. Wann LS. Schuchard GH, et al.Right ventricular and right atrial collapse in patients with cardiac tamponade. Circulation 1984:70:996. A.11. What is in essay failure the differential diagnosis of postcardiopulmonary bypass (post-CPB) bleeding? Significant bleeding following cardiac surgery requiring surgical exploration bring-back occurs in approximately 3#37; of cases. Often, the source of bleeding cannot be ascertained and its etiology is ascribed to nikken, a coagulation defect.

Procedures that require CPB are known to adversely affect the hemostatic mechanisms including vascular endothelium, fibrinolytic and council studies fellowship, coagulation factors, platelet, plasminogen, and inflammatory pathways ( Fig. 15.2 ). Under normal settings, these systems (and others yet unknown) act in concert and in nikken business plan opposition with one another (a) to prevent bleeding by promoting clot formation at the site of endothelial injury (procoagulant effects) and (b) to research paper apa citation, prevent or destroy clot formation (anticoagulant effects#151;either directly or indirectly via inhibitory mediators). Once blood elements come in contact with a nonendothelialized surface (bypass circuit), the procoagulant system becomes activated resulting in consumption of platelets, coagulation factors, and fibrinogen. The potential for postoperative bleeding will depend on the degree of activation and preexisting levels of the business plan, procoagulants as well as other factors such as the duration of CPB, systemic hypothermia, comorbid states (renal and liver insufficiency), type of surgery (reoperation, circulatory arrest, combined procedures), and edexcel essays, prior or current treatment with anticoagulant (platelet inhibitors, coumadin, heparin). Figure 15.2. The coagulation cascade, illustrating the nikken plan, coagulation factors required for various screening tests. Course Essays. HMWK, high molecular weight kininogen; PK, prekallikrein; PL, phospholipid by platelets; PT, prothrombin time; PTT, partial thromboplastin time; TCT, thrombin clotting time; TTPL, tissue thromboplastin. Nikken Business Plan. (From Coleman RW, Hirsch J, Marder VJ, et al, eds. Edexcel History Essays. Hemostasis and thrombosis: basic principles and clinical practice, 2nd ed. Philadelphia: JB Lippincott, 1987:1052, with permission.) Figure 15.2.

The coagulation cascade, illustrating the coagulation factors required for various screening tests. HMWK, high molecular weight kininogen; PK, prekallikrein; PL, phospholipid by platelets; PT, prothrombin time; PTT, partial thromboplastin time; TCT, thrombin clotting time; TTPL, tissue thromboplastin. Plan. (From Coleman RW, Hirsch J, Marder VJ, et al, eds. Hemostasis and thrombosis: basic principles and clinical practice, 2nd ed. Philadelphia: JB Lippincott, 1987:1052, with permission.) Platelets play an important role in the coagulation process.

Once activated, they secrete several types of granules. Granules, containing peptides such as fibrinogen, thrombospondin, factors V and VIII, and essay, -thromboglobulin, are reduced in both number and nikken, content during CPB. Of greater importance is the loss of several membrane glycoproteins (IIb-IIIa) that interact with fibrinogen and other cellular elements allowing for platelet conjugation and studies pre dissertation fellowship, propagation of clot formation. Nikken. Overall, postcardiotomy bleeding is due to (a) a qualitative and a quantitative platelet defect, (b) factor deficiency, and (c) surgical bleeding. The latter can arise from either venous or arterial sources that were undetected before closure of the chest. Attentive and meticulous effort to surgical hemostasis can significantly reduce the edexcel essays, incidence of business, bring-backs. Despotis GJ. Avidan MS. Hogue CW Jr. Mechanisms and attenuation of history essays, hemostatic activation during extracorporeal circulation. Ann Thorac Surg 2001:72:S1821–1831.

Harker L. Malpass TW. Branson HE. Mechanism of abnormal bleeding in patients undergoing cardiopulmonary bypass: acquired transient platelet dysfunction associated with selective alpha-granule release. Blood 1980:56:824. Kojima T. Business Plan. Gando S. Morimoto Y, et al.Systematic elucidation of effects of tranexamic acid on fibrinolysis and council studies pre dissertation, bleeding during and after cardiopulmonary bypass surgery. Thromb Res 2001:104:301–307. Levy JH. Pharmacologic preservation of the hemostatic system during cardiac surgery. Ann Thorac Surg 2001:72:S1814–1820. A.12.

What is the mechanism of nikken business plan, action of low molecular weight heparin (LMWH)? LMWHs are fragments of on christmas, unfractionated heparin produced by controlled enzymatic or chemical depolymerization processes yielding chains having molecular weight of about 5,000 daltons. The parent compound is a heterogeneous mixture of polysaccharide chains with molecular weight of business, 3,000 to 30,000 daltons. The mechanism of action is similar for both unfractionated heparin and LMWH. Thesis. Binding of the nikken plan, pentasaccharide to antithrombin (antithrombin III) results in a conformational change in council for european pre dissertation antithrombin that accelerates its interaction with thrombin and factor X (factor Xa) by 1,000-fold. Whereas unfractionated heparin causes a comparable inhibition of factor Xa as LMWH, its inhibition of thrombin is much more profound than LMWH. To inactivate thrombin, heparin has to bind to both antithrombin and thrombin forming a ternary complex. Heparin pentasaccharide sequences (randomly distributed along heparin chains) of 18 units or more is required for the formation of this ternary complex. Approximately 50#37; of LMWH lack the adequate length necessary for binding antithrombin and thrombin. Furthermore, only 15#37; to 25#37; of plan, chains of LMWH contain pentasaccharide sequences. Essay Market Failure. Therefore, LMWH has greater inhibitory effect of factor Xa, whereas unfractionated heparin exerts an equipotent effect against both thrombin and factor Xa.

Lastly, both LMWH and unfractionated heparin cause release of tissue factor pathway inhibitor from vascular endothelium, which then forms a complex with and inhibits factor Xa. This complex in turn inactivates factor VIIa. Clark SC. Vitale N. Zacharias J, et al.Effect of low molecular weight heparin (fragmin) on bleeding after cardiac surgery. Ann Thorac Surg 2000:69:762–765. Danielsson A. Raub E. Lindahl U, et al.Role of nikken plan, ternary complexes in which heparin binds both antithrombin and proteinase, in the acceleration of the reactions between antithrombin and thrombin for factor Xa. J Biol Chem 1986:261:1546–1573. Gohlke-Barwolf C. Studies Pre Dissertation Fellowship. Anticoagulation in valvar heart disease: new aspects and business, management during non-cardiac surgery.

Heart 2000:84:567–572. Harenberg J. Pharmacology of essay for small kids, low molecular weight heparins. Nikken Business. Semin Thomb Hemost 1990:16:12–18. Kondo NI. Council For European Studies Fellowship. Maddi R. Ewenstein BM, et al.Anticoagulation and hemostasis in cardiac surgical patients.

J Card Surg 1994:9:443–461. Weitz JI. Drug therapy: low molecular weight heparins. Plan. N Engl J Med 1997:337:688–698. A.13. Describe the advantages of council for european fellowship, LMWH over nikken business, standard heparin therapy. There are several clinical and pharmacologic advantages of LMWH over unfractionated heparin.

The plasma half-life of LMWH is two to four times longer than unfractionated heparin, which undergoes a dose-dependent elimination by essay on christmas kids the liver and the kidneys. A significant amount of nikken plan, unfractionated heparin is market failure bound to plasma proteins, vascular endothelium, and macrophages resulting in less bioavailability and an unpredictable anticoagulant effect. Consequently, careful laboratory monitoring is required. Additional benefits of LMWH over unfractionated heparin include less bleeding (less platelet inhibition and less propensity for increasing microvascular permeability). Several clinical trials have demonstrated both improved efficacy and safety of LMWH over unfractionated heparin.

Of note, LMWH is not recommended in the setting of renal failure, and its anticoagulant activity may be measured by assaying factor Xa levels. There are, however, many different types of LMWH available in business the market, each having slightly different pharmacologic effects (bioavailability, anticoagulant effect). Lastly, our understanding of the anticoagulant mechanism of is a good thesis statements, LMWH continues to evolve, and, although its indications continue to nikken business, broaden, there may be safety concerns that ought not to be dismissed. Alban S. Gastpar R. Paper. Plasma levels of total and free tissue factor pathway inhibitor (TFPI) as individual pharmacological parameters of various heparins. Thromb Haemost 2001:85:824–829.

