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beginning of essay Introductions and historical period, Conclusions. D ownload a complete PDF version of this module. Download a complete Word version of this module. Essays are the most commonly assigned form of writing at University and are central to the academic process. Through essays, scholars communicate with one another; in them, professors and students present data to one another and explain new ways of thinking about ideas or events.

Professors assign essays to you because they want to define fauvism give you the opportunity to historical period think, in a deep and prolonged manner, about a topic. They want you to examine a historical question, create a unique and interesting answer to that question, and use sound historical evidence to prove that answer. Define Fauvism? While they can take many forms and range in length from one page to thirty or more pages, academic essays share a set of central characteristics. Most significantly, all essays are made up of two basic elementsan argument and evidenceand they generally all follow a similar writing structure. First, let us consider what we mean by historical the idea that essays are made up of arguments and evidence. The arguments within the essay are your interpretations of a given topic or answer to a question.

Take, for example, an essay assessing the impact of Prime Minister Diefenbaker’s reaction to the Cuban Missile Crisis; your argument would be YOUR assessment of what that impact was. For example: Prime Minister Diefenbaker’s indecisiveness during the Cuban Missile Crisis not only damaged his chances of re-election but also hurt Canada’s image abroad. Your arguments are summarized in The Struggle Essay, a clear thesis statement that is historical period, presented at social, the beginning of the essay. For more information on how to write a strong thesis statement, please see the module entitled Constructing an Argument . The evidence in historical period, an essay is the feminist information and examples that you use to historical period prove to the reader that your argument is convincing. Evidence can take the form of historical events, figures, concepts, images, or historical documents or literature that are relevant to the argument that you are making. The evidence is greek powers, generally presented in the body of historical period, your essay. Athena Goddess Powers? In presenting it, you need not only to historical period give the example, paraphrase, or quotation, but also explain how it illustrates the arguments that you are making.

The Structure of an impact mean, Essay. Whether they are two pages in length or fifteen, most essays follow a similar structure. Essays always begin with a clear introduction. The introduction sets up the historical question, presents a clear thesis to the reader, and establishes the scope of the essay--the time period, places, and subjects discussed in the essay. In a short paper, the introduction is one paragraph in length. In a longer paper (over ten pages), it could be two or three paragraphs in length. Introductions will be covered in period, more detail later in this module. Following the introduction, the feminist essay contains body paragraphs. These paragraphs systematically, and in a logical order, develop and prove each argument. In the body paragraphs, you present and explain the period evidence that supports your thesis. There is does social impact, no set number of period, body paragraphs for an essay (you are NO LONGER writing only five-paragraph essays).

Use as many paragraphs as you need to develop the arguments within your thesis. The essay ends with a clear conclusion. The conclusion brings together the points made in the essay and draws out define fauvism, their larger significance. In a short paper, the conclusion is one paragraph in period, length. Of Necessity? In a longer paper (over ten pages), it could be two or three paragraphs in length. Conclusions will be covered in more detail later in this module.

The Building Blocks of Essays: Paragraphs. Whether you are writing the introduction or the body of your essay, you will always be writing paragraphs. Indeed, the paragraph is the most basic building block of the essay. It is essential, then, for you to familiarize yourself with how a good, clear paragraph is constructed. Historical? A good paragraph is does mean, a group of historical, sentences that is The Struggle for Equality and Respect in a Man’s World Essay, unified around ONE central point. This point is expressed clearly in a topic sentence.

This point is historical, then developed in the paragraph through details, examples, and explanations. A good paragraph is like a mini-essay; it begins with a clear topic sentence and develops the point in that sentence through examples and discussion. Guidelines for Writing Good Paragraphs. Essay About Over Fifteen Years? Make sure that you and your reader are clear on the ONE main point that the paragraph is trying to make. In general, paragraphs in an essay should be about 150-200 words. Avoid overly long paragraphs as they usually cover more than one main point and leave your reader confused. Don’t be afraid to historical period start a new paragraph! Avoid one or two sentence paragraphs. Transitions are words or phrases that connect ideas and/or show the The Struggle for Equality and Respect Man’s Essay relationship between them. Use transitions to connect the historical period sentences within your paragraphs.

Examples of transitional words and phrases include: • Nevertheless • However • Therefore • In addition • As a result • Equally important. You can also use transitional statements at the beginning and/or end of paragraphs to connect the paragraph to the paragraphs before or after as well as to athena goddess powers your thesis. Historical Period? Of all the about Poland Over the Next Years different paragraphs, many people consider introductions the most difficult to write. This is because the introduction must grab the reader’s attention and provide an historical period, absolutely clear, but sufficiently concise explanation of the paper’s main point. And Liberty? In a shorter paper, the introduction will only be one paragraph. In a longer paper, it could be lengthier and involve multiple paragraphs.

Structure of the Introduction. Grab the reader’s attention and introduce the historical question the paper will explore. Clearly explain the scope of the essay - the time period, places, and subjects discussed in the essay. Give basic background if needed and explain the historical setting. State thesis and give an overview of main points or categories of period, evidence. You can also use your introduction to the Next introduce your main primary sources, if used, historiography, or theoretical framework. Good Ideas for the Introduction. Begin with a quotation and show its relevance. Or, begin with a story, example, or anecdote. Or, begin with a paradox or apparent contradiction. Or, emphasize the difference between your evidence or interpretation and the arguments of other scholars.

Always provide background information and establish the historical setting if necessary. Always clearly state your thesis and historical period, provide a road map to your reader of what does mean, what is to come. What to Avoid in the Introduction. Using dictionary definitions. Echoing the instructor’s question exactly.

Using inflated declaration or a cliché (Throughout human history; The more things change, the more they stay the same) Apologizing for the deficiencies in the paper. Quoting extensively the words and ideas should be your own. Including gratuitous personal preambles (such as long digressions about your personal feelings about a topic). Like the introduction, the conclusion can be a challenging paragraph to write. Historical Period? This is because the conclusion must review the define fauvism main points without being repetitive or boring. Structure of the Conclusion. Sum up and review your main points. Re-examine your thesis in light of everything that you have proven. Point toward the larger significance of your ideas. If your readers now believe everything in your thesis, what do they now know and why is it important?

In other words, so what? Good Ideas for Conclusions. If your essay began with a question, include the answer in your conclusion. Use a short, significant quotation or anecdote that summarizes the main intent of the essay. If your essay pointed out a problem, suggest solutions. Widen the perspective of what you have discussed; in light of your thesis, what does your reader now know about a given time period? What to Avoid in the Conclusion. The phrase, “In conclusion, I have shown that” Recopying your topic sentences or introduction exactly. Putting in historical period, minor details or afterthoughts.

Using inflated declarations or cliché Apologizing for what you failed to do in Of Necessity Essay, the essay. Going off in an entirely new or unrelated direction.

Major periods in world history | Biography

Historical period

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Red flags are a critical consideration to make when writing your cover letter. A red flag is something in your professional or personal history that could negatively impact the way a hiring manager views your job application. While many red flags should be directly addressed in a cover letter, some others are best left for the job interview stage. The following list is of 8 of the biggest cover letter red flags. If any apply to historical period, you, click to learn more about how to for Equality in a World Essay, effectively handle it so it doesnt become a roadblock in your efforts to secure your next job. i need cover letter for my resume. You can either write your own cover letter with the guide above or use our software to build one instead. If you want to use our software just go to our homepage at https://resumegenius.com/ What about period, references? Can they go on the Resume or do I need a separate sheet for greek those? References should NOT be included on your resume nor should you write References Available Upon Request on historical, your resume.

The hiring manager will request that information from Essay about, you at a later date if they are interested in doing so. (Note: If the period employer ASKS you to include references with your application, obviously you should do that.) Thanks for your question! This has given me a better understanding in the resume field! Glad we could help! Good luck on marxist theory, the job hunt! thanks. you have explained clearly what i need to do.

We are glad that the article could help! I just applied for a $14/hr job on Indeed. Period! After 6 years of working for the same company for $10/hr. Im praying this cover letter is enough to land me the job. I converted the Essay Over the Next Fifteen Years Sales Cover Letter into a Warehouse Manager cover letter. Of course I tweaked it to my specifications and needs but it turned out to be one professional piece of work when I was finished. Historical! I cant thank you all enough for Of Necessity and Liberty Essay this posting. Period! Ill be back to update if I land the job.

We are happy to what does social impact mean, hear that as well! Hope to hear back from you soon. Historical Period! Keep us updated throughout the process and let us know if you have any interview questions. Best luck on your job hunt! This was definitely helpful. Recently I came across a job opening and they had asked for a cover letter. I had no damn idea what a cover letter was. Googled it.. nd came here.. im thankfull to you.. #128578;

We are glad that we were able to help you with your cover letter. We hope you get the define fauvism interview! I have a significant gap in full-time employment. I need to create a cover letter that can briefly explain that gap. The template of a mother returning to work wont cut it, IMO. Do you have a template that matches my needs? Thanks in advance #128578;

We regret that you werent able to find what you were looking for. Period! The stay at Of Necessity and Liberty home mom resume is one of our most popular and has received a lot of positive feedback. We suggest that you check out our resume formats page: https://resumegenius.com/resume/resume-formats. You may want to consider using functional format to help cover up your work gaps. If you still need help, you may also want to consider signing for a subscription with us. Historical! We offer the Ask The Expert service, which gives you access to a professional resume writer.

Good luck on the job hunt! Hello I am applying for flight attendant position, but I have never worked in this position before. What Social Impact Mean! What title I need to put in the header of the historical period resume? Our flight attendant sample has all the information you need to write your own resume. (https://resumegenius.com/resume/flight-attendant-resume-sample). Good luck on the job hunt! I only have volunteer work how do I put that in a resume ? thanks you. Check out our How to Write a Resume writing guide. (https://resumegenius.com/how-to-write-a-resume) It should be helpful in answering your question. Very true and informative.

Just googled it and and Liberty Essay, no doubt remains now. Cover letter will be easy for me now. Glad you found our cover letter guide useful. Let us know if you have any additional questions. Good luck on the job hunt!

This was helpful. is it same for Student / Entry Level Cover Letter and Internship cover letter? We are glad you found our cover letter page useful. As far as your question goes, the student cover letter above could be reworked for historical period an internship application. Please let us know if you have any other questions. This helped me so much, Ive never written a cover letter before. Thank you so much RG! We are glad that the information is helpful! Please feel free to read other related articles and define fauvism, let us know if you have any questions. Hey please i want to apply for a post of an armorer in the ministry of historical period, defense in our country advertised in the dailies.

It wants people with high school education and i basically have that. Please lead me through We will need more information regarding the job posting as well as your background to lead you. Hi! Do you have cover letter samples to apply as a job intern?

Not currently, but it is on our list of samples to add. What Does Mean! For now, our student sample above should be helpful in giving you some ideas on how to format your own. Thanks a lot RG this was very helpful. Before today I have never done a one, now I have confidence with putting together a cover letter. Historical Period! One small question though, what should I name the cover letter? We are glad that you found our cover letter resources helpful. You can simply name your it Deitric (last name)s Cover Letter. That way, it will be easier for the employer to spot as they go through all the applicants in their inbox. Good luck on the job hunt! Hi! I have never written a cover letter before and would like to apply to a work from home jobbut, have no idea how to The Struggle for Equality in a Man’s World Essay, write it.

Please help! We have plenty of industry-specific samples above. Find your industry and get a few detailed tips on how to structure your own cover letter. RG I must say this helps me a lot. Not sure if I could master it but this would definitely help.

Thank you so much for historical period making my day 3. We are really glad to hear that and thank you for your support. The Struggle For Equality And Respect Man’s! Please let us know if you have any question. I remain stumped as to how to address a cover letter in response to a job advertisement that gives neither the company name nor the name of the person in period, charge of does social impact mean, hiring. This is true of many job postings on Craigslist, for example. I dislike To Whom It May Concern, but what other greeting would you recommend? Many job seekers also run into this issue. When the posting doesnt include a name of the company or hiring manager, try copying some of the job description and searching for historical it on Google. You may find the job ad with the names included. If this doesnt work, then it is acceptable to marxist theory, address the period cover letter with Dear Hiring Manager. Good luck on the job hunt,

I normally just put Dear Hiring Manager. Ive had issues where you call and there are multiple people who do the hiring, so I dont know who will be doing my interview until the day I have my interview. If I ask the employee there like, Oh Im not sure. Im going to forward this to a client of mine I was just talking to him about this. Marxist Theory! Now hell know that Im not just trying to make his life miserable. Great! We hope they find our resources helpful. I have done my resume and now Im preparing myself to do CL, but I have problem with it, because everything is historical, wrote in greek goddess, resume especialy introduction. It would be the best if I could copy my introduction from resume to historical, CL, because there is social impact, almost the historical period same to Essay, write. please advise. Some of the contents from your resume intro should be used in you CL, but should not simply be copied. Historical! If you read the and Liberty above guide and download the period template pack, you will learn exactly what information should be included.

Also, be sure to check out Essay our CL samples to give you a better idea on how you can word your cover letter. Good luck on the job hunt! I am trying to write a cover letter for a managerial position in historical period, the hospitality field. Essay! However, I do not see any examples. We are in the process of period, adding new cover letter samples and social impact mean, have included your suggestion in the list. Period! In the athena greek goddess meantime, follow the guide above and download one of cover letter templates. Good luck on the job hunt! Basically, a cover letter is a letter of introduction. Period! Usually I state the define fauvism name of the historical period position Im applying for and why I am qualified for the position.

At the end of the letter, Ill write something like If you have any questions or to define fauvism, schedule an historical appointment for an interview, please contact me at ***-**-****. Then double space and impact, type Sincerely and historical, then space 4 times and type your name. Youll be signing in the space above your typed name. This has been most helpful. GBU. Glad you liked it. Share it with you your friends. GBU, too! I am working on a resume for greek powers an experienced welder, One of the requirements is a valid drivers license, which I do not possess at historical period this time , but if I was hired, I could pay the traffic fine and get my license back with my first paycheck.

Should I explain this on my resume or by marxist feminist, telephone or in person or not at mall. In all honesty, your best bet is to find a way to pay the period traffic fine and get you license back before applying for greek powers the position. Thanks for the advice. I was thinking that very thing or appearing at traffic court and setting up a payment plan which would clear the way for a re issue. All about the money. which I happen to be in short supply of. Thanks again. We know the struggle. Hang in there brother!

Try add figures that will impress an employer and that pertain to historical, the position you are applying for. Best of luck! I live in Thailand and odd numbers here are auspicious so it probably wont hurt to throw some of them in. Im still not sure what you all are referring to with bullet point numbers. Can someone explain? Thank you. thank you so much RG you really shade light on Poland Fifteen, cover letters, i was clueless wat it was so mostly i would ignore it and send my applications without one from today i will do thngs differently.

Download our cover letter template pack and use the historical period tips written above. Define Fauvism! That should get you started. Best of luck! How to address gaps in employment. Historical Period! My mom passed away unexpectedly in 2005. I was incapacitated by depression and unable to work from 2005-2008. Got a job in The Struggle for Equality in a Man’s World, 2008 was employed until 2012 when I had a baby. i have been a stay at home mom. Ready to go back to historical period, work again. How do I address the gaps when posting my resume on job resource sites?

I have spent the past six months working reworking my resume. Ive searched hundreds of Over the Next, resume websites; Resme Genius is, by historical period, far, the best. Would appreciate any advice. Thanks for the kind words. One of the easiest ways to mask your work gaps is to use a functional format: https://resumegenius.com/resume-formats/functional-samples-writing-guide. Give it a try and see what you think. Good luck on the job hunt! How do explain a reason for leaving a company when you hate your job/employer, more management than the does impact job itself. We always recommend not to burn any bridges with former employers and to leave on a positive note.

So in that case, we suggest that you explain that you are looking for an opportunity in period, a new industry or a different position. Although it may sting, make sure to also thank management for the opportunity you were given. Good luck! Struggling with how to address a cover letter for a summer internship. Im not applying for a posted internship, just going to show up at an organization that my school advisor suggested I reach out to. I have no idea who Ill be giving my cover letter to, but I dont want to say dear hiring manager because technically they wouldnt be hiring me right? Aside from that, this guide was still very helpful. Were glad that you found our advice helpful. And Liberty! In your case, Dear Hiring Manager or Dear Madam or Sir would be appropriate. Good luck! So i have been asked to email my salary requirements, Here is my situation though, I previously worked with this company in period, the same exact role.

I left for another job opportunity ( which built my skill set and experience) about a year ago this month. They have asked me to come back and fill that position again. How do I compose a salary requirement. In this situation you have the leverage, so it would be fair to ask for 10-20% more than you were paid before. The skills and experience you gained over the last year make you more valuable than you were before. Good luck! Hi, I am trying to athena goddess, help a friend who is looking to move into a completely different line of work, he has only had 1 job since high school, which has nothing to historical period, do with what he really wants to do.

How do you approach that in a cover letter, since he has no experience in the field? Your friend will have to discuss their general skills or traits that are relevant to the job. I just turned 62 and want to retire from define fauvism, my current job, but not ready to retire. Any suggestions on historical, how to put my best foot forward when applying for a new position in an industry Ive never worked in Essay about Poland Over Fifteen Years, before? When applying for a position in an industry that youve never worked in before, the first thing you should do is come up with a list of the relevant skills that you can transfer over to that industry. From there, you can work on historical period, selling those particular skills in your cover letter and resume. Mean! Good luck!

So glad I stumbled upon period, this. Glad you found it helpful! Im applying for a new job but the The Struggle for Equality and Respect Man’s World mining company has different projects. Would I have the companys address or the project site address? We recommend that you use the address that the period cover letter is being sent to. If you are not sure, then use the companys address.

Good luck! Some cover letter here have helped me move on to another level. Through this i had to feminist, pay bills for my ailing child . Thanks you have been of great help through the way to write a winning cover letter. Great information! My question is I have been out of the work force for historical about a year and a half due to birthing children and staying home for what does impact them. I am wondering if this is something i should include on my CL to explain my gap in work history or is this information to personal to include? Great question! If your work gap is longer than a couple of months, then you should certainly include an explanation in your cover letter. Dont spend more than 1-2 sentences on your explanation though. Remember that you want to keep the focus of your cover letter on historical period, your experience and for Equality and Respect Man’s Essay, qualifications.

You can say something like After taking some time at home with my family, then express how excited and enthusiastic you are to return to the work force and historical, how this position is exactly what convinced you that now is the time to do so. You can use that phrase for maternity leave, or caring for older family members, or even your own issues. Define Fauvism! Shoot, you can use that even when you didnt choose to take a break, so to speak. Historical! Good luck! Im a college dropout and greek goddess powers, I couldnt decide on which template to historical, use for my cover letter. I quit school during my sophomore year. We suggest using the Non-Student templates.

If your college experience is relevant to the job you are applying for, you might consider including it your cover letter. Best of luck on the job hunt! Thank you Resume Genius! what if there is no job description given? how do you start of with the cover application in such a scenario? Even without a job description you can still follow the template above. Look up job descriptions for the same position from other companies to get an idea of what the employers is looking for. Unless requested in the job ad, leave your salary requirements off your cover letter. Good Luck! Fair point its always good to be careful when sending out personal information. Thanks for the suggestion!

Share How to Write a Cover Letter #038; 40+ Free Templates Our code geeks and define fauvism, HR experts are proud to introduce our new Free Resume Builder software to help you land more interviews in todays competitive job market. We provide HR-approved resume templates, built-in job description bullet point phrases to period, choose from, and easy export to MS Word and define fauvism, PDF. Get awesome job opportunities sent directly to historical, 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 Thatll Show You How to Improve Your Resume. Think you can judge the quality of define fauvism, a resume within 6 seconds? The answer may surprise you. Period! Put your skills to the test, and learn how to make your resume 6 second worthy! 3 Reasons Why I Wouldn't Hire Tom Brady. Tom Bradys resume is what social impact, a couple yards short of historical, a touchdown.

There are tons of errors throughout. See why. How to Modify and Maximize your Resume Template. Need a resume template? Feel free to what impact mean, 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 historical 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 athena goddess, HR experts are proud to introduce our new Free Resume Builder software to historical period, help you land more interviews in The Struggle in a, today's competitive job market. HR-proven resume templates, built-in job description bullet point phrases to choose from, and easily export to period, MS Word and PDF.

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Write a Cover Letter to Introduce a Resume. In response to period your employment listing in the (Name of Essay, Newspaper), I am writing today to submit my resume in application for the position of (Name of Position). As my resume demonstrates, my previous work experiences have enabled me to gain a deep and diverse understanding of the mindset and historical, skills needed to succeed as a (Name of Position). These experiences, combined with my ability to impact mean adapt to a wide variety of circumstances and to historical period manage many responsibilities while nurturing necessary lines of communication with others, make me a very suitable candidate for your open position. If this possibility interests you, I would welcome the opportunity to discuss the matter further. Please feel free to and Liberty contact me at any time; I am available for a phone conversation or office visit most days during the week. Historical Period! Thank you very much for your time and consideration.

Thank you for faxing me the social, job description for historical period the Springfield City auditor position. Marxist Theory! I am enclosing a brief resume outlining my experience in both business and city planning. I have had significant experience with budgets at the state level and understand both state and federal regulations. I have good communication skills and can work well with the public. Historical Period! I believe I can make a significant contribution to the efficiency and security of the city's financial dealings. I look forward to feminist your response. RE: ACCOUNTANT POSITION LISTED IN THE DAILY EXAMINER. Please accept my application for historical period the accountant position that was advertised in this week's Daily Examiner. As you will note in my enclosed resume, I have worked as the assistant accountant for City Enterprises for the last two years.

Before that, I attended City University and subsequently earned my CPA license. I feel very qualified to fill your accountant position and would like to arrange an interview at your earliest convenience. RE: FOLLOW-UP REQUEST FOR EMPLOYMENT AT DOE RESOURCES. Thank you for taking time to talk with me on the telephone yesterday. Does! I appreciated your answering my questions about positions in historical period your company. Per your request, I am forwarding you a copy of my resume. I think you will agree that I have many of the skills you are looking for. What a resume cannot express is the pride I take in my resourcefulness and being a creative problem solver. I also believe my experience at City Corporation would make me a valuable member of the theory, Doe Resources team.

I would like to schedule a meeting to speak with you in person about how my skills could benefit Doe Resources. I can be reached at 555-5555. I look forward to hearing from you soon. I am interested in the night security position advertised in the City Examiner on period March 29. I have enclosed a resume outlining my background and showing my potential as an employee within your organization. My security background spans eight years and two positions: City Bank and City Correctional Facility. I am a graduate of City College, where I earned my (name) degree. You will see that my list of references includes (name prominent people). I look forward to meeting you in an interview to define fauvism discuss my qualifications and the position. Historical Period! I may be reached at 555-5555.

RE: APPLICATION FOR EMPLOYMENT WITHIN DOE FILMS. I became acquainted with Doe Films while I was doing film editing for our mutual colleague, (name). With the hope that you will be interested in my skills and background, I have enclosed my resume. I would appreciate meeting with you to goddess powers discuss your company's needs and potential employment opportunities. I believe my experience would be valuable to you. I will call your office next week to request a mutually convenient time for an appointment. Historical Period! Or I can be reached at 555-5555. I am applying for the technical writing position that your firm advertised in the local newspaper and have attached my resume. I have been writing for what social impact mean over 10 years in both contract and salaried positions in the computer industry.

Writing has always brought me great satisfaction. I look forward to an opportunity to meet with you to introduce myself and discuss my qualifications. I am submitting my resume for historical period consideration for the position of High-Rise Operations Manager, as advertised on the Doe Employment Hotline. My experience on the Springfield Tower crew has taught me the proper balance of respect and Essay, efficiency necessary for operating repair and period, cleaning equipment 50 or 60 stories above the earth. I am looking forward to meeting with you to about Fifteen discuss my potential leadership of your high-rise crew.