Cohen AT. Bailey CS. Alikhan R, et al.Extended thromboprophylaxis with low molecular weight heparin reduces symptomatic venous thromboembolism following lower limb arthroplasty#151;a meta-analysis. Thromb Haemost 2001:85:940–941. Huse DM. Cummins G. Nikken. Taylor DC, et al.Outpatient treatment of venous thromboembolism with low-molecular-weight heparin: an economic evaluation. Am J Managed Care 2002:8:(1Suppl)S10–16. Kleinschmidt K. Charles R. Pharmacology of low molecular weight heparins [Review]. Emerg Med Clin North Am 2001:19:1025–1049. A.14.

What is heparin-induced thrombocytopenia (HIT)? How is the essays, diagnosis made? HIT is a serious complication of heparin therapy that is predominantly immunemediated by a binary complex of heparin and platelet factor 4 (PF4). The reaction is commonly caused by an immunoglobulin (IgG) antibody that binds and activates platelets in business the presence of essay failure, heparin. Other immunoglobulins may also potentiate HIT. HIT exists in plan two forms. A benign form of HIT, type 1, is observed in approximately 10#37; to 20#37; of patients receiving unfractionated heparin. This mild form of thrombocytopenia (rarely less than 100 x 10 3 / L) occurs after 1 to 4 days of therapy and generally improves despite continuing heparin administration.

In contrast, type II HIT is a life-threatening condition that develops 5 to 10 days after initiating heparin therapy and is associated with devastating thromboembolic processes (most commonly arterial thrombosis resulting in limb ischemia, cerebrovascular events, and myocardial infarction). Edexcel History. The platelet count falls to less than 50 x 10 3 / L and in business plan severe cases to less than 5 x 10 3 / L. The incidence of HIT in patients receiving full-dose heparin ranges between 0#37; to 30#37;. Although there is no randomized prospective study looking at the true incidence of HIT, the expected incidence is edexcel history estimated to be less than 5#37;. Those patients who have had a previous exposure to heparin (recent and in some cases remote history) may develop HIT earlier after institution of heparin therapy as compared with those with no previous exposure. The frequency of HIT is also higher in patients receiving porcine mucosal heparin compared with bovine lung heparin. The diagnosis of HIT should be entertained in any patient with a significant fall in platelet count while on nikken, heparin therapy (less than 150 x 10 3 / L or a 50#37; or greater decrease in platelet count after 5 days of therapy). The definitive diagnosis requires the following steps: (a) thrombocytopenia while on heparin, (b) exclusion of other etiology of thrombocytopenia, (c) improvement in platelet count following cessation of heparin therapy, and (d) presence of heparin-dependent platelet antibody by an in vitro test.

In most cases, the diagnosis is made on essays, clinical findings. Gerotziafas GT. Elalamy I. Lecrubier C, et al.The role of platelet factor 4 in platelet aggregation induced by the antibodies implicated in heparin-induced thrombocytopenia. Blood Coag Fibrinolysis 2001:12:511–520. Robitaille D. Carrier M. Cartier R, et al.Successful management strategy for mechanical assistance and business plan, heart transplantation in patients suffering from heparin-induced thrombocytopenia type II. Course. J Heart Lung Transplantation 2001:20:1237–1240. Shea SI.

Sands JJ. Nudo SA, et al.Frequency of nikken business, anti-heparin-platelet factor 4 antibodies in hemodialysis patients and correlation with recurrent vascular access thrombosis. Am J Hematol 2002:69:72–73. Warkentin TE. Dunn GL. Cybulsky IJ. Off-pump coronary artery bypass grafting for acute heparin-induced thrombocytopenia. Ann Thorac Surg 2001:72:1730–1732. A.15.

What is the therapy for HIT? Because HIT type II is a potentially lethal condition, the most effective therapy is discontinuation of on christmas for small, heparin. The thrombocytopenia should improve progressively. Although tempting, the need for platelet transfusion is discouraged because bleeding occurs infrequently and vascular thrombosis may be potentiated. Several agents have been recommended for use in HIT. These include direct thrombin inhibitors (hirudin, argatroban), LMWH, LMW heparinoid, ancrod, and plan, antiplatelet agents. Most of these agents are not available in essay failure the United States for nikken business, use; others are under clinical investigation. Hirudin has been extensively used in Europe with demonstrable benefit and safety. The LMWH have been shown to have cross reactivity with unfractionated heparin approaching 100#37; [C-serotonin release or by heparin-induced platelet aggregation (HIPA) assays] and is a, should not be used in the setting of HIT unless there are demonstrable negative cross reactivity assays with standard heparin.

The ancrod is nikken plan a defibrinogenating agent (not available in for small the United States) extracted from the Malayan pit viper and business, is immunologically distinct from heparin. It acts by what good thesis cleaving fibrinopeptide A from fibrinogen and its activity can be measured by nikken business plan assaying for plasma fibrinogen concentration. For European Studies Pre Dissertation Fellowship. Lastly, in the setting of HIT, a synthetic analogue of prostacyclin (iloprost#151;a potent inhibitor of platelet activation) has been used successfully during cardiac surgery to prevent further reduction of platelet count. Cheng-Lai A. Cardiovascular drug highlight: hirudin. Heart Dis J Cardiovasc Med 1999:1:41–49. Deitcher SR. Carman TL. Heparin-induced thrombocytopenia: natural history, diagnosis, and management.

Vasc Med 2001:6:113–119. Gill J. Kovacs MJ. Successful use of danaparoid in treatment of heparin-induced thrombocytopenia during twin pregnancy. Obstet Gynecol 1997:90:(4 Pt 2)648–650. Koster A. Business Plan. Meyer O. Fischer T, et al.One-year experience with the platelet glycoprotein IIb/IIIa antagonist tirofiban and heparin during cardiopulmonary bypass in patients with heparin-induced thrombocytopenia type II.

J Thorac Cardiovasc Surg 2001:122:1254–1255. Robitaille D. Essay. Carrier M. Cartier R, et al.Successful management strategy for mechanical assistance and nikken, heart transplantation in patients suffering from heparin-induced thrombocytopenia type II. J Heart Lung Transplantation 2001:20:1237–1240. Warkentin TE. Dunn GL. Cybulsky IJ. Off-pump coronary artery bypass grafting for acute heparin-induced thrombocytopenia. Essay Market Failure. Ann Thorac Surg 2001:72:1730–1732. A.16. Can HIT be caused by nikken business plan LMWH?

Based on confirmed laboratory tests, the prevalence of HIT is 2#37; for on christmas for small kids, patients receiving unfractionated heparin. Nikken Plan. Although the essay on christmas, incidence of plan, HIT is is a good infrequent in the setting of LMWH, it is not zero and avoidance of the nikken plan, latter is edexcel history recommended for patients demonstrating signs of nikken business plan, HIT while receiving unfractionated heparin. Fabris F. Luzzatto G. Stefani PM, et al.Heparin-induced thrombocytopenia [Review]. Haematologica 2000:85:72–81. Kleinschmidt K. Charles R. Pharmacology of low molecular weight heparins. Emerg Med Clin North Am 2001:19:1025–1049. Warkentin TE. Sheppard JA. Horsewood P, et al.Impact of the essays, patient population on the risk for heparin-induced thrombocytopenia. Blood 2000:96:1703–1708.

A.17. Plan. What is the mechanism of heparin antagonism by protamine? Heparin is a large glycosaminoglycan molecule consisting of chains of research apa citation, alternating residues of D -glucosamine and nikken business plan, uronic acid. It is highly negatively charged, whereas protamine is mostly positively charged. The two combine irreversibly to form a heparin-protamine complex that does not have the ability to bind to thrombin or factor Xa. Once neutralized, the complex of edexcel history, heparin and protamine is eliminated. Kimmel SE. Sekeres M. Berlin JA, et al.Mortality and adverse events after protamine administration in business patients undergoing cardiopulmonary bypass. Anesth Analg 2002:94:1402–1408.

A.18. Good. What is heparin rebound? The ACT is used to confirm adequacy of heparin neutralization by protamine. The concept of heparin rebound and coagulopathy following protamine reversal may occur as follows: first, heparin that is business sequestered in tissues that are poorly perfused (i.e., fat) may not undergo neutralization by essay on christmas for small protamine and plan, second, the half-life of course essays, heparin is longer than that of protamine (45 minutes) such that as heparin is mobilized back into plan, circulation it can inhibit thrombin formation and predispose post-CPB bleeding. Studies in which 1 mg of protamine is essays given per 100 units of heparin (total dose) found no evidence of heparin rebound. Thus, bleeding in the postoperative cardiac surgical patient is unlikely to be from heparin rebound. Heller EL. Business Plan. Paul L. History. Anticoagulation management in a patient with an acquired antithrombin III deficiency. J Extra Corpor Technol 2001:33:245–248.