I will follow up this letter with a telephone call within the week. I appreciated the time you spent on the phone with me earlier today discussing the zookeeper position. Enclosed is a copy of my current resume, which you requested. I have always enjoyed working with animals, and although my formal education does not entirely reflect this interest, I spent all my summers throughout high school and historical period, college working for and Liberty veterinary surgeons. I worked for four years in an urban, small animal practice, and three years on a large dairy farm. I am eager and historical, quick to learn and, once I have been shown what to do, can work without supervision. Thank you again for agreeing to look at my resume. I look forward to meeting you. A friend who works at the Springfield branch told me that you are seeking to fill the position of Consumer Loan Processing Manager. As my enclosed resume indicates, I have had considerable experience in processing a variety of consumer and about Poland the Next Years, real estate loans.

In my previous position, I processed and historical, documented appraisals, titles, flood certifications and insurance after, of course, verifying each client's income. I have been involved in numerous real estate and consumer loans, and often resolved credit issues that could have been potential deal breakers. In the process, I have developed substantial telephone and interpersonal skills and am now proficient in closing successful transactions with satisfied customers. To stay current in my field, I have become proficient in using the Internet and email to process and Essay Over the Next, send various loan-related transfers and attachments. Of necessity, I have developed a typing speed that exceeds 80 wpm. As would be expected, I have excellent PC skills and can operate Word and Excel. Historical Period! In the define fauvism, past year, I have also created several motivational Power Point Presentations for our team members. My current expertise and future potential should help me stand out as the period, candidate who could most adequately fill the position that is now open in your loan department. I am confident that I can be a valuable asset to XYZ Bank Corporation as the Consumer Loan Processing Manager. I would appreciate the opportunity to meet with you to discuss my qualifications and experience. If agreeable to you, have your secretary call me at 555-5555 and we can set up an interview at your earliest convenience.

I am writing in response to last Sunday's ad for the Regional Sales Manager position in your Account Development Group. As this position involves increasing your classified ad clientele by The Struggle for Equality and Respect World Essay, improving sales presentations, I believe that I am the dynamic person with the recent experience you are looking for. As a Sales Associate for a modest newspaper organization in Denver, I developed and maintained client relationships for five successful years. Period! During that time, the goddess powers, newspaper enjoyed a large volume of historical, repeat business involving accounts of greek powers, all sizes. In this position I was able to develop excellent sales presentation skills, and found the challenge of winning the trust and business of new clients an especially rewarding experience. More recently, as Assistant Sales Manager in period a somewhat larger organization, I helped to bolster the low profit margin by streamlining and updating the company's sales presentations. Essay Poland The Next Years! After they implemented an employee development seminar based on historical my guidelines, account sales increased substantially, leading to define fauvism a new customer increase of 21 percent. Period! In the following fiscal year, this new clientele generated more than $150,000 in additional revenue.

I believe my ample experience, innovative ideas, and effective interpersonal skills would make me a desirable addition to the Newspaper Enterprise Company. I would welcome the opportunity to help Newspaper Enterprise Company achieve its full potential. I would appreciate the opportunity to talk with you in person concerning the advertised position. I am available for about Poland Fifteen an interview any weekday morning. If you are agreeable, please have your secretary call me and we can set up an appointment.

I have enclosed my current resume and period, will be happy to supply you with two letters of recommendation as well. My friend, Jane Doe, who is a teller in your Springfield branch, told me that you are looking for a Consumer Loan Processing Specialist. As my enclosed resume shows, I have had considerable experience in The Struggle and Respect in a Man’s World Essay processing real estate and consumer loans. With my previous employers, I have requested and handled all aspects of historical, processing and feminist, documenting appraisals, titles, flood certifications and historical period, insurance as well as verifying income. Because of my well-developed human relations and communications abilities, I have successfully processed many real estate and for Equality and Respect Man’s Essay, consumer loans and period, successfully resolved a variety of loan problems. My customer service and detail orientation skills will enable me to meet the customer's needs at XYZ Bank Corporation as well. In addition, my typing speed is over 60 wpm with 99 percent accuracy. I have excellent PC skills and can operate Word and Excel. I would like to about the Next talk with you about my loan processing experiences and historical period, describe how I can assist XYZ Bank Corporation with their consumer and real estate loans.

Please call me at 555-5555 so we can plan a time to marxist theory talk about the historical, position. I will call your office in a few days if I have not heard from theory you by period, then. The purpose of my letter is to let you know of Of Necessity and Liberty, my strong interest in historical period the Project Manager position that you advertised in the San Jose Mercury News on Sunday. As you can see from my enclosed resume, my experience and qualifications closely match the advertised requirements. I feel my outstanding work experience and excellent educational credentials qualify me for the position. Theory! At a previous employer, I accomplished the following: * Created, developed and period, implemented a new project tracking system that reduced work load by 23 percent, saving more than $145,000 in operating expenses. * Reduced expenses by $278,000 in six months by modifying the and Respect Man’s World Essay, manufacturing process, which also significantly improved employee productivity. Five years ago, I received my MBA from historical period Duke University, Magna Cum Laude with a 3.96/4.0 GPA. Feminist Theory! I was recognized as being first in the graduating class. I would very much appreciate talking with you about how I can assist you in improving your operations and reducing expenses.

I will call you in a few days to follow-up and answer any questions you may have. I would like to be considered for the Senior Treasury Analyst position that you are advertising in the Cincinnati Herald. If you look over my enclosed resume, you will see that I have earned an MBA as well as a CPA. I believe this training, coupled with 10 years of experience in accounting and finance, fully qualifies me to fill this position. I have worked in historical period several large banking organizations where I have conducted various independent financial analysis projects. I am proficient in using GAAP and Excel, and define fauvism, have developed excellent organizational skills as well. Historical Period! For example, in my last position I modified several procedures, which significantly reduced the analysis time previously spent on theory company projects. Within eight months, this enabled my employer to save over historical period $200,000 in operating expenses. I was subsequently named Employee of the Year and received a $5,000 bonus check at the annual banquet. I would like to discuss my qualifications with you in define fauvism person because I believe I can assist ABC Bank in reaching its analysis objectives. I will call next week to historical period see if I can set up an Essay about Poland Over Fifteen Years, interview with you at your convenience.

I saw your ad for period an experienced sewing machine operator in Of Necessity and Liberty Essay the Springfield Times and would like to be considered for this position. I have enjoyed sewing for family and friends for many years. Three years ago, I entered the workforce and joined the sewing team at Durable Luggage Company. My experience on period the Juki Industrial machine includes sewing all sizes of luggage together, vinyl as well as canvas. I have also gained experience sewing vinyl and leather upholstery. Of Necessity And Liberty! Last year, my employer received an order from a furniture manufacturing company that provided us with a lot of upholstery work for several months. Unfortunately, the company is now sending a lot of historical period, their work to India because of increasing labor costs here and I need to look for a new job.

My employer has also used some of my ideas and designs. For example, I recommended that the sewing process at feminist theory, Durable Luggage Company be slightly modified. Historical! By sewing the inside flaps first and changing the order of how the bag's components are attached to each other, the company was able to streamline the luggage manufacturing process. Feminist! Because of this change, the company's productivity rate increased by 12 percent and I earned the Outstanding Employee Award, which included a bonus check for $500. I believe that I am well-qualified to be a sewing machine operator at Doe Luggage Company. Please look over historical period my enclosed resume for more details. My phone number is 555-5555. Define Fauvism! I will call your office in a few days to see if I can set up an interview with you at historical, that time. I am very interested in the administrative position that is presently available in your company.

After learning about the athena powers, duties associated with this position, I am confident that I can meet your needs. My skills in this area are strong, as are my educational background and experience. Historical Period! Allow me to discuss this with you, and you will discover a dedicated and athena greek goddess, competent professional who will work hard to benefit your company. Please review the enclose resume, as it outlines my qualifications in further detail. By examining it you will find that my educational achievements and historical period, past employment accomplishments are more than adequate.

You will also see that I can bring an impressive range of skills to this position. I would appreciate the opportunity to provide you with additional information or answer any questions you may have. Perhaps we can set a time to meet in person to discuss the possibilities of allowing me to fill this position. Essay! Thank you in historical period advance; I look forward to hearing from you soon. Having recently come across your employment listing in Over the (Name of Newspaper), I am writing today to submit my resume in application for the position of (Name of Position).

As you will notice when reviewing my resume, the advanced skills and conceptual understanding acquired through coursework and challenging practicums during my studies equip me to adapt and thrive within many circumstances. Although I haven't yet acquired extensive on-the-job experience, given the strength of my academic record and my successful previous employment within other industries and period, positions, I am confident that I could perform excellently as a (Name of Position) for (Name of Company). If this possibility interests you, please contact me at Of Necessity and Liberty Essay, your earliest convenience to set up a phone conversation or interview. I welcome the opportunity to learn more about the period, position and to discuss my abilities in greater detail. And Respect In A Man’s World! Thank you for your time and consideration. I learned about this (name of position) position from (name of contact), who recommended that I apply.

Through my previous job experience, I have approximately (number) years of (field) experience, from which I have gained many of the historical period, skills you are looking for. I am interested in applying for the Next Years this position because (company) sounds like an enjoyable place to work, and I think I would enjoy the work I would do there. My experience in previous positions has provided me with the essential skills needed for this position, and I believe I can also add not only my experience, but my warm personality to the work environment. I look forward to historical period hearing from you. I am available for define fauvism an interview at your convenience and can be reached at (phone number). Thank you so much for your time. I am responding to your ad in the Thursday Tribune for a marketing director. I have had 10 years of experience in marketing, and period, am currently employed as the director of define fauvism, Stevens Marketing, a niche specialist with 40 employees. I have had extensive experience in period writing ad copy, a skill that you specified in your advertisement. I am now in a position to what impact take on historical period greater responsibilities. I have followed the growth of Over Fifteen Years, Doe Incorporated, and I would appreciate being associated with such a fine organization.

Please review my enclosed resume. I will contact your office next week in the hope of making an appointment to historical period discuss a position with Doe Incorporated. John Doe, our mutual associate, explained that you are interested in social mean a Sales Executive to take City Food Service to new heights. I have enclosed my resume with the hope that we can meet to discuss my application for historical that position. You will find that my performance at Regional Foods Incorporated contributed substantially to their millions of dollars in revenue. I would be just as dedicated to building your organization's sales. Please note a few key items on my resume: *(list key achievements) Of course, what my resume cannot convey is my enthusiasm for food service sales and helping to build a company. Essay Poland Over! The people I have listed as references will endorse me as honest and hard working. May I please request an interview at your convenience to discuss how I can make a lasting contribution to City Food Service?

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edit Homework Classification and Dichotomy. In this so-called class you must face occult rituals known as labs. Period? These rituals usually involve the sacrificing of students. Essay? Labs usually involve calling upon demonic forces and possessions, as well as the inherent risks created by historical period burning acids and toxic fume inhalation. Students often pass the time by smashing up anything in the lab made of glass and pretending someone else did it. Often, the define fauvism teachers are witches or warlocks set on using a torture method called science on the children or helping them prepare for Hogwarts. Daily homework is assigned daily and is designed for historical period, monotony, repetition, and slow torture. Athena Goddess? It comes in a few main varieties: English homework is by far the most numerous variety of daily homework.

It is unique in that it often is entirely comprised of reading, necessitating no thought or comprehension whatsoever. Period? When it is marxist feminist no comprised entirely of reading, it usually appears as a short passage, poem, speech, or other piece of literature followed by period ten to thirty multiple choice questions, followed by two to five multiple choice questions, followed optionally by what those in the business like to call a 'finisher', called an 'essay' by those subjected to Essay about Poland Over the Next Fifteen them. Multiple choice questions are usually deployed in very large numbers, in historical period, an attempt to overwhelm students with their sheer size and intimidating appearance. They usually appear in one of a few formats: As used in lines X-Y, what does the word ZZZZZ most closely mean? followed by Essay about Years several words synonymous with ZZZZZ, one of which makes sense in the context of historical period, lines X-Y Below is a definition of ZZZZZ. followed by The Struggle and Respect World Essay several dictionary-esque definitions of period, ZZZZZZ. Which definition most closely matches how ZZZZZ is used in lines X-Y? Given the context of paragraph A (lines X-Y), what does ZZZZZZ most closely mean? followed by multiple definitions of ZZZZZ, one of greek, which makes sense in historical, context. etc. Short answer questions are designed to strike a middle ground between number and length. They are often used immediately after multiple choice questions, to appear as numerous while maintaining their formidable time requirement. Usually, they require responses in a format, called The golden response, by some, to be considered completed: 1. A short sentence must be used for introduction, usually requiring a word-for-word rephrasing of the question and a brief explanation of its purpose. Of Necessity Essay? 2. A Short piece of the historical period provided passage, enclosed in define fauvism, quotation marks and historical, properly cited. 3. An in-depth explanation of define fauvism, exactly what this piece means and why it helps develop the historical period argument described for you 4. repetition of steps two and three, sometimes twice 5. A closing statement that's structurally identical to the intro from step one, but feels nicer at the end.

Essays are long, drawn-out assignments designed to single-handedly double the length of any homework assignment. structurally, they are identical to Short answer questions, except anywhere you would normally write a sentence, you must write a paragraph. History homework is a specific type of homework that tends to what be longer and more arduous. It is often necessary for its completion that history homework be given alongside a series of historical period, textbooks relating to the topic. Rather than causing hunchbackedness, people simply drop history homework, often crushing toes and creating bottomless pits due to its sheer weight. Once the teacher finds out that the history homework has not been completed, all hell breaks loose. The trauma of this is actually how 99% of nerds are created. Believe it or not, this variety of homework is still done today. Homework is what does mean assigned regularly but when assigned, none of the teenage humans in the room ever bother to do it except from the historical period previously mentioned nerds. Social Impact Mean? If you ever get the historical period opportunity to sneak into their natural habitat (AKA bedroom) you will most likely find them watching pornography, or doing extra homework.

This terrifies all who witness it. Maths, or 'math', the most painful subject at school, is often given to some of the more retarded and idiotic children for extra punishment. Some mentally challenged children whom many call Nerds will often ask for extra maths homework, thus a whole pack of define fauvism, normal students suffer for period, a fortnight. Essay Poland Over The Next? Overdoing maths homework usually results in suicide, penis removal or transformation into a nerd. Some prisoners are fed maths homework as a form of punishment for not doing their homework which was in fact about Maths. They are then unable to complete the punishment, so the period circle goes round. And round. And round.

Speeling hoomwork ys yuzhully givin owt two theh childrin hoo fine sbelyng haird nown ihn theh skool. Speling hoamwouck iz theh eeziarst buht iff tha chiled cann't reed, thenn itt's ay lawng, lawng storie. nermaly,spling homwirk s gvn too tha cids hoo arn't vary old, aproximetley for or feyv. This type of homework is not that common and is also known as The Cardey. It is given by hypocritical teachers who try to teach you to be healthy, and yet are ten times fatter than you. This kind of homework is normally used because the athena goddess powers teacher thinks that he/she is historical period teaching English but actually it's P.E. The result is that this confused teacher gives you an essay to what impact write about how you can improve your fitness in historical period, P.E. This kind of torture first started in the 1200s. Though one solution is to slap the shit out of your teacher, shouting loudly that this is define fauvism P.E. not English, this is not recommended, as the historical period teacher, if one of the rare, actually fit ones, will beat you up, or if they are a more common fatter one, they will simply sit on you, resulting in your suffocation. Homework has evolved from schoolwork, although some fundamentalist fanatical Muslims believe that homework was simply created through the magical powers of teachers. Schoolwork is a variety of work that is handed to a student during school, and words are supposed to be scrawled during school, but due to unfair detentions, Teletubbies, gas chambers, Metallica fans, and Russian goldfish, this schoolwork is often sent home with the student, hence the social impact mean theory of evolution.

By this stage, the schoolwork is fully fledged homework. Eyewitnesses claim that this schoolwork adds to the pile of homework the historical student is already carrying home, and that this often leads to the contraction of define fauvism, Super AIDS, or listening to emo music. Both of these things usually cause death, hence why there are cemeteries in historical, most schools. Considered the 'Boss Level' of all homeworks, this normally takes weeks to complete. It may be set just before a holiday ( see above ), which it usually is. This takes the relaxing and enjoyable parts out of the holiday, leaving only pure stress for the student. Of Necessity Essay? Not completing the project usually results in humiliation in front of your fellow classmates, as well as an 'F' grade from the teacher. edit Why do 'teachers' give homework? No one yet fully understands why homework is given to the students. Some, such as the Nerd species previously mentioned, think it's for their own good.

Others think it's an attempt to brainwash us all into retarded geeks. However, in a scientific breakthrough, a new theory has emerged that the reason the teachers/torturers set homework is that they like to see the children suffering and trying to commit suicide by eating lead. We recommend that's the option you believe. Homework was originally carved into stone tablets before the invention of paper. Students would have to carry around numerous tablets to finish their homework and that's where hunchbacks came from. After constant carving, some became artists; others lost the function of their hands. Today the equivalent of a stone tablet is the textbook.

Textbooks are also known by the slang name bricks. Occasionally, the torturers temporarily regain sanity and let the period students go home to their grieving parents. This is known as a weekend, break, half-term or holiday. However, many torturers are permanently past the point of recovery, and greek, will set extra to historical period be completed during this free time. Destroy All Homeworks! video game boxart, looks promising.

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cardiac case study Anesthesiology: Problem-Oriented Patient Management. CASE 15: Cardiac Tamponade. Manuel L. Fontes. Quick Links to Sections in this Chapter. Related Links in period, other Resources. Four days following two-vessel coronary artery bypass graft (CABG) procedure and 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 2.7 L/minute. And Liberty. Both the prothrombin and period, the partial thromboplastin times were elevated. Medical Disease and Differential Diagnosis What is the The Struggle and Respect Man’s, differential diagnosis of low cardiac output (CO) postoperatively? A. Medical Disease and Differential Diagnosis. A.1. Historical. What is the differential diagnosis of low cardiac output (CO) postoperatively? CO is determined by the product of and Respect stroke volume (SV) and historical period, heart rate (HR) during 1 minute (CO = HR x SV). Thus, a low output state can occur when SV and/or HR decrease.

Tachyarrhythmias of mean either ventricular or atrial origin can also cause a low output state (i.e., atrial fibrillation). To more accurately determine the etiology of a reduced SV, it is necessary to explore whether there has been a change in the preload, the historical, afterload, and/or the marxist feminist theory, contractile state. Either too much preload (ventricular overdistention) or too little preload can lower the CO. Historical. Similarly, a significant reduction in afterload (vasodilators, anesthetics, sympatholysis) or an increase in afterload (arterial resistance) can diminish SV. 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 indirect causes (mechanical factors as in cardiac tamponade; pharmacologic agents; and by toxins, namely, inflammatory cytokines and marxist theory, bacterial endotoxins). A combination of period hemodynamic disturbances can coexist in Essay Over, the same patient. For example, a patient can have both a decrease in contractility and a reduced preload to account for historical period, the low output state. Correcting one problem alone may not produce the optimal hemodynamic condition.

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, 1999:11551191. A.2. What is cardiac tamponade? Enumerate the about Fifteen Years, common etiologies of cardiac tamponade. Cardiac tamponade is defined as significant compression of the period, heart by for Equality and Respect Essay, 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 air. How significant cardiac tamponade is depends on whether the definition is clinical versus physiologic.

That is, tamponade is a pathophysiologic continuum that on historical, one extreme may be clinically insignificant whereas on another extreme presents as a life-threatening condition requiring emergent surgical attention. Clinical tamponade is frequently associated with marked increase in pericardial pressure relative to 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 cardiovascular medicine 6th ed. Philadelphia: WB Saunders, 2001:1498. Fowler NO. The Struggle For Equality In A Man’s. 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. Philadelphia: WB Saunders, 1999:847. Spodlick D. Historical Period. Pathophysiology of cardiac tamponade. Chest 1998:113:13721378. 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 feminist 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 historical, blood clots impeding mediastinal drainage. Delayed tamponade has been arbitrarily defined as cardiac tamponade occurring greater than 5 to 7 days after pericardiotomy. The incidence is 0.3#37; to 2.6#37; and is often misdiagnosed because of a low index of suspicion and because the Essay Poland Over, clinical signs and symptoms can be comparable to those of congestive heart failure, pulmonary embolism, and historical, 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 Over Fifteen Years, demonstrated that 103/122 (84#37;) had pericardial effusions. Generally, effusions reach their maximum size by the tenth postoperative day and historical, regress spontaneously thereafter. D'Cruz IA. Overton DH. Pai GH. Pericardial complications of cardiac surgery: emphasis on the diagnostic role of echocardiography.

J Card Surg 1992:7:257268. Nelson RM. Jeson CB. Smoot WM. Pericardial tamponade following open-heart surgery. J Thorac Cardiovasc Surg 1969:58:510516. Weitzman LB. Tinker WC. Kronzon I, et al.The incidence and natural history of pericardial effusions after cardiac surgery: an about Over the Next Fifteen, 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 historical often difficult and requires a high degree of clinical suspicion, proficient knowledge of Of Necessity Essay pulmonary artery catheter (PAC) derived measures, physical examination, and diagnostic tools such as echocardiography and chest x-ray film. Historical. Often, the diagnosis is made in the operating room whereby evacuation of clot and does social impact, blood from the mediastinum is period associated with drastic improvement in hemodynamics. Relying on one modality alone for diagnosis can lead to inaccurate management decisions and increase patient morbidity. For example, the PAC is an important device for monitoring cardiac function; however, its measures can be misleading postcardiotomy unless the clinician is cognizant of define fauvism 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 historical period produce equalization of pericardial diastolic pressures. Generally, the CVP is Poland Over the Next Fifteen Years elevated but the 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 historical the left heart can yield lower pressures that would be inconsistent with classical tamponade physiology. Russo and colleagues found that only 33#37; of patients with the marxist theory, diagnosis of historical cardiac tamponade had right heart catheterization findings that reflected equalization of feminist theory diastolic blood pressures. Period. Overall, 90#37; of patients with postcardiotomy cardiac tamponade had either atypical clinical, hemodynamic, and/or echocardiographic findings. Therefore, the diagnosis of postoperative cardiac tamponade should be considered whenever hemodynamic deterioration is encountered, particularly when reduction in define fauvism, CO or blood pressure or both are not readily responsive to conventional management. Furthermore, in delayed tamponade the complaints tend to be vague and less hemodynamic data is available (i.e., PAC) to allow prompt diagnosis of historical tamponade.

Whenever, the patient is marxist feminist not progressing as expected postoperatively with some signs of end-organ dysfunction [fall in urine output and or increase blood urea nitrogen (BUN) and creatinine], an echocardiogram should be obtained to rule out cardiac tamponade. Russo A. O'Connor W. Waxman H. Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery. Chest 1993:104:7178. Spodlick D. Pathophysiology of cardiac tamponade. Chest 1998:113:13721378. A.5. What is period 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 define fauvism, right ventricle is the most common echocardiographic finding in 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 the oblique sinus. Selective hematoma compression of the right heart becomes less prominent in delayed tamponade as the historical, right heart becomes adherent or tethered to greek goddess powers the anterior chest wall. 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 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. Historical. Mohanty PK, et al.Left ventricular diastolic collapse. An echocardiographic sign of regional cardiac tamponade. Of Necessity And Liberty. Circulation 1991:83:19992006. Fowler NO. Historical. Gabel M. The Struggle For Equality And Respect World Essay. Regional cardiac tamponade: a hemodynamic study.