Subramaniam P. Skillington P. Tatoulis J. Heparin-rebound in the early postoperative phase following cardiopulmonary bypass. Austr N Z J Surg 1995:65:331–333. Woodman RC. Harker LA. Bleeding complications associated with cardiopulmonary bypass. Blood 1990:76:1680. A.19. How does coumadin affect the coagulation system? What is the nikken plan, therapy for reversing its effect? Coumadin remains the most commonly used anticoagulant agent in the outpatient setting (atrial fibrillation, prosthetic valves and devices).

Its predominant pharmacodynamic effect is inhibition of synthesis of vitamin K-dependent factors (II, VII, IX, and X) in the liver and its clinical efficacy is monitored by research apa citation measuring the PT or more specifically the international normalized ratio (INR). Business Plan. The safe or efficacy levels of research, either INR or PT is variable due to multiple factors, including hepatic, nutritional, drug interaction, age, and plan, presence of other comorbid conditions. On average, it takes several days of therapy to achieve the desired INR (2 to 4); consequently, administration of what good thesis, either LMWH or unfractionated heparin may be necessary for initiating anticoagulation. Complications occur either because of inadequate anticoagulation (thrombosis) or because of excessive anticoagulation (bleeding and hemorrhage). To reverse its effect, coumadin should be discontinued several days (more than 3 days) to allow levels of the aforementioned factors to normalize. Acute reversal is achieved with FFP. Administration of vitamin K is business plan often necessary to accelerate the is a good statements, synthetic process. Erban S. Initiation of warfarin therapy: recommendations and nikken business plan, clinical pearls. J Thromb Thrombolysis 1999:7:145–148. Henderson MC.

White RH. Anticoagulation in the elderly. Curr Opin Pulm Med 2001:7:365–370. Horton JD. Bushwick BM. On Christmas For Small. Warfarin therapy: evolving strategies in plan anticoagulation. Am Fam Physician 2002:65:172. Keller C. Matzdorff AC. Kemkes-Matthes B. Pharmacology of warfarin and clinical implication. Sem Thromb Hemost 1999:25:13–16. A.20.

What do the following measure: prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time, activated clotting time (ACT), bleeding time? PT measures the activity of the extrinsic pathway: factors I (fibrinogen), II (prothrombin), V, VII, and ptlls, X ( Fig. 15.2 ). Deficiencies of business, factors V, VII, and X (50#37; of normal) significantly prolong the PT. Much lower concentrations of fibrinogen and what good statements, prothrombin are required to prolong the PT. Activities of three of the four vitamin K-dependent factors (II, VII, IX, and X) are measured by the PT. Normal values are less than 12 seconds. Activated Partial Thromboplastin Time.

Activated partial thromboplastin time (aPTT) measures the activity of the intrinsic pathway: factors XII, XI, IX, VIII, V, X, prothrombin, and plan, fibrinogen ( Fig. What. 15.2 ). The aPTT is prolonged by concentrations of less than 20#37; to 30#37; of plan, these factors. For European Studies Pre Dissertation Fellowship. Normal values are 25 to nikken plan, 40 seconds. Thrombin time measures the conversion of fibrinogen to fibrin by thrombin#151;the final step in the coagulation cascade ( Fig. 15.2 ). The thrombin time is decreased in the presence of low concentrations of fibrinogen and thrombin. Essay On Christmas. Heparin prolongs the thrombin time, whereas coumadin has little effect. Plan. Normal values are less than 10 seconds. Activated Clotting Time.

ACT measures the general function of the on christmas for small kids, coagulation system. It is used primarily to measure the nikken plan, adequacy of heparinization during CPB and protamine reversal of paper, heparin following CPB. Prolonged ACTs may be due to heparin, low levels of coagulation factors, or thrombocytopenia. It is, however, not particularly specific for platelet or factor deficiencies. Normal values are 110 to 140 seconds. Bleeding time measures platelet activity, including both platelet number and aggregation.

The bleeding time becomes prolonged with platelet counts less than 50 x 10 3 / L and in the presence of inhibitors of platelet aggregation such as aspirin. Normal values are less than 5 minutes. The bleeding time has not been shown to be predictive of postoperative bleeding and is no longer performed routinely preoperatively. Barash PG, Cullen BF, Stoelting RK, Clinical anesthesia 4th ed. Philadelphia: Lippincott, Williams Wilkins, 2001:219–224. Braunwald E, Fauci A, Kasper DL, et al., Harrison's principles of internal medicine 15th ed.

New York: McGraw Hill, 2001:354–358. Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and thrombosis: basic principles and clinical practice 2nd ed. Philadelphia: JB Lippincott, 1987:1048. A.21. How is the anticoagulant effect of plan, LMWH monitored? There is no evidence that monitoring the dose improves the clinical efficacy. In contrast, any overdose increases the risk of hemorrhage. Because the kidneys play a significant role in the elimination of LMWH, therapeutic use of market failure, these agents should be monitored with an antifactor Xa assay, especially in patients who have renal insufficiency, are elderly, and nikken plan, have clinical conditions that increase the risk of bleeding. Boneu B. de Moerloose P. How and edexcel essays, when to monitor a patient treated with low molecular weight heparin. Sem Thromb Hemost 2001:27:519–522.

A.22. Nikken Business. What is a thromboelastograph? What is a Sonoclot? The thromboelastograph is an instrument that measures the development of blood clot viscoelastic strength over course, time. A rotating piston is suspended in nikken business plan a cuvette filled with heated blood. Ptlls Course. As clot formation proceeds, the rotation of the piston is affected and characteristic curves are generated ( Fig. 15.3 ). The etiology of a coagulopathy may be obtained by analyzing these curves ( Fig. 15.4 ). The Sonoclot similarly measures the development of nikken plan, clot viscoelastic strength. The Sonoclot piston moves vertically and measures the course essays, impedance to vibration at nikken business, the tip of the probe. Sonoclot tracings obtained from platelet-rich plasma and platelet-poor plasma are shown in the Fig.

15.5 . Figure 15.3. Production of essay on christmas, normal thromboelastogram and measured parameters. Nikken. R, reaction time, 7 to 14 minutes; K value, 3 to 7 minutes; , clot formation rate, 40 degrees to 60 degrees, MA, maximum amplitude, 50 to 60 mm, A60/MA, amplitude 60 minutes after MA; whole blood clot lysis index, greater than 0.85; F, whole blood clot lysis time, greater than 300 minutes. (From Tumen KJ, Spiess BD, McCathy RJ, et al. Paper. Effects of progressive blood loss on coagulation as measured by thromboelastography. Anesth Analg 1987;66:856#150;863.) Figure 15.3. Production of normal thromboelastogram and measured parameters.

R, reaction time, 7 to 14 minutes; K value, 3 to 7 minutes; , clot formation rate, 40 degrees to 60 degrees, MA, maximum amplitude, 50 to 60 mm, A60/MA, amplitude 60 minutes after MA; whole blood clot lysis index, greater than 0.85; F, whole blood clot lysis time, greater than 300 minutes. (From Tumen KJ, Spiess BD, McCathy RJ, et al. Effects of progressive blood loss on coagulation as measured by thromboelastography. Anesth Analg 1987;66:856#150;863.) Figure 15.4. Qualitative analysis of thromboelastograms. Figure 15.4. Qualitative analysis of thromboelastograms. Figure 15.5. Plan. Sonoclot tracings of platelet-rich plasma (PRP) and platelet-poor plasma (PPP). On Christmas For Small. A: lag period, B: primary wave, C: shoulder, D: secondary wave, E: peak, F: downward wave. (From Saleem A, Blifeld C, Saleh SA, et al. Viscoelastic measurement of clot formation: a new test of platelet function.

Ann Clin Lab Sci 1983;13:115, with permission.) Figure 15.5. Sonoclot tracings of platelet-rich plasma (PRP) and nikken, platelet-poor plasma (PPP). A: lag period, B: primary wave, C: shoulder, D: secondary wave, E: peak, F: downward wave. (From Saleem A, Blifeld C, Saleh SA, et al. Viscoelastic measurement of clot formation: a new test of platelet function. Ann Clin Lab Sci 1983;13:115, with permission.) Avidan MS. Da Fonseca J. Parmar K, et al.The effects of aprotinin on thromboelastography with three different activators. Anesthesiology 2001:95:1169–1174.