J Am Coll Cardiol 1987:10:164169. Hutchins GM. Isolated right atrial tamponade caused by hematoma complicating coronary artery bypass graft surgery [Letter]. Arch Pathol Lab Med 1980:104:612614. Jadhav P. Asirvatham S. Craven P, et al.Unusual presentation of late regional cardiac tamponade after aortic surgery.

Am J Cardiac Imaging 1996:10:204206. Kochar GS. Jocab LE. Holter MN. Period. Right atrial impression in postoperative patients: detection by transesophageal cardiography.

J Am Coll Cardiol 1990:16:511516. Russo A. O'Connor W. Waxman H. Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and Essay about Fifteen, late after cardiac surgery. Chest 1993:104:7178. Sandifer DP. Gonzalez JL.

Refractory postoperative hypoxemia associated with regional cardiac tamponade and patent foramen ovale. Crit Care Med 1997:25:16081611. 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 an accompanying inspiratory fall in the venous pressure. However, a paradoxical pulse differs from the normal situation in two aspects: (a) the historical period, 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 greek goddess powers 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 period, interventricular septum toward the left ventricle. Of importance, pulsus paradoxus is not unique to cardiac tamponade.

The phasic respiratory changes in and Liberty Essay, ventricular dimensions with exaggerated decrease in systemic systolic arterial pressure during inspiration can be present in a variety of clinical conditions whereby intrapleural pressure is significantly diminished. That is, the historical, magnitude of paradoxical pulse is directly proportional to the inspiratory decrease of left ventricular dimension, diastolic volume, and does social, 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 historical, fall in left ventricular SV. Similarly, those who are receiving positive pressure mechanical ventilation (early postoperative period) and patients with severe aortic regurgitation do not exhibit pulsus paradoxus. D'Cruz IA. Overton DH. Pai GH. Pericardial complications of cardiac surgery: emphasis on Essay, the diagnostic role of echocardiography.

J Card Surg 1992:7:257268. Frey B. Freezer N. Diagnostic value and pathophysiologic basis of pulsus paradoxus in infants and children with respiratory disease. Pediatr Pulmonol 2001:31:138143. Jay GD. Onuma K. Davis R, et al.Analysis of physician ability in the measurement of pulsus paradoxus by period, sphygmomanometry. Chest 2000:118:348352. McGregor M. Pulsus paradoxus. N Engl J Med 1979:301:480.

Tsang TS. Barnes ME. Hayes SN, et al.Clinical and echocardiographic characteristics of The Struggle for Equality and Respect in a Man’s World significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979#150;1998. Chest 1999:116:322331. A.7. Describe ventricular interaction in cardiac tamponade.

Ventricular interaction is extremely important for maintenance of adequate cardiac performance. Under normal conditions, the average SV of the historical period, right ventricle equals the SV of the left ventricle; however, cyclical respiratory differences in left and Essay Over the Next Fifteen, right ventricular SV do occur. During the inspiratory cycle, negative intrapleural pressure is generated facilitating venous return to the right heart, whereas venous return to the left heart is diminished for period, the following reasons: (a) lung expansion increases its reservoir for blood and (b) the increase in right ventricular filling causes the interventricular septum to bulge leftwardly reducing left ventricular dimension and altering its compliance and filling (ventricular interaction). During exhalation, the reverse process occurs. In the case of cardiac tamponade, ventricular interaction also involves the interventricular septum but it can involve other chamber and define fauvism, processes depending on the etiology of the tamponade (fluid vs. 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. Historical Period. Because of the fixed space within the pericardium, cardiac chamber dimensions become smaller. First, the does social impact mean, thin-walled and more compliant atriums progressively get compressed followed by historical, the right ventricle and lastly the left ventricle.

Overall, the feminist, physiology of ventricular interaction in 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 historical period cardiac tamponade. Chest 1998:113:13721378. A.8. How is coronary blood flow affected in cardiac tamponade? In the absence of coronary artery disease, coronary blood flow is reduced in cardiac tamponade but this reduction is not sufficient to what does social impact 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. In contrast, patients with coronary artery disease may be at increased risk for myocardial ischemia or infarction or both. Reddy PS.

Curtiss EL. Otoole JD, et al.Cardiac tamponade; hemodynamic observation in man. Circulation 1978:58:265272. Spodlick DH. Threshold of pericardial constraint: the pericardial reserve volume and auxiliary pericardial functions.

J Am Coll Cardiol 1985:6:296299. 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 pericarditis, and period, electrical alternans ( Fig. 15.1A ). The latter is seen in patients with large effusions and is characterized by interbeat shifts in electrical axis. This beat-to-beat alteration may be due to increased distance between the 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 for Equality and Respect Man’s World, 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. 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 left ventricle (LV) during systole and diastole. (From Longo MJ, Jaffe CC. Images in historical, clinical medicine. 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:H516530.

Kosta E. Kronzon I. Electrical alternans in cardiac tamponade. Echocardiography 2000:17:(6 Pt 1)575576. Kronzon I. Cohen M. Winer H. Contribution of echocardiography to social impact mean the understanding of the pathophysiology of historical period cardiac tamponade. J Am Coll Cardiol 1983:1:11801182. Longo MJ. Jaffe CC. Images in clinical medicine. Electrical alternans. N Engl J Med 1999:341:2060. A.10. What roentgenographic and echocardiographic findings are noted in marxist theory, cardiac tamponade?

On standard anterior-posterior chest roentgenography, the cardiac silhouette may appear normal in size or extremely enlarged depending on historical period, the acuity and 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 define fauvism, pulmonary vessels at the hilum and a globular or water bottle configuration of the 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 historical, respective chamber. Additional echocardiographic signs observed in tamponade include (a) diminished left ventricular dimension and mitral valve excursion during inspiration, (b) shifting of the interventricular septum toward the left ventricle, (c) changes in athena greek powers, transvalvular (mitral and aortic) flow characteristics seen by Doppler techniques, (d) diastolic posterior motion of the right ventricular wall, and historical period, (e) in marxist feminist theory, some cases, a systolic notch on the right ventricular epicardium ( Fig. 15.1B and C ). Although many of the historical, findings of 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 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 marxist, right atrial collapse in historical, patients with cardiac tamponade. Circulation 1984:70:996. A.11. What is in 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 feminist, its etiology is ascribed to a coagulation defect.

Procedures that require CPB are known to historical period adversely affect the hemostatic mechanisms including vascular endothelium, fibrinolytic and feminist, coagulation factors, platelet, plasminogen, and inflammatory pathways ( Fig. 15.2 ). Under normal settings, these systems (and others yet unknown) act in concert and in opposition with one another (a) to historical period prevent bleeding by promoting clot formation at the site of endothelial injury (procoagulant effects) and (b) to 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 about Over the Next Fifteen, fibrinogen. The potential for postoperative bleeding will depend on historical period, the degree of activation and preexisting levels of the procoagulants as well as other factors such as the duration of CPB, systemic hypothermia, comorbid states (renal and for Equality and Respect in a Man’s Essay, liver insufficiency), type of surgery (reoperation, circulatory arrest, combined procedures), and prior or current treatment with anticoagulant (platelet inhibitors, coumadin, heparin). Figure 15.2. The coagulation cascade, illustrating the historical, coagulation factors required for various screening tests. What Impact. 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. (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.) 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. (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 historical period, 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 for Equality and Respect Man’s, -thromboglobulin, are reduced in both number and content during CPB. Of greater importance is the period, loss of several membrane glycoproteins (IIb-IIIa) that interact with fibrinogen and other cellular elements allowing for platelet conjugation and propagation of clot formation. Overall, postcardiotomy bleeding is due to (a) a qualitative and marxist, a quantitative platelet defect, (b) factor deficiency, and (c) surgical bleeding. Historical Period. The latter can arise from either venous or arterial sources that were undetected before closure of the chest. Attentive and meticulous effort to about Over the Next Fifteen Years surgical hemostasis can significantly reduce the incidence of bring-backs. Despotis GJ. Avidan MS. Hogue CW Jr. Mechanisms and attenuation of hemostatic activation during extracorporeal circulation. Period. Ann Thorac Surg 2001:72:S18211831.

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. Gando S. Morimoto Y, et al.Systematic elucidation of effects of tranexamic acid on fibrinolysis and bleeding during and after cardiopulmonary bypass surgery. Thromb Res 2001:104:301307. Levy JH. Pharmacologic preservation of the define fauvism, hemostatic system during cardiac surgery. Historical Period. Ann Thorac Surg 2001:72:S18141820. A.12.

What is the Essay the Next Years, mechanism of action of low molecular weight heparin (LMWH)? LMWHs are fragments of 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 3,000 to historical period 30,000 daltons. The mechanism of action is Poland Over the Next Years similar for both unfractionated heparin and LMWH. Binding of the pentasaccharide to historical period antithrombin (antithrombin III) results in a conformational change in antithrombin that accelerates its interaction with thrombin and factor X (factor Xa) by athena greek powers, 1,000-fold. Whereas unfractionated heparin causes a comparable inhibition of factor Xa as LMWH, its inhibition of thrombin is historical 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 goddess powers 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 chains of LMWH contain pentasaccharide sequences. 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 period 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 2000:69:762765. Danielsson A. Define Fauvism. Raub E. Lindahl U, et al.Role of historical ternary complexes in which heparin binds both antithrombin and proteinase, in the acceleration of the reactions between antithrombin and The Struggle and Respect Man’s Essay, thrombin for factor Xa. J Biol Chem 1986:261:15461573. Gohlke-Barwolf C. Anticoagulation in valvar heart disease: new aspects and management during non-cardiac surgery.

Heart 2000:84:567572. Harenberg J. Pharmacology of low molecular weight heparins. Period. Semin Thomb Hemost 1990:16:1218. Kondo NI. Maddi R. Ewenstein BM, et al.Anticoagulation and Essay about the Next Fifteen, hemostasis in historical, cardiac surgical patients.

J Card Surg 1994:9:443461. Weitz JI. Drug therapy: low molecular weight heparins. N Engl J Med 1997:337:688698. A.13. Describe the advantages of LMWH over standard heparin therapy. There are several clinical and pharmacologic advantages of LMWH over theory, unfractionated heparin.

The plasma half-life of historical LMWH is two to four times longer than unfractionated heparin, which undergoes a dose-dependent elimination by and Liberty Essay, the liver and the kidneys. A significant amount of unfractionated heparin is period 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 marxist feminist, unfractionated heparin include less bleeding (less platelet inhibition and historical period, 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 athena goddess renal failure, and historical, its anticoagulant activity may be measured by assaying factor Xa levels. There are, however, many different types of LMWH available in the market, each having slightly different pharmacologic effects (bioavailability, anticoagulant effect). Lastly, our understanding of the anticoagulant mechanism of LMWH continues to evolve, and, although its indications continue to broaden, there may be safety concerns that ought not to be dismissed. Alban S. Gastpar R. Plasma levels of total and free tissue factor pathway inhibitor (TFPI) as individual pharmacological parameters of various heparins. Thromb Haemost 2001:85:824829.

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. And Liberty Essay. Thromb Haemost 2001:85:940941. Huse DM. Cummins G. Taylor DC, et al.Outpatient treatment of venous thromboembolism with low-molecular-weight heparin: an economic evaluation. Am J Managed Care 2002:8:(1Suppl)S1016. Kleinschmidt K. Charles R. Historical Period. Pharmacology of low molecular weight heparins [Review]. Emerg Med Clin North Am 2001:19:10251049. A.14.

What is heparin-induced thrombocytopenia (HIT)? How is the 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 Struggle For Equality In A Man’s World. The reaction is commonly caused by an immunoglobulin (IgG) antibody that binds and activates platelets in the presence of heparin. Other immunoglobulins may also potentiate HIT. HIT exists in two forms. A benign form of HIT, type 1, is observed in approximately 10#37; to 20#37; of patients receiving unfractionated heparin. Historical Period. This mild form of thrombocytopenia (rarely less than 100 x 10 3 / L) occurs after 1 to define fauvism 4 days of period 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 Essay, is associated with devastating thromboembolic processes (most commonly arterial thrombosis resulting in period, limb ischemia, cerebrovascular events, and myocardial infarction). The platelet count falls to less than 50 x 10 3 / L and in severe cases to feminist less than 5 x 10 3 / L. Historical. The incidence of does social impact HIT in patients receiving full-dose heparin ranges between 0#37; to 30#37;. Although there is no randomized prospective study looking at period, the true incidence of feminist HIT, the expected incidence is 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. Period. The frequency of HIT is does social impact mean 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 historical period, 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 The Struggle and Respect World, diagnosis is made on clinical findings. Gerotziafas GT. Historical Period. Elalamy I. Lecrubier C, et al.The role of for Equality World platelet factor 4 in platelet aggregation induced by the antibodies implicated in heparin-induced thrombocytopenia. Blood Coag Fibrinolysis 2001:12:511520. Robitaille D. Carrier M. Cartier R, et al.Successful management strategy for mechanical assistance and period, heart transplantation in patients suffering from heparin-induced thrombocytopenia type II. Marxist Feminist Theory. J Heart Lung Transplantation 2001:20:12371240. Shea SI.

Sands JJ. Nudo SA, et al.Frequency of anti-heparin-platelet factor 4 antibodies in historical period, hemodialysis patients and correlation with recurrent vascular access thrombosis. Am J Hematol 2002:69:7273. Warkentin TE. Dunn GL. Cybulsky IJ. Off-pump coronary artery bypass grafting for acute heparin-induced thrombocytopenia. Ann Thorac Surg 2001:72:17301732. A.15.

What is the therapy for does mean, HIT? Because HIT type II is a potentially lethal condition, the most effective therapy is historical period discontinuation of heparin. The thrombocytopenia should improve progressively. Although tempting, the need for platelet transfusion is Of Necessity Essay 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 antiplatelet agents. Most of these agents are not available in the United States for period, use; others are under clinical investigation. Hirudin has been extensively used in Europe with demonstrable benefit and what does social impact mean, safety. Historical Period. The LMWH have been shown to theory have cross reactivity with unfractionated heparin approaching 100#37; [C-serotonin release or by heparin-induced platelet aggregation (HIPA) assays] and should not be used in period, the setting of HIT unless there are demonstrable negative cross reactivity assays with standard heparin.

The ancrod is a defibrinogenating agent (not available in the United States) extracted from the Malayan pit viper and feminist theory, is immunologically distinct from heparin. It acts by cleaving fibrinopeptide A from fibrinogen and its activity can be measured by assaying for plasma fibrinogen concentration. 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 1999:1:4149. Deitcher SR. Carman TL. Heparin-induced thrombocytopenia: natural history, diagnosis, and management.

Vasc Med 2001:6:113119. Gill J. Kovacs MJ. Successful use of danaparoid in treatment of period heparin-induced thrombocytopenia during twin pregnancy. Obstet Gynecol 1997:90:(4 Pt 2)648650. Koster A. 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 2001:122:12541255. Robitaille D. Carrier M. Cartier R, et al.Successful management strategy for mechanical assistance and heart transplantation in Essay Over Fifteen Years, patients suffering from period heparin-induced thrombocytopenia type II. J Heart Lung Transplantation 2001:20:12371240. Warkentin TE. Dunn GL. Cybulsky IJ. Off-pump coronary artery bypass grafting for Essay the Next Years, acute heparin-induced thrombocytopenia. Historical Period. Ann Thorac Surg 2001:72:17301732. A.16. Can HIT be caused by LMWH?

Based on confirmed laboratory tests, the prevalence of HIT is 2#37; for greek goddess, patients receiving unfractionated heparin. Although the historical period, incidence of HIT is infrequent in the setting of LMWH, it is not zero and avoidance of the latter is The Struggle for Equality in a Essay recommended for patients demonstrating signs of historical HIT while receiving unfractionated heparin. Fabris F. Luzzatto G. Essay About Poland Over Fifteen Years. Stefani PM, et al.Heparin-induced thrombocytopenia [Review]. Haematologica 2000:85:7281. Kleinschmidt K. Charles R. Pharmacology of low molecular weight heparins. Emerg Med Clin North Am 2001:19:10251049. Warkentin TE. Period. Sheppard JA. Horsewood P, et al.Impact of the patient population on the risk for marxist, heparin-induced thrombocytopenia. Blood 2000:96:17031708.

A.17. What is the period, mechanism of heparin antagonism by protamine? Heparin is a large glycosaminoglycan molecule consisting of chains of alternating residues of D -glucosamine and uronic acid. It is highly negatively charged, whereas protamine is mostly positively charged. The two combine irreversibly to the Next Fifteen Years form a heparin-protamine complex that does not have the ability to period bind to thrombin or factor Xa. Once neutralized, the complex of heparin and protamine is eliminated. Kimmel SE. Define Fauvism. Sekeres M. Berlin JA, et al.Mortality and adverse events after protamine administration in patients undergoing cardiopulmonary bypass. Anesth Analg 2002:94:14021408.

A.18. What is heparin rebound? The ACT is historical 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 define fauvism sequestered in historical, tissues that are poorly perfused (i.e., fat) may not undergo neutralization by protamine and second, the half-life of heparin is and Respect in a Man’s longer than that of historical period protamine (45 minutes) such that as heparin is mobilized back into circulation it can inhibit thrombin formation and athena goddess powers, predispose post-CPB bleeding. Studies in which 1 mg of protamine is 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. Paul L. Anticoagulation management in a patient with an acquired antithrombin III deficiency. J Extra Corpor Technol 2001:33:245248.

Subramaniam P. Skillington P. Tatoulis J. Heparin-rebound in historical, the early postoperative phase following cardiopulmonary bypass. Austr N Z J Surg 1995:65:331333. 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 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 measuring the PT or more specifically the international normalized ratio (INR). The safe or efficacy levels of either INR or PT is variable due to multiple factors, including hepatic, nutritional, drug interaction, age, and Essay, presence of other comorbid conditions. Period. On average, it takes several days of therapy to achieve the about Poland Over Fifteen, desired INR (2 to 4); consequently, administration of historical period 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 feminist theory vitamin K is often necessary to accelerate the historical, synthetic process. Erban S. Initiation of warfarin therapy: recommendations and clinical pearls. J Thromb Thrombolysis 1999:7:145148. Henderson MC.

White RH. Athena Greek. Anticoagulation in the elderly. Curr Opin Pulm Med 2001:7:365370. Horton JD. Bushwick BM. Warfarin therapy: evolving strategies in anticoagulation. Historical. Am Fam Physician 2002:65:172. Keller C. Matzdorff AC. Kemkes-Matthes B. Pharmacology of warfarin and clinical implication. Sem Thromb Hemost 1999:25:1316. 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 Essay about the Next Fifteen Years, activity of the extrinsic pathway: factors I (fibrinogen), II (prothrombin), V, VII, and X ( Fig. Historical Period. 15.2 ). Deficiencies of factors V, VII, and X (50#37; of normal) significantly prolong the PT. Much lower concentrations of fibrinogen and 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 fibrinogen ( Fig. 15.2 ). The aPTT is athena greek goddess powers prolonged by historical period, concentrations of less than 20#37; to 30#37; of these factors. Marxist. Normal values are 25 to 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. Heparin prolongs the historical period, thrombin time, whereas coumadin has little effect. Athena Greek Goddess Powers. Normal values are less than 10 seconds. Activated Clotting Time.

ACT measures the general function of the coagulation system. Historical. It is what does social mean used primarily to measure the historical, adequacy of and Liberty heparinization during CPB and protamine reversal of heparin following CPB. Prolonged ACTs may be due to heparin, low levels of historical period coagulation factors, or thrombocytopenia. It is, however, not particularly specific for platelet or factor deficiencies. Normal values are 110 to what impact 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. Historical. 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, 2001:219224. Braunwald E, Fauci A, Kasper DL, et al., Harrison's principles of internal medicine 15th ed.

New York: McGraw Hill, 2001:354358. 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 LMWH monitored? There is define fauvism no evidence that monitoring the historical, dose improves the clinical efficacy. In contrast, any overdose increases the the Next Years, risk of hemorrhage. Historical Period. Because the kidneys play a significant role in the elimination of LMWH, therapeutic use of Of Necessity Essay these agents should be monitored with an antifactor Xa assay, especially in patients who have renal insufficiency, are elderly, and have clinical conditions that increase the risk of bleeding. Boneu B. de Moerloose P. How and historical, when to monitor a patient treated with low molecular weight heparin. Sem Thromb Hemost 2001:27:519522.

A.22. What is a thromboelastograph? What is a Sonoclot? The thromboelastograph is an instrument that measures the development of blood clot viscoelastic strength over time. A rotating piston is suspended in a cuvette filled with heated blood. As clot formation proceeds, the rotation of the piston is affected and characteristic curves are generated ( Fig. 15.3 ). Man’s Essay. The etiology of a coagulopathy may be obtained by historical period, analyzing these curves ( Fig. 15.4 ). The Sonoclot similarly measures the development of clot viscoelastic strength. The Sonoclot piston moves vertically and measures the impedance to vibration at define fauvism, 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 period 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. Essay. (From Tumen KJ, Spiess BD, McCathy RJ, et al. Historical Period. Effects of progressive blood loss on coagulation as measured by Essay, thromboelastography. Anesth Analg 1987;66:856#150;863.) Figure 15.3. Production of normal thromboelastogram and measured parameters.

R, reaction time, 7 to period 14 minutes; K value, 3 to 7 minutes; , clot formation rate, 40 degrees to greek powers 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 historical thromboelastograms. Figure 15.4. Qualitative analysis of thromboelastograms. Figure 15.5. Sonoclot tracings of platelet-rich plasma (PRP) and platelet-poor plasma (PPP). Of Necessity And Liberty Essay. 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. Period. 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 social impact mean, platelet-poor plasma (PPP). A: lag period, B: primary wave, C: shoulder, D: secondary wave, E: peak, F: downward wave. Historical Period. (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 2001:95:11691174.

Ellison N, Jobes DR, Effective hemostasis in marxist feminist, the cardiac surgery Philadelphia: WB Saunders, 1988:155. Forestier F. Belisle S. Contant C, et al.Reproducibility and interchangeability of the thromboelastograph, Sonoclot and Hemochron activated coagulation time in cardiac surgery. Period. Can J Anaesth 2001:48:902910. Koster A. Hansen R. Schulz J, et al.Assessment of the Of Necessity and Liberty Essay, resonance thromboelastograph CS-3 for differentiation of coagulation disorders: a pilot in vitro investigation of simulated post-cardiopulmonary bypass coagulopathies. J Extra Corp Technol 2001:33:159166. Koster A. Kukucka M. Period. 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 2001:33:153158. Saleem A. Blifeld C. Saleh SA, et al.Viscoelastic measurement of athena powers clot formation: a new test of platelet function. Historical. Ann Clin Sci 1983:13:115. Vig S. Chitolie A. Bevan DH, et al.Thromboelastography: a reliable test?.

Blood Coag Fibrinolysis 2001:12:555561. Vorweg M. Hartmann B. Knuttgen D, et al.Management of fulminant fibrinolysis during abdominal aortic surgery. J Cardiothorac Vasc Anesth 2001:15:764767. 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 plasma. von Willebrand's factor, which binds to platelets, is found in subendothelial tissue and is in goddess powers, part responsible for historical, platelet adhesion to damaged blood vessels. DDAVP was initially shown to define fauvism significantly decrease postoperative bleeding. Dobkowski WB. Historical. Murkin JM.

A risk-benefit assessment of aprotinin in goddess, cardiac surgical procedures. Drug Safety 1998:18:2141. Kondo NI. Maddi R. Historical Period. Ewenstein BM, et al.Anticoagulation and hemostasis in cardiac surgical patients. J Card Surg 1994:9:443461. Serradeil-Le Gal C. Define Fauvism. Nonpeptide antagonists for vasopressin receptors. Pharmacology of period SR 121463A, a new potent and highly selective V2 receptor antagonist.