Ellison N, Jobes DR, Effective hemostasis in the cardiac surgery Philadelphia: WB Saunders, 1988:155. Forestier F. Market. Belisle S. Contant C, et al.Reproducibility and interchangeability of the thromboelastograph, Sonoclot and Hemochron activated coagulation time in business plan cardiac surgery. Can J Anaesth 2001:48:902–910. Koster A. Hansen R. Schulz J, et al.Assessment of the research paper apa citation, resonance thromboelastograph CS-3 for differentiation of coagulation disorders: a pilot in vitro investigation of simulated post-cardiopulmonary bypass coagulopathies. J Extra Corp Technol 2001:33:159–166. Koster A. Kukucka M. Fischer T, et al.Evaluation of post-cardiopulmonary bypass coagulation disorders by differential diagnosis with a multichannel modified thromboelastogram: a pilot investigation. J Extra Corp Technol 2001:33:153–158. Saleem A. Nikken. Blifeld C. Saleh SA, et al.Viscoelastic measurement of clot formation: a new test of platelet function. Ann Clin Sci 1983:13:115. Vig S. Chitolie A. Essay. Bevan DH, et al.Thromboelastography: a reliable test?.

Blood Coag Fibrinolysis 2001:12:555–561. Vorweg M. Hartmann B. Knuttgen D, et al.Management of fulminant fibrinolysis during abdominal aortic surgery. Nikken Business. J Cardiothorac Vasc Anesth 2001:15:764–767. A.23. How does desmopressin aid hemostasis? Desmopressin [1-deamino-8- D -arginine vasopressin (DDAVP)] increases von Willebrand's factor and factor VII activity in course plasma. von Willebrand's factor, which binds to platelets, is found in subendothelial tissue and is in part responsible for platelet adhesion to damaged blood vessels. DDAVP was initially shown to business, significantly decrease postoperative bleeding. Dobkowski WB. Apa Citation. Murkin JM.

A risk-benefit assessment of aprotinin in cardiac surgical procedures. Business. Drug Safety 1998:18:21–41. Kondo NI. Maddi R. Ewenstein BM, et al.Anticoagulation and hemostasis in cardiac surgical patients. J Card Surg 1994:9:443–461. Serradeil-Le Gal C. Nonpeptide antagonists for vasopressin receptors. Pharmacology of SR 121463A, a new potent and highly selective V2 receptor antagonist.

Adv Exp Med Biol 1998:449:427–438. A.24. What is fibrinolysis? Fibrinolysis is fibrin breakdown in thrombi. Plasmin, derived from failure, plasminogen, is the enzyme involved in this process. Physiologic fibrinolysis involves clot remodeling and removal during the healing process. Nikken Business Plan. Pathologic fibrinolysis occurs when fibrin in a thrombus is what good thesis broken down before healing. Although elevated concentrations of plasminogen activators are found during CPB, their half-lives are very short after bypass. Nikken Plan. In cardiac surgery, fibrinolysis is a rare cause of postoperative bleeding.

Hackman T. Gascoyne CD. Naiman SC, et al.A trial of desmopressin to reduce blood loss in uncomplicated cardiac surgery. N Engl J Med 1989:321:1437. Salzman EW. Essay For Small. Weinstein MJ. Weintraub RM, et al.Treatment with desmopressin acetate to reduce blood loss after cardiac surgery. Business. N Engl J Med 1986:314:1402. A.25. What is aminocaproic acid?

Aminocaproic acid (Amicar) is an analogue of lysine. Its primary mechanism of action is inhibition of for small, plasmin, resulting in business plan less breakdown of fibrinogen, fibrin (fibrinolysis), and other clotting components. Aminocaproic acid has been effective in treating coagulopathy in the setting of heart surgery, portocaval shunts, hematologic disorders such as aplastic anemia, abruptio placentae, hepatic cirrhosis, and neoplastic diseases. Compared with placebo, both tranexamic acid and aminocaproic acid have been shown to reduce blood loss by 30#37; to 49#37; as well as reduce homologous blood transfusion. When compared with aprotinin, in high-risk patients, high dose-Amicar has also been shown to have favorable results related to reduction of blood loss and transfusion requirement.

Considering the low cost associated with aminocaproic acid therapy (less than $12), many cardiac surgical centers use this agent routinely for ptlls course essays, uncomplicated open-heart procedures. The standard intravenous preparation and dosage for cardiac surgery include 5 to 10 g of business, aminocaproic acid diluted and infused over 1 hour, followed by a continuous infusion at a rate of 1 g per hour. Higher infusion rates may be used. There are several adverse events that include thrombosis (early graft closure, myocardial ischemia and infarction), agranulocytosis, leukopenia, and thrombocytopenia. Although rare, bradycardia and essays, mild reduction in blood pressure have also been reported. Levi M. Nikken Plan. Cromheecke ME. de Jonge E, et al.Pharmacological strategies to decrease excessive blood loss in ptlls essays cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet 1999:354:1940–1947. A.26. Plan. What is aprotinin? Aprotinin is a complex polypeptide molecule belonging to the family of serine protease inhibitors that is extracted from bovine lung. After intravenous administration, aprotinin undergoes rapid total extravascular distribution with a plasma half-life of approximately 150 minutes.

It is filtered by council the glomeruli and reabsorbed by the proximal tubules. The terminal half-life is plan approximately 10 hours. The basis for its efficacy is not fully understood but consists of a complex activation-interaction of the following systems: kallikrein resulting in kinin generation, complement and edexcel, inflammatory pathways, coagulation (intrinsic and extrinsic), fibrinolytic, angiotensin, and others not yet determined ( Fig. Nikken Business. 15.6 ). Studies Pre Dissertation. Initial contact between blood elements and the nonendothelialized surface of the CPB circuit promote contact activation of both humoral and cellular inflammatory processes. The coagulation system may be the first to be activated by contact generating factor XIIa from factor XII, which then interacts with prekallikrein and high molecular weight kininogen (HMWK) to form kallikrein as well as promote the nikken plan, activation of the other coagulation factors. History Essays. Once activated, kallikrein functions to stimulate and business, accelerate the generation of bradykinin from HMWK, factor XIIa, angiotensin, and complement activation. Factor XIIa, in turn, also interacts with fibrinogen to produce plasmin ( Fig. 15.7 ). Figure 15.6. Contact activation and the role of the kallikrein system. Factor 12, XII; activated factor 12, XIIa; high-molecular weight kininogen, HK; prekallikrein, PKK; factor 11, XI; activated factor 11, XIa. (From slide set no.

3, tryaslol slide library [online]. Bayer, 2000. Available at http://www.trasylol.com/slides.htm with permission.) Figure 15.6. Contact activation and the role of the kallikrein system. Factor 12, XII; activated factor 12, XIIa; high-molecular weight kininogen, HK; prekallikrein, PKK; factor 11, XI; activated factor 11, XIa. (From slide set no.

3, tryaslol slide library [online]. Bayer, 2000. Available at http://www.trasylol.com/slides.htm with permission.) Figure 15.7. Involvement of the various components of coagulation including the coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and the fibrinolytic system. C1, complement; HMW, high molecular weight. (From slide set no. Course Essays. 3, tryaslol slide library [online]. Bayer, 2000. Available at: http://www.trasylol.com/slides.htm with permission.)

Figure 15.7. Involvement of the various components of coagulation including the coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and the fibrinolytic system. C1, complement; HMW, high molecular weight. (From slide set no. 3, tryaslol slide library [online]. Business. Bayer, 2000. Available at: http://www.trasylol.com/slides.htm with permission.) Aprotinin has been shown to markedly reduce the aforementioned humoral processes thereby mitigating the coagulopathy associated with CPB-related procedures. Market Failure. In addition, aprotinin may reduce blood loss by plan preserving platelet function.

The mechanism of edexcel history essays, this relates to nikken business, preservation of platelet surface glycoproteins (IIb/IIIa), which is ptlls essays necessary for platelet-fibrinogen interaction and clot formation. The inflammatory properties of aprotinin (both cellular and humoral) have been shown in nikken plan animal and in some human studies; however, clinical outcome trials addressing this effect have not been conducted. In contrast, clinical trials comparing Aprotinin to placebo and/or to Amicar have consistently shown greater efficacy related to reduction in blood loss and transfusions of blood elements. Concerns regarding prothrombotic potentials, including myocardial infarction and renal dysfunction, have since been dismissed. The infarction rate and the incidence of renal dysfunction are comparable to apa citation, those of placebo ( Table 15.1 ). Aprotinin does compete with creatinine for excretion and, in nikken business plan some patients, there may be a mild increase in serum creatinine. Rarely, if aprotinin is used in research apa citation patients with protein C or S deficiency, they may experience life-threatening thrombotic events shortly after protamine neutralization of heparin. Another important aspect of aprotinin use is the type of reagent used to monitor adequacy of heparinization (ACT). Kaolin is the nikken business plan, recommended agent to be used to assess ACT when aprotinin is used (greater than 480 seconds). If Celite is used, the ACT value should be more than 750 seconds before initiation of CPB. Aprotinin is not an antithrombotic agent, and, therefore, adequate amount of market, heparin must be given.

Because it is a serine protease inhibitor, it interacts with antithrombin III to inhibit the action of all intrinsic and common pathway factors resulting in prolongation of measures of coagulation such as ACT. Aprotinin has a very good safety profile but serious anaphylaxis or shock can occur. This risk is nikken business increased in patients who are reexposed to aprotinin within 6 weeks. Most of the cases reported occurred within 200 days of exposure. It is edexcel recommended that a test dose of 1 mL be given when it is possible to emergently perform cannulation for instituting bypass. Whether use of histamine antagonists or steroid lessens the incidence is not known.

The following dosing regimen is suggested: 1 mL [10,000 kallikrein inactivator units (KIU)] test dose is administered intravenously at least 10 minutes before the loading dose, followed by business close observation for signs of an allergic reaction. Essay For Small Kids. A loading dose of 2 million KIU should then be given over 20 to 30 minutes. An additional 2 million KIU dose is nikken plan added to the priming solution. The maintenance dose is a constant infusion of 500,000 KIU/hour for the duration of surgery. It may be beneficial and cost effective to continue the infusion of the remaining amount of the edexcel history essays, drug while the nikken, patient is transferred and recovering in the ICU. A half-dose regimen has been proposed and entails reducing the previously mentioned recommendation in half. Cosgrove DM III. Heric B. Lytle BW, et al.Aprotinin therapy for reoperative myocardial revascularization: a placebo-controlled study. Ann Thorac Surg 1992:54:1031–1038. Dobkowski WB.

Murkin JM. A risk-benefit assessment of aprotinin in cardiac surgical procedures. Drug Safety 1998:18:21–41. Fujii S, Kinins V, Part B. Advances in experimental medicine and biology vol 247B: New York: Plenum Press, 1989:35–42. Hoffmann H. Siebeck M. Thetter O, et al.Aprotinin concentrations effective for the inhibition of tissue kallikrein and plasma kallikrein in vitro and in what is a thesis vivo. Abe K, Moriya H, Landis RC, et al., The antithrombotic and antiinflammatory mechanisms of plan, action of aprotinin. Ann Thorac Surg 2001:72:2169–2175. Murkin JM. Attenuation of neurologic injury during cardiac surgery. Ann Thorac Surg 2001:72:S1838–1844.

Orchard MA. Goodchild CS. Prentice CRM, et al.Aprotinin reduces cardiopulmonary bypass-induced blood loss and inhibits fibrinolysis without influencing platelets. Br J Haematol 1993:85:533–541. Peters DC. Noble S. Aprotinin: an essays, update of business, its pharmacology and therapeutic use in market open-heart surgery and coronary artery bypass surgery. Drugs 1999:57:233–260.

Serradeil-Le Gal C. Nikken Plan. Nonpeptide antagonists for vasopressin receptors. Pharmacology of SR 121463A, a new potent and highly selective V2 receptor antagonist. Adv Exp Med Biol 1998:449:427–438. Wahba A. Is A Statements. Black G. Koksch M, et al.Aprotinin has no effect on platelet activation and adhesion during cardiopulmonary bypass. Thromb Haemost 1996:75:844–848. B. Preoperative Evaluation and Preparation. B.1. Interpret the hemodynamic findings of this patient. The patient has an adequate blood pressure; however, this appears to be maintained via compensatory mechanism including increase in both arterial resistance [systemic vascular resistance (SVR)] and HR. The PA systolic pressure is consistent with pulmonary hypertension arising most likely from chronic mitral valvular disease (either stenosis or insufficiency). Both the PAD and the PAOP suggest that the left ventricular end diastolic pressure#151;a correlate of nikken business plan, left ventricular preload#151;is within the normal limits.

Pressure measurements are more representative of the ventricle's state of is a good thesis, compliance than the ventricle's volume status. Nikken Business. Thus, a PAOP of apa citation, 14 mm Hg could represent hypovolemia, normovolemia, or hypervolemia depending on the compliance of the left ventricle. Nikken Plan. A CVP of 23 torr is suggestive of right ventricular or biventricular dysfunction, tricuspid stenosis or insufficiency, or obstruction and compression of the right atrium. The CO is inadequate. The derived SV of 22 mL (CO/HR), combined with the other derangements (elevated CVP and PAOP of 14 mm Hg), strongly reflect right heart dysfunction. Taking into council studies, consideration the patient's overall presentation (physical examination and laboratory findings), the nikken business plan, differential diagnosis includes right ventricular ischemia and or infarction, pulmonary embolism, atrial or ventricular septal defect (most likely left-to-right), and cardiac tamponade. An echocardiogram should be performed to assist in the diagnostic process and is a good thesis, clinical management. Fontes ML. Nikken Plan. Bellows W. Ngo L et al. and McSPI Research Group.

Assessment of ventricular function in critically ill patients: limitations of pulmonary artery catheterization. J Cardiothorac Vasc Anesth 1999:13:1–8. B.2. How would you treat the low output status of this patient? Although the HR is elevated, it may be unwise to attempt to normalize it before correcting the SV. History Essays. The latter is a function of the nikken plan, preload, the what is a thesis, afterload, and the contractile status of the nikken business, myocardium. Whereas the preload of the essay for small kids, right heart may be excessive (CVP = 23 mm Hg), the preload of the nikken plan, left heart may not be adequate despite a PAOP of edexcel history, 14 mm Hg.

While waiting for the echocardiogram to business plan, be performed, a fluid bolus can be attempted. If there is a positive response (i.e., the blood pressure and ptlls course essays, or the nikken plan, CO increase), additional fluid bolus can be administered until the limit of the preload reserve has been reached (operating on the flat end portion of the Frank Starling's curve). In the setting of right ventricular failure, it is essay failure customary to fluid load the patient maintaining the business plan, CVP in the 20s. It is important to note that fluid challenge alone will not improve cardiac performance without addressing the contractility and the afterload that, in studies pre dissertation this patient, appear to be deranged. Because there is no knowledge of the nikken business plan, exact etiology of the low output state, it would be rational to institute inotropic support (initially, the choice of the inotrope is not that important despite the tachycardia). With regard to the afterload, both systemic and paper apa citation, pulmonary afterloads are elevated. On the nikken business, right side, PA hypertension can be improved with the nitrossovasodilators (nitroglycerin or nitroprusside) but the associated systemic hypotension would prohibit their use. In fact, most vasodilators with the exception of nitric oxide would compromise the systemic pressures. Essay On Christmas For Small Kids. Alternatively, an inotrope that has vasodilatory properties (phosphodiesterase inhibitors#151;milrinone or amrinone#151;or dobutamine) would be better choices. The SVR is a derived number (mean arterial pressure minus CVP divided by the CO and nikken plan, multiplied by a factor of 80). It is important to identify and fellowship, treat the cause of the nikken business, altered CO (i.e., change in HR or SV) and not to react to changes in SVR.

For example, if the ptlls essays, CO is low because of a rhythm issue or a reduced preload, it would be inappropriate to administer a vasodilator to correct the high SVR. In summary, a rational management of the hemodynamic findings presented would include administering fluid (crystalloid or blood products as indicated), giving inotropic support, obtaining an echocardiogram, and addressing the other systemic complications (pulmonary, renal, and coagulation). Fontes ML. Hines RL. Cardiogenic shock. Murray MJ, Coursin DB, Pearl RG, et al., Critical care medicine: perioperative management New York: Raven Press, 1997:295–306. Fontes ML. Hines RH.

Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. B.3. How would you evaluate this patient's coagulation status? A complete blood cell count and a complete coagulation panel should be performed.

Assuming that both the hematocrit and the platelet function are adequate, attention should be directed to the elevated PT and the aPTT. The most obvious etiology for the existing coagulopathy is anticoagulation therapy. The patient has a prosthetic valve and plan, it would be appropriate to surmise that she has been taking anticoagulants. The most common agent to be used 4 days after surgery is warfarin (coumadin). This agent affects the vitamin-K dependent factors (II, VII, IX, and X) whose synthesis occurs in course essays the liver. Measuring the PT and or the INR assesses the status of business, its anticoagulant effect. Why is the aPTT also elevated? This coagulation measure reflects the function of the essay market, following factors: V, VIII, IX, X, XI, XII, prothrombin, and fibrinogen. Nikken Business. It can also be surmised that the elevated aPTT is due to anticoagulant therapy (e.g., excessive coumadin therapy, use of unfractionated heparin, or a combination of treatment with heparin and coumadin). The latter approach is standard practice in cardiac surgery for patients requiring prolonged anticoagulation (i.e., valvular replacement) and is a good thesis statements, can account for elevations of both the PT and the aPTT.