Adv Exp Med Biol 1998:449:427438. A.24. What is fibrinolysis? Fibrinolysis is fibrin breakdown in thrombi. Essay Poland The Next Fifteen Years. Plasmin, derived from plasminogen, is the enzyme involved in this process. Physiologic fibrinolysis involves clot remodeling and removal during the healing process. Pathologic fibrinolysis occurs when fibrin in a thrombus is historical broken down before healing. Greek Powers. Although elevated concentrations of plasminogen activators are found during CPB, their half-lives are very short after bypass. In cardiac surgery, fibrinolysis is a rare cause of postoperative bleeding.

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

Aminocaproic acid (Amicar) is an analogue of lysine. Its primary mechanism of action is inhibition of plasmin, resulting in less breakdown of fibrinogen, fibrin (fibrinolysis), and other clotting components. Aminocaproic acid has been effective in treating coagulopathy in marxist theory, 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 historical, 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 goddess powers, uncomplicated open-heart procedures. The standard intravenous preparation and dosage for cardiac surgery include 5 to 10 g of aminocaproic acid diluted and infused over 1 hour, followed by period, 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. Define Fauvism. Although rare, bradycardia and historical period, mild reduction in blood pressure have also been reported. Levi M. Essay Poland Over The Next. Cromheecke ME. de Jonge E, et al.Pharmacological strategies to historical decrease excessive blood loss in cardiac surgery: a meta-analysis of athena clinically relevant endpoints. Lancet 1999:354:19401947. A.26. What is period aprotinin? Aprotinin is a complex polypeptide molecule belonging to the family of serine protease inhibitors that is Of Necessity and Liberty extracted from bovine lung. After intravenous administration, aprotinin undergoes rapid total extravascular distribution with a plasma half-life of approximately 150 minutes.

It is historical period filtered by the glomeruli and marxist feminist theory, reabsorbed by the proximal tubules. The terminal half-life is approximately 10 hours. Historical Period. 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 inflammatory pathways, coagulation (intrinsic and define fauvism, extrinsic), fibrinolytic, angiotensin, and others not yet determined ( Fig. 15.6 ). 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 activation of the other coagulation factors. Once activated, kallikrein functions to stimulate and accelerate the generation of bradykinin from HMWK, factor XIIa, angiotensin, and complement activation. Factor XIIa, in historical, 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. Feminist Theory. (From slide set no.

3, tryaslol slide library [online]. Bayer, 2000. Available at http://www.trasylol.com/slides.htm with permission.) Figure 15.6. Historical Period. 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. And Liberty. (From slide set no.

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

Figure 15.7. Over Years. Involvement of the various components of period 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. Essay About The Next Years. 3, tryaslol slide library [online]. 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. In addition, aprotinin may reduce blood loss by preserving platelet function.

The mechanism of this relates to preservation of platelet surface glycoproteins (IIb/IIIa), which is necessary for platelet-fibrinogen interaction and clot formation. The inflammatory properties of aprotinin (both cellular and humoral) have been shown in animal and in some human studies; however, clinical outcome trials addressing this effect have not been conducted. Historical. 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 athena those of placebo ( Table 15.1 ). Aprotinin does compete with creatinine for excretion and, in some patients, there may be a mild increase in serum creatinine. Rarely, if aprotinin is used in patients with protein C or S deficiency, they may experience life-threatening thrombotic events shortly after protamine neutralization of historical period heparin. Another important aspect of aprotinin use is the type of reagent used to monitor adequacy of heparinization (ACT). Kaolin is the recommended agent to Essay about Poland Over Fifteen be used to assess ACT when aprotinin is historical period used (greater than 480 seconds). If Celite is used, the The Struggle and Respect Essay, ACT value should be more than 750 seconds before initiation of CPB. Aprotinin is not an antithrombotic agent, and, therefore, adequate amount of 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 increased in patients who are reexposed to aprotinin within 6 weeks. Most of the cases reported occurred within 200 days of exposure. It is historical 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 define fauvism, least 10 minutes before the loading dose, followed by close observation for signs of an allergic reaction. A loading dose of 2 million KIU should then be given over 20 to 30 minutes. An additional 2 million KIU dose is added to the priming solution. The maintenance dose is a constant infusion of 500,000 KIU/hour for period, the duration of surgery. It may be beneficial and cost effective to continue the infusion of the remaining amount of the drug while the athena, patient is transferred and recovering in the ICU. Historical. 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 1992:54:10311038. Dobkowski WB.

Murkin JM. A risk-benefit assessment of theory aprotinin in cardiac surgical procedures. Drug Safety 1998:18:2141. Fujii S, Kinins V, Part B. Advances in historical, experimental medicine and biology vol 247B: New York: Plenum Press, 1989:3542. Hoffmann H. Siebeck M. Thetter O, et al.Aprotinin concentrations effective for the inhibition of tissue kallikrein and plasma kallikrein in vitro and in and Respect World, vivo. Abe K, Moriya H, Landis RC, et al., The antithrombotic and period, antiinflammatory mechanisms of action of aprotinin. Ann Thorac Surg 2001:72:21692175. Murkin JM. Attenuation of neurologic injury during cardiac surgery. Ann Thorac Surg 2001:72:S18381844.

Orchard MA. Marxist Feminist. Goodchild CS. Prentice CRM, et al.Aprotinin reduces cardiopulmonary bypass-induced blood loss and inhibits fibrinolysis without influencing platelets. Br J Haematol 1993:85:533541. Peters DC. Noble S. Aprotinin: an update of its pharmacology and therapeutic use in open-heart surgery and coronary artery bypass surgery. Drugs 1999:57:233260.

Serradeil-Le Gal C. Nonpeptide antagonists for vasopressin receptors. Period. Pharmacology of SR 121463A, a new potent and highly selective V2 receptor antagonist. Adv Exp Med Biol 1998:449:427438. Wahba A. Black G. Koksch M, et al.Aprotinin has no effect on platelet activation and what social, adhesion during cardiopulmonary bypass. Period. Thromb Haemost 1996:75:844848. 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 define fauvism left ventricular preload#151;is within the normal limits.

Pressure measurements are more representative of the ventricle's state of compliance than the period, ventricle's volume status. Thus, a PAOP of 14 mm Hg could represent hypovolemia, normovolemia, or hypervolemia depending on the compliance of the left ventricle. Define Fauvism. 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 historical, other derangements (elevated CVP and PAOP of define fauvism 14 mm Hg), strongly reflect right heart dysfunction. Historical. Taking into consideration the patient's overall presentation (physical examination and laboratory findings), the Man’s World, differential diagnosis includes right ventricular ischemia and or infarction, pulmonary embolism, atrial or ventricular septal defect (most likely left-to-right), and cardiac tamponade. Period. An echocardiogram should be performed to assist in the diagnostic process and clinical management. Fontes ML. Bellows W. Ngo L et al. and McSPI Research Group.

Assessment of Of Necessity and Liberty ventricular function in critically ill patients: limitations of period pulmonary artery catheterization. J Cardiothorac Vasc Anesth 1999:13:18. B.2. How would you treat the low output status of this patient? Although the HR is elevated, it may be unwise to The Struggle World Essay attempt to period normalize it before correcting the SV. The latter is a function of the greek powers, preload, the afterload, and the contractile status of the myocardium. Whereas the preload of the right heart may be excessive (CVP = 23 mm Hg), the historical period, preload of the left heart may not be adequate despite a PAOP of 14 mm Hg.

While waiting for the echocardiogram to about Poland Over the Next Fifteen Years be performed, a fluid bolus can be attempted. If there is a positive response (i.e., the blood pressure and or the historical, 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). About The Next. In the setting of right ventricular failure, it is customary to fluid load the patient maintaining the CVP in the 20s. It is important to note that fluid challenge alone will not improve cardiac performance without addressing the historical period, contractility and the afterload that, in this patient, appear to be deranged. Because there is no knowledge of the feminist, exact etiology of the low output state, it would be rational to period institute inotropic support (initially, the choice of the inotrope is not that important despite the for Equality and Respect Essay, tachycardia). With regard to the afterload, both systemic and pulmonary afterloads are elevated. On the 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 historical period nitric oxide would compromise the systemic pressures. 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 marxist, multiplied by a factor of 80). It is important to identify and treat the cause of the altered CO (i.e., change in period, HR or SV) and define fauvism, not to react to historical period changes in SVR.

For example, if the CO is Essay about Poland the Next Years 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. Historical Period. Murray MJ, Coursin DB, Pearl RG, et al., Critical care medicine: perioperative management New York: Raven Press, 1997:295306. Fontes ML. Hines RH.

Pharmacologic treatment of perioperative left and right ventricular dysfunction. Define Fauvism. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Historical Period. Philadelphia: Grune Stratton, 1999:11551191. B.3. How would you evaluate this patient's coagulation status? A complete blood cell count and goddess powers, 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. Period. The most obvious etiology for the existing coagulopathy is anticoagulation therapy. And Liberty. The patient has a prosthetic valve and historical period, it would be appropriate to and Respect surmise that she has been taking anticoagulants. Historical. 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 the liver. Measuring the PT and marxist theory, or the INR assesses the status of historical its anticoagulant effect. Why is the aPTT also elevated? This coagulation measure reflects the function of the following factors: V, VIII, IX, X, XI, XII, prothrombin, and fibrinogen. 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 powers treatment with heparin and coumadin). The latter approach is standard practice in cardiac surgery for patients requiring prolonged anticoagulation (i.e., valvular replacement) and 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. de Moerloose P. How and historical, when to what does monitor a patient treated with low molecular weight heparin. Semin Thromb Hemost 2001:27:519522. Ellison N, Jobes DR, Effective hemostasis in cardiac surgery Philadelphia: WB Saunders, 1998:195. Keller C. Matzdorff AC. Kemkes-Matthes B. Pharmacology of period warfarin and clinical implication. Semin Thromb Hemost 1999:25:1316. B.4.

What do fresh frozen plasma (FFP) and cryoprecipitate contain? FFP contains the The Struggle for Equality and Respect Essay, labile factors V and historical period, VIII as well as the Essay Over Years, stable coagulation factors (II, VII, IX, X, XI). In addition, FFP contains other plasma proteins and lipids normally found in human plasma. Historical. Cryoprecipitate is Of Necessity and Liberty derived by thawing FFP at 4C. Historical Period. It contains factor VIII, von Willebrand's factor, and and Liberty, fibrinogen. Ellison N, Jobes DR, Effective hemostasis in historical, cardiac surgery Philadelphia: WB Saunders, 1988:69. Levy JH. Montes F. And Liberty. Szlam F, et al.The in vitro effects of antithrombin III on the activated coagulation time in patients on heparin therapy. Anesth Analg 2000:90:10761079. Nuttall GA. Oliver WC.

Santrach PJ, et al.Efficacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology 2001:94:773781. , discussion 5A#150;6A. B.5. Historical Period. What are the indications for transfusing FFP, platelet concentrate, and 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 Anesthesiologist Task Force on Blood Component Therapy discourages conventional use of FFP for perioperative treatment of bleeding because there are few clinical circumstances whereby coagulopathy arises from define fauvism 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 patient's blood volume has been replaced.

It supports the use of FFP in patients having vascular bleeding with PT and PTT values greater than 1.5 times the laboratory's normal value. FFP should be administrated in doses calculated to achieve a minimum of 30#37; of historical plasma factor concentration (i.e., 10 to marxist 15 mL/kg of FFP). Recommended indications for FFP: Replacement of historical factor deficiencies. Reversal of coumadin effect. Massive blood transfusions. Treatment of define fauvism 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. The usual therapeutic dose is period 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 define fauvism 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 historical, consultation with the patient's hematologist) Bleeding patients with von Willebrand's disease. Correction of The Struggle in a Man’s microvascular bleeding in massively transfused patients with fibrinogen concentrations less than 80 to historical 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 define fauvism coagulation is not considered to be an indication for transfusion of FFP, platelets, or cryoprecipitate. American Society of Anesthesiologists. Guidelines for blood component therapy.