Other etiologies to consider include liver disorder, sepsis, and other hematologic dysfunction. Boneu B. Nikken Plan. de Moerloose P. How and when to good thesis statements, monitor a patient treated with low molecular weight heparin. Nikken Business. Semin Thromb Hemost 2001:27:519–522. Ellison N, Jobes DR, Effective hemostasis in cardiac surgery Philadelphia: WB Saunders, 1998:195. Keller C. Matzdorff AC. Kemkes-Matthes B. Pharmacology of warfarin and clinical implication. Semin Thromb Hemost 1999:25:13–16. B.4.

What do fresh frozen plasma (FFP) and cryoprecipitate contain? FFP contains the labile factors V and VIII as well as the stable coagulation factors (II, VII, IX, X, XI). In addition, FFP contains other plasma proteins and good thesis, lipids normally found in human plasma. Cryoprecipitate is derived by thawing FFP at nikken plan, 4°C. What. It contains factor VIII, von Willebrand's factor, and fibrinogen. Ellison N, Jobes DR, Effective hemostasis in cardiac surgery Philadelphia: WB Saunders, 1988:69. Levy JH. Montes F. Szlam F, et al.The in vitro effects of antithrombin III on the activated coagulation time in patients on heparin therapy. Anesth Analg 2000:90:1076–1079. Nuttall GA. Oliver WC.

Santrach PJ, et al.Efficacy of a simple intraoperative transfusion algorithm for nikken business plan, nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology 2001:94:773–781. , discussion 5A#150;6A. B.5. Research Apa Citation. What are the indications for business, transfusing FFP, platelet concentrate, and course essays, cryoprecipitate? Blood usually coagulates appropriately when coagulation factor concentrations are at least 20#37; to 30#37; of normal and when fibrinogen levels are greater than 75 mg/dL. Although laboratory values such as PT and partial thromboplastin time (PTT) may be abnormal, The American Society of business, Anesthesiologist Task Force on Blood Component Therapy discourages conventional use of FFP for perioperative treatment of for small, bleeding because there are few clinical circumstances whereby coagulopathy arises from factor deficiency. Whereas massive blood replacement can produce prolongation of PT and/or PTT, the task force states that a true dilutional coagulopathy does not ordinarily occur until more than 100#37; of the nikken business plan, patient's blood volume has been replaced.

It supports the use of FFP in patients having vascular bleeding with PT and research, PTT values greater than 1.5 times the laboratory's normal value. FFP should be administrated in doses calculated to nikken business, achieve a minimum of 30#37; of plasma factor concentration (i.e., 10 to 15 mL/kg of FFP). Recommended indications for essay on christmas, FFP: Replacement of factor deficiencies. Reversal of coumadin effect. Massive blood transfusions. Treatment of antithrombin III deficiency in patients who are heparin resistant requiring systemic anticoagulation with heparin. In 1994 the College of American Pathologists recommended platelet transfusions after CPB in patients with normal coagulation values and platelet count below 100,000/ L when major unexplained bleeding occurs.

Transfusion of one platelet concentrate will increase the platelet count by approximately 5 to 10 x 10 3 / L in the average adult. Nikken Business Plan. The usual therapeutic dose is one platelet concentration per 10-kg body weight. Platelet concentrate is indicated in the following: Active bleeding associated with thrombocytopenia. Massive blood transfusions.

The American Society of Anesthesiologist's Task Force on Blood Component Therapy recommends the administration of cryoprecipitate for. Prophylaxis in nonbleeding perioperative or peripartum patients with congenital fibrinogen deficiencies or von Willebrand's disease unresponsive to DDAVP (whenever possible, these decisions should be made in what is a good consultation with the patient's hematologist) Bleeding patients with von Willebrand's disease. Correction of microvascular bleeding in massively transfused patients with fibrinogen concentrations less than 80 to 100 mg/dL. One unit of cryoprecipitate per 10-kg body weight raises plasma fibrinogen concentration approximately 50 mg/dL in the absence of continued consumption or massive bleeding. Bleeding following cardiac surgery without demonstrable abnormalities of coagulation is not considered to plan, be an indication for transfusion of FFP, platelets, or cryoprecipitate. American Society of market, Anesthesiologists. Nikken Plan. Guidelines for blood component therapy.

A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy. Anesthesiology 1996:84:732–747. Despotis GJ. Levine V. Saleem R, et al.Use of point-of-care test in identification of patients who can benefit from market failure, desmopressin during cardiac surgery: a randomized controlled trial. Lancet 1999:354:106–110. Dietrich W. Luth JU. Kormann J, et al.Intraoperative blood requirements and nikken plan, allogeneic blood transfusion in cardioanesthesia. Data analysis of 7729 patients in 12 cardiac surgical clinics. Anaesthesist 1999:48:876–883. Goodnough RL. Rutman RL.

Silberstein LEL. Guidelines for what thesis, transfusion support in patients undergoing coronary artery bypass grafting. Ann Thorac Surg 1990:50:675–683. Murray DJ. Pennell BJ.

Weinstein SL, et al.Packed red cells in acute blood loss: dilutional coagulopathy as a course of surgical bleeding. Business Plan. Anesth Analg 1995:80:336–342. Shore-Lesserson L. Manspeizer HE. Edexcel History. DePerio M, et al.Thromboelastography-guided transfusion algorithm reduces transfusions in nikken plan complex cardiac surgery. Randomized controlled. Anesth Analg 1999:88:312–319. Stover EP. Siegel LC. Parks R, et al.Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study.

Institutions of the Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology 1998:88:327–333. Wilhelmi M. Franke U. Cohnert T, et al.Coronary artery bypass grafting surgery without the edexcel history essays, routine application of blood products: is it feasible?. Nikken. Eur J Cardiothorac Surg 2001:19:657–661. B.6. What are the apa citation, complications associated with blood component transfusions? Complications associated with transfusions of blood elements include transmission of infectious agents (e.g., hepatitis, HIV infection), hemolytic and nonhemolytic transfusion reactions, immunosuppression, anaphylactic or anaphylactoid reactions, and alloimmunization to nikken, platelet-specific antigens and the Rh antigen (resulting from erythrocyte contamination because they are stored at room temperature). Platelets in ptlls essays particular may contain proliferating bacteria.

Finally, in the immunosuppressed, graft-versus-host effects may occur following platelet transfusion. Ford SA. Kam PC. Baldo BA, et al.Anaphylactic or anaphylactoid reactions in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2001:15:684–688. Frere MC. Plan. Rapaille A. Bouillenne C, et al.Analysis of 516 reports of reactions after the transfusion of labile blood products. Transfusion Clin Biol 2001:8:333–342. Fresh frozen plasma: indications and essay on christmas for small, risks. NIH Consensus Development Conference Statement 1985:5:(5)1.

Lacritz EM. Sullen GA. Nikken Plan. Aberle-Grasse J. Estimated risk of transmission of the edexcel essays, human immunodeficiency virus by screened blood in the United States. N Engl J Med 1995:333:1721–1725. Nightingale SD. Department of Health and Human Services Advisory Committee on Blood Safety and Availability. Universal WBC reduction. Transfusion 2001:41:1306–1309. Platelet transfusion therapy.

NIH Consensus Development Conference Statement 1986:6:(7)1. Sazama K. Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion 1990:30:583–590. B.7. What is the risk of nikken business plan, acquiring HIV from blood exposure? The risk of HIV infection in the United States is 1/200,000 to 1/2,000,000 per unit transfused. However, with the essay market, implementation of donor screening tests for HIV-1 antigen, there is an expectation of preventing up to 25#37; of the nikken plan, window period cases (the period between viral infection and essays, its detection by tests for the presence of antibodies). Perhaps the business plan, immunoviral agent most transmitted by blood transfusion is cytomegalovirus.

Bartlett JG. Report from IDSA: symposium on healthcare worker issues. The. Hopkins HIV Report: A Bimonthly Newsletter for Healthcare Providers 2000:12:(1)3, 8. Goodnough LT. Brecher ME. Kanter MH, et al.Transfusion medicine: first of 2 parts#151;blood transfusion. N Engl J Med 1999:340:438–447. Lacritz EM.

Sullen GA. Aberle-Grasse J, et al.Estimated risk of transmission of the history essays, human immunodeficiency virus by screened blood in the United States. N Engl J Med 1995:333:1721–1725. Lowe KC. Business Plan. Farrell K. Fellowship. Ferguson EM, et al.Current perceived risks of transfusion in the UK and relevance to the future acceptance of blood substitutes. Artif Cells Blood Substit Immobil Biotechnol 2001:29:179–189.

B.8. In what situation might aminocaproic acid improve hemostasis? Epsilon-aminocaproic acid (EACA) inhibits plasminogen activation by binding to nikken business, plasminogen. It inhibits primary fibrinolysis, which is what good caused by excessive plasminogen activation by endogenous plasminogen activators (e.g., urokinase, tissue-type plasminogen activator) occasionally seen in urinary tract bleeding and subarachnoid hemorrhage from an intracranial aneurysm. Primary fibrinolysis is rarely a cause of bleeding in the postcardiac surgery patient. Butterworth J. James RL. Lin YA, et al.Gender does not influence epsilon-aminocaproic acid concentrations in nikken business plan adults undergoing cardiopulmonary bypass. Anesth Analg 2001:92:1384–1390. Chauhan S. Kumar BA. Research Paper Apa Citation. Rao BH, et al.Efficacy of aprotinin, epsilon aminocaproic acid, or combination in cyanotic heart disease. Business Plan. Ann Thorac Surg 2000:70:1308–1312.

Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and market failure, thrombosis: basic principles and clinical practice 2nd ed. Philadelphia: JB Lippincott, 1987:1026. Ray MJ. O'Brien MF. Comparison of epsilon aminocaproic acid and low-dose aprotinin in cardiopulmonary bypass: efficiency, safety and cost. Ann Thorac Surg 2001:71:838–843. B.9. Assuming that she has cardiac tamponade, how would you prepare this patient for surgery?

As with any patient undergoing surgery, the business plan, following steps should be taken: first, a complete review of the patient's history, physical examination, and laboratory findings are mandated; second, key areas of concern should be identified and appropriate steps taken to address them; third, an anesthetic plan that is tailored to cardiac tamponade is devised; last, communication with the respective medical (surgeons, nurses, perfusionist, blood bank) and paramedical staff to on christmas kids, ensure readiness and teamwork. The patient's presentation suggests that she is in nikken business plan some degree of respiratory distress. Initially, management should consist of supplemental oxygen, review of kids, chest x-ray film, and assessment of arterial blood gasses. Business Plan. Shortness of breath and research paper apa citation, the inability to lie supine are frequent symptoms in patients having cardiac tamponade physiology and every effort should be made to business, provide comfort and lessen the edexcel, associated emotional stress. Positive pressure ventilation should be avoided at all cost unless the clinical picture indicates that the patient will have a cardiac arrest. The persistent oliguria most likely reflects prerenal or renal (acute tubular necrosis) process secondary to reduced CO and the associated vasoconstrictive state. As described in the previous answer, optimization of hemodynamics should also improve the renal function. Whereas some may administer diuretics in this setting, such management is business strongly discouraged. The most effective management is surgical evacuation of the pericardial effusion or clot.

The hematologic issues include elevated PT and aPTT, blood loss, and the potential for further blood loss perioperatively. The coagulopathy should be corrected appropriately, the patient's hematocrit and council for european studies, platelets should be checked and treated accordingly, and sufficient blood (four to six units) will be required in the room before commencing surgery. Fontes ML. Hines RL. Cardiogenic shock. Murray MJ, Coursin DB, Pearl RG, et al., Critical care medicine: perioperative management New York: Raven Press, 1997:295–306. Kirklin JK, Barratt-Boyes BG, Cardiac surgery 2nd ed. New York: Churchill Livingstone, 1993:1685. Nelson RM. Jeson CB. Smoot WM.

Pericardial tamponade following open-heart surgery. J Thorac Cardiovascular Surg 1969:58:510–516. B.10. What premedication would you prescribe? Although it is important to reduce the emotional stress preoperatively, in the setting of cardiac tamponade it would be unwise to administer any type of anxiolytic. The most effective approach is nikken plan communication with the patient. Often, the edexcel history essays, physical appearance and the hemodynamics can be misguiding and catastrophic consequences can arise from premedicating patients in tamponade. A state of marked sympathoadrenal activation exists to support perfusion to vital organs. By partially blocking this compensatory effect with an business, anxiolytic, cardiovascular collapse may ensue and most efforts to resuscitate the patient would fail.

The chest would have to research paper apa citation, be opened emergently predisposing the patient to additional morbidity as well as mortality. C. Intraoperative Management. C.1. Plan. How would you monitor this patient during transport to the operating room? What emergency drugs would you bring with you? The patient must be under hypervigilance and essay for small kids, vital signs must be continuously assessed including invasive monitoring of systemic blood pressure, electrocardiogram, and oxygen saturation.

In addition, emergency cardioactive and vasoactive drugs should be available during transport: Oxygen: increase the F IO 2 as needed. All necessary equipment for intubation should be present (laryngoscope and several blades, bag-mask units, and adult-size endotracheal tube) DC cardioversion unit: in case of tachyarrhythmias. Phenylephrine: dose: bolus, 0.1 to 0.5 mg; infusion, 25 to 125 g/minute. Epinephrine: dose 0.01 to nikken business plan, 0.1 g/kg/minute. Calcium chloride: dose 2 to 4 mg/kg. Lidocaine: 1 to statements, 2 mg/kg. Atropine: 0.01 mg/kg. C.2. Nikken Business Plan. In this patient, what hemodynamic effects would occur from intravenous induction with ketamine, thiopental, fentanyl, propofol, etomidate, and midazolam?

After intravenous administration, ketamine (1 mg/kg) has a rapid onset of action and achieves a peak plasma concentration in less than 1 minute. It also possesses a short duration of history, action. After the plan, initial dose, patients may remain unconscious for 10 to 15 minutes, but the analgesic effect (somatic greater than visceral) persists for an additional 30 minutes or longer. Some of the hemodynamic effect of ketamine may include small increases in blood pressure, HR, CO, and myocardial oxygen demand. This response is mediated by a direct central sympathetic stimulation and by edexcel history inhibition of norepinephrine uptake into postganglionic sympathetic nerve endings. Ketamine has also been shown to have intrinsic depressant properties on the myocardium.

In clinical conditions whereby norepinephrine stores are reduced and in the presence of plan, preexisting cardiac dysfunction (mechanical or myocardial), administration of ketamine can produce hemodynamic disturbance. Thiopental (4 mg/kg) has a mild to moderate negative inotropic effect as well as vasodilatory property. The hemodynamic response relates to the dose, coexisting diseases (hypertension, ventricular dysfunction), age, intravascular volume, and intactness of autonomic sympathetic responses. Generally, doses of 1 to 2 mg/kg do not cause significant hemodynamic disturbance; however, in patients with cardiac tamponade, thiopental should not be used for induction. These patients are, literally, on research paper apa citation, the edge of nikken business, cardiovascular collapse. Fentanyl does not possess any depressant effects on myocardial contractility but because of on christmas kids, its vagotonic effect (decreases in HR) and mild sympatholytic effect (central sympathetic outflow), a reduction in blood pressure may be noted. This response may be more profound in shock or preshock states and when fentanyl is used concomitantly with other induction agents (benzodiazepines, thiopental, propofol).

Propofol produces very similar effects as thiopental. It can cause significant reductions in systemic pressures (greater than 30#37;) and there have been several reports of cardiovascular arrest in both adults and business, children following inductions with propofol. Propofol also has some antiarrhythmic effect on what thesis, the atrioventricular (AV) node as well as on other conduction pathways. It should be used with caution when other agents that similarly slow down AV nodal conduction are present (calcium channel blockers, -blockers, digoxin). As with thiopental, the use of propofol for plan, induction in cardiac tamponade is strongly disfavored. Etomidate has a very favorable hemodynamic profile and is the research apa citation, preferred agent to plan, be used during induction when cardiovascular collapse is anticipated. With an induction dose (0.2 to 0.3 mg/kg), etomidate may cause a slight decrease in mean arterial pressure but such changes are not attributable to myocardial depression as is typical of propofol and sodium thiopental. Pain at the injection site and involuntary muscle movements are the most common adverse events noted with etomidate. History Essays. It also appears to reduce seizure threshold and enhance its duration when used during electroconvulsion therapy.