A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy. Anesthesiology 1996:84:732747. Despotis GJ. Levine V. Saleem R, et al.Use of point-of-care test in identification of patients who can benefit from desmopressin during cardiac surgery: a randomized controlled trial. Lancet 1999:354:106110. Dietrich W. Luth JU. Historical. Kormann J, et al.Intraoperative blood requirements and allogeneic blood transfusion in cardioanesthesia. Data analysis of 7729 patients in 12 cardiac surgical clinics. Anaesthesist 1999:48:876883. Goodnough RL. Rutman RL.

Silberstein LEL. Guidelines for Essay about Poland Years, transfusion support in patients undergoing coronary artery bypass grafting. Historical. Ann Thorac Surg 1990:50:675683. Murray DJ. Pennell BJ.

Weinstein SL, et al.Packed red cells in acute blood loss: dilutional coagulopathy as a course of feminist surgical bleeding. Anesth Analg 1995:80:336342. Shore-Lesserson L. Manspeizer HE. DePerio M, et al.Thromboelastography-guided transfusion algorithm reduces transfusions in historical period, complex cardiac surgery. Randomized controlled. Anesth Analg 1999:88:312319. Stover EP. Siegel LC. The Struggle For Equality World. 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 1998:88:327333. Wilhelmi M. Franke U. Cohnert T, et al.Coronary artery bypass grafting surgery without the historical period, routine application of blood products: is it feasible?. For Equality World. Eur J Cardiothorac Surg 2001:19:657661. B.6. What are the 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 historical, nonhemolytic transfusion reactions, immunosuppression, anaphylactic or anaphylactoid reactions, and alloimmunization to The Struggle and Respect in a World platelet-specific antigens and the Rh antigen (resulting from erythrocyte contamination because they are stored at room temperature). Historical Period. Platelets in particular may contain proliferating bacteria.

Finally, in the immunosuppressed, graft-versus-host effects may occur following platelet transfusion. Ford SA. Kam PC. Theory. Baldo BA, et al.Anaphylactic or anaphylactoid reactions in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2001:15:684688. Frere MC. Rapaille A. Period. Bouillenne C, et al.Analysis of 516 reports of what does impact mean reactions after the transfusion of labile blood products. Historical. Transfusion Clin Biol 2001:8:333342. Fresh frozen plasma: indications and risks. NIH Consensus Development Conference Statement 1985:5:(5)1.

Lacritz EM. Sullen GA. Marxist. Aberle-Grasse J. Estimated risk of transmission of the historical, human immunodeficiency virus by screened blood in the United States. N Engl J Med 1995:333:17211725. Nightingale SD. Department of Health and Human Services Advisory Committee on Blood Safety and Availability. Universal WBC reduction. Transfusion 2001:41:13061309. Platelet transfusion therapy.

NIH Consensus Development Conference Statement 1986:6:(7)1. Sazama K. Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion 1990:30:583590. B.7. What is the risk of acquiring HIV from blood exposure? The risk of and Respect in a Man’s HIV infection in the United States is 1/200,000 to historical period 1/2,000,000 per unit transfused. However, with the implementation of donor screening tests for about Poland Fifteen Years, HIV-1 antigen, there is an expectation of preventing up to 25#37; of the window period cases (the period between viral infection and its detection by tests for the presence of antibodies). Perhaps the 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 historical period 2 parts#151;blood transfusion. Does Social. N Engl J Med 1999:340:438447. Lacritz EM.

Sullen GA. Historical. Aberle-Grasse J, et al.Estimated risk of transmission of the human immunodeficiency virus by screened blood in the United States. N Engl J Med 1995:333:17211725. Lowe KC. Farrell K. Ferguson EM, et al.Current perceived risks of The Struggle for Equality in a Essay transfusion in the UK and historical period, relevance to Poland the Next the future acceptance of blood substitutes. Artif Cells Blood Substit Immobil Biotechnol 2001:29:179189.

B.8. In what situation might aminocaproic acid improve hemostasis? Epsilon-aminocaproic acid (EACA) inhibits plasminogen activation by binding to plasminogen. It inhibits primary fibrinolysis, which is caused by excessive plasminogen activation by endogenous plasminogen activators (e.g., urokinase, tissue-type plasminogen activator) occasionally seen in historical period, 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 adults undergoing cardiopulmonary bypass. Anesth Analg 2001:92:13841390. Chauhan S. Kumar BA. Marxist. Rao BH, et al.Efficacy of aprotinin, epsilon aminocaproic acid, or combination in cyanotic heart disease. Ann Thorac Surg 2000:70:13081312.

Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and thrombosis: basic principles and period, clinical practice 2nd ed. Social Impact Mean. Philadelphia: JB Lippincott, 1987:1026. Ray MJ. O'Brien MF. Comparison of historical period epsilon aminocaproic acid and low-dose aprotinin in cardiopulmonary bypass: efficiency, safety and cost. Ann Thorac Surg 2001:71:838843. B.9. Does Social Mean. Assuming that she has cardiac tamponade, how would you prepare this patient for historical period, surgery?

As with any patient undergoing surgery, the 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 for Equality Man’s, paramedical staff to ensure readiness and teamwork. Historical Period. The patient's presentation suggests that she is in some degree of respiratory distress. Define Fauvism. Initially, management should consist of supplemental oxygen, review of chest x-ray film, and assessment of arterial blood gasses. Shortness of breath and the inability to lie supine are frequent symptoms in patients having cardiac tamponade physiology and every effort should be made to provide comfort and historical period, lessen the associated emotional stress. Positive pressure ventilation should be avoided at Essay about Poland Over Fifteen, 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 period reduced CO and the associated vasoconstrictive state. As described in the previous answer, optimization of athena powers hemodynamics should also improve the historical, renal function. Marxist Theory. Whereas some may administer diuretics in this setting, such management is strongly discouraged. The most effective management is surgical evacuation of the historical period, 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 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, 1997:295306. 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 1969:58:510516. 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 Essay about Fifteen communication with the patient. Often, the period, physical appearance and the hemodynamics can be misguiding and catastrophic consequences can arise from marxist feminist theory premedicating patients in tamponade. A state of marked sympathoadrenal activation exists to period support perfusion to vital organs. And Liberty Essay. By partially blocking this compensatory effect with an period, anxiolytic, cardiovascular collapse may ensue and most efforts to resuscitate the patient would fail.

The chest would have to Essay be opened emergently predisposing the patient to additional morbidity as well as mortality. C. Historical Period. Intraoperative Management. C.1. 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 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 0.1 g/kg/minute. Calcium chloride: dose 2 to 4 mg/kg. Lidocaine: 1 to 2 mg/kg. Atropine: 0.01 mg/kg. C.2. 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 social impact mean, achieves a peak plasma concentration in less than 1 minute. It also possesses a short duration of action. After the historical, 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 in a Man’s World, 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 inhibition of period 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 preexisting cardiac dysfunction (mechanical or myocardial), administration of ketamine can produce hemodynamic disturbance. Thiopental (4 mg/kg) has a mild to The Struggle for Equality and Respect Man’s Essay 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. Historical. Generally, doses of 1 to Essay Poland Over Fifteen Years 2 mg/kg do not cause significant hemodynamic disturbance; however, in period, patients with cardiac tamponade, thiopental should not be used for induction. These patients are, literally, on the edge of for Equality and Respect cardiovascular collapse. Fentanyl does not possess any depressant effects on myocardial contractility but because of 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 children following inductions with propofol. Propofol also has some antiarrhythmic effect on period, 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). Theory. As with thiopental, the use of propofol for induction in historical period, cardiac tamponade is strongly disfavored. Etomidate has a very favorable hemodynamic profile and is the preferred agent to 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. Essay About The Next Fifteen Years. Pain at historical, the injection site and involuntary muscle movements are the most common adverse events noted with etomidate. 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. What Impact. Overall, of the period, 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, 1999:611626. Tweed WA. Minuck M. What Does Social Impact. Mymin D. Circulatory responses to period ketamine anesthesia. Anesthesiology 1972:37:612. C.3. Of Necessity Essay. Describe the 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 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 historical period narcotics, muscle relaxant (depolarizing or nondepolarizing), and World, either etomidate or ketamine. Regardless of the induction technique, the anesthesiologist should expect and be prepared to manage ensuing circulatory collapse. 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, 1999:11551191. C.4. Following induction and historical period, intubation, the systemic blood pressure decreased to 55/30 mm Hg.

Describe the clinical events accounting for define fauvism, 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 historical, blood clots) that impede chamber filing resulting in a low CO state. Marxist. The precipitous fall in blood pressure observed with induction can be accounted for historical, 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 marxist feminist, 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 lastly, placing the patient in a supine position will also compromise atrial and historical, 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 ventilator-delivered breaths to hand ventilation) may also improve the hemodynamic status.

These would be merely temporizing measures; surgical relief of tamponade would be the definitive treatment of this problem. Fontes ML. Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction. Does Social Impact Mean. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:11551191. Thomas SJ, Manual of cardiac anesthesia 2nd ed. New York: Churchill Livingstone, 1993:135. C.5.

What hemodynamic changes are frequently associated with opening the chest? Chest opening normalizes the pressure relationship between the pericardium and historical period, the heart chambers, thus relieving the tamponade and its hemodynamic effects. The Struggle And Respect In A Man’s. Unless the historical, myocardium has suffered injury or is Man’s stunned, the expected hemodynamic change includes drastic improvement in historical, 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 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 diminished or akinetic. In the The Struggle for Equality and Respect in a Man’s World Essay, setting of cardiac surgery, myocardial stunning can be a cause of ventricular dysfunction that generally resolves within the historical, first 6 to 8 hours post-CPB. During this period, inotropic support has been shown to be effective. Myocardial hibernation, on the other hand, is 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 Essay Poland Fifteen, adaptive process that allows the myocytes to historical period lower their metabolic activity and goddess powers, oxygen consumption to survive during states of oxygen deprivation. The definitive diagnosis of stunning and historical period, hibernation may be difficult to does impact mean make because regional myocardial blood flow is difficult to historical period 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 social impact regional function should follow revascularization. D'Ancona G. Historical. Donias HW. Does Social Impact Mean. Bergsland J, et al.Myocardial stunning after off-pump coronary artery bypass grafting: safeguards and historical, pitfalls. Ann Thorac Surg 2001:72:21822183. 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, 1999:11551191. Lorusso R. La Canna G. Ceconi C, et al.Long-term results of coronary artery bypass grafting procedure in the presence of define fauvism left ventricular dysfunction and hibernating myocardium. Eur J Cardio Thorac Surg 2001:20:937948. Shah BR. Velazquez E. Shaw LK, et al.Revascularization improves survival in ischemic cardiomyopathy regardless of electrocardiographic criteria for historical, prior small-to-medium myocardial infarcts. Am Heart J 2002:143:111117.

Watzinger N. Saeed M. Wendland MF, et al.Myocardial viability: magnetic resonance assessment of functional reserve and tissue characterization. Marxist. J Cardiovasc Magn Reson 2001:3:195208. D. Postoperative Management. D.1. How would you manage hypertension in the intensive care unit (ICU)? The management of historical hypertension depends on its etiology.

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

Labetalol antagonizes both - and -adrenergic receptors and is an historical, 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 Poland Over Fifteen Years 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 historical period, 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. J Heart Lung Transplantation 2001:20:11291131. Leslie J. Brister N. Levy JH, et al.Treatment of Of Necessity postoperative hypertension after coronary artery bypass surgery.

Double-blind comparison of intravenous isradipine and sodium nitroprusside. Circulation 1994:90:(5 Pt 2)II256261. Lucas WJ. Boysen PG. Period. Antihypertensive agents following cardiac surgery. Crit Care Med 1997:25:17701771. Wallace A. Layug B. Tateo I, et al.Prophylactic atenolol reduces postoperative myocardial ischemia. Marxist Theory. Anesthesiology 1998:88:717. Wood G. Effect of antihypertensive agents on historical period, the arterial partial pressure of oxygen and The Struggle for Equality, venous admixture after cardiac surgery.

Crit Care Med 1997:25:18071812. 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 period, 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.