Midazolam may cause mild to moderate systemic vasodilation, particularly when used in combination with narcotics. Overall, of the agents discussed, etomidate would be the preferred agent for induction followed by ketamine, and/or fentanyl; whereas, thiopental and propofol would be the least desired. Kaplan JA, Cardiac anesthesia 4th ed. Philadelphia: WB Saunders, 1999:611–626. Tweed WA. Minuck M. Mymin D. Circulatory responses to ketamine anesthesia. Business. Anesthesiology 1972:37:612. C.3. Describe the council fellowship, induction process for cardiac tamponade. The patient should have standard monitors placed as well as invasive monitors to include indwelling arterial access for beat-to-beat displaying of systemic arterial pressures and for obtaining blood gases.

This patient has a PAC in nikken place; however, its use in this setting remains debatable. The actual induction should proceed ONLY in the presence of a surgical team that is ready and gowned and after the patient has been completely prepared and draped. The choice of induction agents is limited to is a good thesis, narcotics, muscle relaxant (depolarizing or nondepolarizing), and either etomidate or ketamine. Regardless of the induction technique, the plan, anesthesiologist should expect and be prepared to manage ensuing circulatory collapse. Fontes ML. Hines RH.

Pharmacologic treatment of perioperative left and essay market failure, right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Nikken Plan. Philadelphia: Grune Stratton, 1999:1155–1191. C.4. Following induction and council for european, intubation, the systemic blood pressure decreased to 55/30 mm Hg.

Describe the clinical events accounting for nikken business, this perturbation and the management steps required for resuscitating this patient. Cardiac tamponade is caused by significant pericardial pressure from accumulating pericardial contents (fluid, blood, and blood clots) that impede chamber filing resulting in a low CO state. The precipitous fall in blood pressure observed with induction can be accounted for by the following: first; most induction agents will have negative hemodynamic effects that are either direct or indirect; second, sympatholysis reduces arterial resistance as well as chronotropy and inotropy of the heart; third, the physiologic consequences of switching from negative pressure ventilation to positive pressure ventilation will further reduce cardiac filling by increasing intrathoracic pressure and afterload; and course, lastly, placing the patient in a supine position will also compromise atrial and ventricular preload (i.e., hydrostatic effects, loss of diaphragm, and weight of mediastinal structures on the heart). The management of hypotension will require use of vasoactive drugs, cardioactive drugs, and/or fluid challenge. Reducing inspiratory positive pressure (i.e., lowering tidal volume or switching from plan, ventilator-delivered breaths to hand ventilation) may also improve the for small kids, hemodynamic status.

These would be merely temporizing measures; surgical relief of tamponade would be the definitive treatment of this problem. Fontes ML. Nikken Business. Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. Thomas SJ, Manual of cardiac anesthesia 2nd ed. Research. New York: Churchill Livingstone, 1993:135. C.5.

What hemodynamic changes are frequently associated with opening the nikken business plan, chest? Chest opening normalizes the pressure relationship between the pericardium and the heart chambers, thus relieving the tamponade and its hemodynamic effects. Unless the ptlls essays, myocardium has suffered injury or is stunned, the expected hemodynamic change includes drastic improvement in blood pressure and SV. Most of the vasoactive and cardioactive agents being administered can be quickly weaned. In addition, oxygenation, acid-base status, and renal function (urine output) tend to improve significantly.

C.6. What is business myocardial stunning? What is myocardial hibernation? The myocardium can exhibit segmental dysfunction or hypofunction related to injury (i.e., ischemia and infarction). It has also been noted that myocardial function can be coupled or uncoupled with tissue perfusion. For example, following a period of oxygen deprivation and restoration of flow, the affected myocardium can resume normal function, diminished function, or no function (dysfunction). The term myocardial stunning represents a state of uncoupling between function and flow whereby myocardial flow is normal but function is is a thesis statements diminished or akinetic. In the setting of cardiac surgery, myocardial stunning can be a cause of ventricular dysfunction that generally resolves within the first 6 to 8 hours post-CPB. During this period, inotropic support has been shown to nikken business, be effective. Myocardial hibernation, on the other hand, is for european studies fellowship a myocardial process that manifests after weeks or months and denotes a condition whereby both myocardial function and flow are reduced (coupled).

Perhaps this is an adaptive process that allows the myocytes to lower their metabolic activity and oxygen consumption to survive during states of oxygen deprivation. The definitive diagnosis of stunning and hibernation may be difficult to make because regional myocardial blood flow is nikken business plan difficult to market failure, assess or quantify clinically. Therefore, most cases of stunning and hibernation require a retrospective analysis. First, segmental myocardial dysfunction must be established; second, myocardial blood flow should be restored by revascularization (surgical, pharmacologic, or angioplasty/stenting); and third, improvement of regional function should follow revascularization. D'Ancona G. Donias HW. Bergsland J, et al.Myocardial stunning after off-pump coronary artery bypass grafting: safeguards and pitfalls. Ann Thorac Surg 2001:72:2182–2183. Fontes ML. Business Plan. Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction.

Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. Lorusso R. La Canna G. Ceconi C, et al.Long-term results of coronary artery bypass grafting procedure in the presence of left ventricular dysfunction and hibernating myocardium. Eur J Cardio Thorac Surg 2001:20:937–948. Shah BR. Velazquez E. Shaw LK, et al.Revascularization improves survival in ischemic cardiomyopathy regardless of electrocardiographic criteria for prior small-to-medium myocardial infarcts. Am Heart J 2002:143:111–117.

Watzinger N. Essay On Christmas. Saeed M. Wendland MF, et al.Myocardial viability: magnetic resonance assessment of functional reserve and tissue characterization. J Cardiovasc Magn Reson 2001:3:195–208. D. Postoperative Management. D.1. How would you manage hypertension in the intensive care unit (ICU)? The management of hypertension depends on its etiology.

Rather than administering antihypertensive agents indiscriminately, the nikken business plan, clinician should exclude the following conditions as causality of hypertension: hypoxemia, hypercarbia, acid-base derangements, and pain. The occurrence of hypertension is a common phenomenon during the market, first several hours in the ICU. In most cases, the business plan, etiology is what is a uncertain and probably represents a state of business, marked sympathoadrenal activation. Once correctable causes of hypertension have been addressed, antihypertensive therapy can be achieved with a variety of essays, agents. Most often, sodium nitroprusside is nikken plan used because of its potent effect and titratability. Because the underlying mechanism of the essay market, hypertension involves endogenous release of plan, norepinephrine (with minimal epinephrine), the most rational agents to ptlls essays, use are the business plan, -blockers.

Labetalol antagonizes both - and -adrenergic receptors and failure, is an plan, effective antihypertensive agent. Alternatively, metoprolol, atenolol, esmolol, or propranolol can be used particularly if the hypertension is associated with tachycardia. Unfortunately, these agents are used infrequently because of theoretical concerns of myocardial depression and bradycardia. Current cardiology practice strongly endorses the use of -blockers in the setting of moderate and severe ventricular dysfunction. In addition, the cardioprotective effects of -blockers have been shown in several perioperative trials whereby the incidence of myocardial injury and mortality (up to 2 years postoperatively) are significantly reduced in patients treated perioperatively with -blockers. Kotlyar E. Macdonald PS. Keogh AM, et al.Optimization of left ventricular function with carvedilol before high-risk cardiac surgery. Research Apa Citation. J Heart Lung Transplantation 2001:20:1129–1131. Leslie J. Brister N. Levy JH, et al.Treatment of postoperative hypertension after coronary artery bypass surgery.

Double-blind comparison of plan, intravenous isradipine and sodium nitroprusside. Circulation 1994:90:(5 Pt 2)II256–261. Lucas WJ. Boysen PG. Antihypertensive agents following cardiac surgery. Crit Care Med 1997:25:1770–1771. Wallace A. Good Statements. Layug B. Tateo I, et al.Prophylactic atenolol reduces postoperative myocardial ischemia. Anesthesiology 1998:88:7–17. Wood G. Effect of antihypertensive agents on the arterial partial pressure of oxygen and plan, venous admixture after cardiac surgery.

Crit Care Med 1997:25:1807–1812. D.2. When would it be appropriate to extubate this patient? The timing of extubation depends on the following: Clinical stability (stable hemodynamics without need for significant inotropic or vasoactive support) Intact neurologic function (alertness and ability to comprehend and execute simple verbal commands) Adequate pulmonary function (acceptable arterial blood gases and acid-base status and adequate weaning parameters#151;tidal volume, respiratory rate, vital capacity, and inspiratory effort) Normal body temperature and neuromuscular function (reverse paralysis if necessary)

Normal coagulation (bleeding less than 60 mL/hour and normalization of coagulation parameters) Following relief of tamponade, most patients can be extubated as early as possible assuming that the previously listed criteria have been met.