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College board ap world history essay questions

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Security Guard Services in Bangalore. . Jerry Sheehan, Ms. Catalina Martinez and Ms. Sandrine Kergroach of the OECD Secretariat. The report showed that the importance of college history questions service to the global economy has grown gradually whiles the importance of goods has declined. Essay Intorduction? The service has taken up to 70% of the aggregate production and employment in the Organization for Economic Cooperation and Development, (OECD). The product and service are continuing increase in board history essay cost but on news coursework drink the other hand, customer service is continuing decrease. The delivery of great quality service is one of the ap world essay, most important task and very hard to achieve by the most organization. This is middle evaluative essays because of service is very hard to evaluate. In most of the cases, the quality of service is judged by the customer and not the organization. This situation is very important because it forces service marketers to look at their service quality from the college board ap world, customers’ viewpoint.

For example, a bank may view service quality like having knowledgeable and responsibility employees. On the other hand, from the customers’ perspective of this bank may be more concerned with waiting time while making a payment, ATM access security and statement accuracy. Therefore, it is important for a service oriented industry to determine what the expectation from the customer is and then come out with a service way that can fulfill the customers’ need. Words: 479 - Pages: 2. . -mouth communication; price sensitivity; and complaining behaviour. Further analysis yields an intricate pattern of service quality-service loyalty relationships at intorduction the level of the individual dimensions with notable differences across industries. Full Text (9407 words) Copyright MCB UP Limited (MCB) 1999 Josee Bloemer: Faculty of Applied Economics, Limburg University Centre, Diepenbeek, Belgium, and Ko de Ruyter: Maastricht University, Maastricht, The Netherlands Martin Wetzels: Maastricht University, Maastricht, The Netherlands Introduction The literature on ap world history services marketing has advanced to a level of considerable sophistication and researchers are ready to take on the fundamental questions concerning an in-depth understanding of the concept of service quality (Gronroos, 1993; Patterson and Johnson, 1993; Anderson and Fornell, 1994; Rust and Oliver, 1994; Taylor and Baker, 1994). Intorduction? In defining the key constructs in the discipline, conceptual advances and college nuances have been achieved, though differences of opinion remain.

For instance, concerning the role of expectations in intorduction the formation of evaluative judgements and the sequential order of the constructs of essay service satisfaction and service quality (Cronin and Taylor, 1992; Zeithaml et al., 1996). One area that has remained relatively underdeveloped, however, is the relationship between evaluations of service quality and loyalty of service customers (Gremler and homework help Brown, 1996), despite the fact that loyalty is essential for. Words: 10084 - Pages: 41. . Castillo, Lovely Mae. Gorospe, Michelle Day C. . SVC MKT/ MM09306 Report # 10: Chapter 11- Physical Evidence and the Servicescape Chapter's Objectives are to: 1. Explain the profound Impact of physical evidence, particularly the servicescape, on customer perceptions and ap world essay questions expereinces. 2. Illustrate differences in types of middle school evaluative servicescapes, the roles played by history essay questions the servicescape, and the implications for strategy. 3. Explain why the servicescape affects customer and employee behavior, using a framework based in marketing, organizational behavior, and environmental psychology, 4. Middle Evaluative Essays? Present elements of an board ap world history essay questions effective physical evidence strategy. Introduction Physical evidence is important for middle evaluative, communicating service quality attributes, setting customer expectations, and essay questions creating the service experience.

It is important for communicating credence services. Ex. Auto repair, health care, hospitals, hotels, theme parks (which are dominated by experience attributes.) Physical evidence is the environment in which the essay intorduction, service is delivered and in which the firm and the customer interact, and any tangible commodities that facilitate performance or communication of the service. -The first part of it means the actual facility in which the service is performed, delivered, and consumed. Physical facility is also known as servicescape. Board Essay? Physical Evidence What is Physical Evidence? Customers rely on tangible cues, or physical evidence, to evaluate the. Words: 2241 - Pages: 9. . today’s National Guard contribute to improving guardsmen’s everyday life and personal growth in u.s history essay questions today’s society. In early colonial times, a need for protection and security for college board history essay questions, the town and families was sought. The country was new and enemies were numerous.

The National Guards roots date back to 1636 when colonial Militia, made up of ordinary citizen, would put down their plows and doesn't pick up their weapons to protect families and towns from hostile attack (National Guard, 2012). This is where the term citizen solider comes from. Every day people either it be store owners, inn keepers, or a local farmer in the field, would be ready to pick up their weapons at a moment’s notice would defend and protect their community. It was this earliest commitment and self-sacrifice that help turn the National Guard into what it is today. Even in the earliest beginnings of this nation, the National Guard helped in development and safety of it community whenever possible. This dedication and personal sacrifice has been the driving force in the citizen solider since the beginning. Serving the community has been the history essay, goal of the National Guard.

Providing relief efforts both in the local areas and overseas, the ingilizce essay yazma, guard shows itself to be a key factor in the development of history today’s society. Even now as the National Guard reaches its 365th birthday, they keep striving to improve itself and its soldiers. Through training and proper leadership, one’s own ability can grow to new levels. It is only limited. Words: 1592 - Pages: 7. . James Cameron Mr. Randolph Engl. 210 9/21/12 Tainted History in Natasha Tretheway’s Native Guard Passion, precision, and technique are all synonyms used to describe Natasha Tretheway’s Native Guard that take the evaluative, reader through the heart of the south and the heart of the family. This essay will examine the contradictions of (African) American life, especially concerning themes of history and memory. “Southern History”, “Incident”, and “South” will demonstrate these contradictions of (African) American history and ap world history questions memory. Serving as a scribe, Tretheway writes these poems for those people history has muted and closed the veil on. Southern History, Incident, and South; poems from school evaluative essays, section two of her book, depict racism during slavery and the Civil War, which is a part of forgotten history in the eyes of “Americans.” These historic experiences have not been given the proper examination, discussion, or acknowledgement. Tretheway refuses to allow African American history to remain as footnotes and brings out the history essay, real “American” history in ingilizce yazma her collection of poems.

Tretheway’s personal experience growing up as a mulatto in the South is seen in her poem “Southern History”. This poem shows that even after more than a hundred years after the Civil War, history is still tainted. History Questions? History is intorduction imperfect and at times intentionally false as textbooks in this time period were used to misinform students; keeping them bound and restricted from the board history questions, real history of America. As. Words: 1280 - Pages: 6. . Homework? S Service Talk June 21st 2009 “Bear ye one another’s Burdens and fulfill the board ap world, law of Christ.” as Stated in Galatians 6.2 Service as defined by dictionary.com is: an act of tuition research paper helpful activity; help; aid As members of the Church of Jesus Christ we have been given a commandment by our Lord and board questions Savior to, as the sacrament prayer states “Take upon school evaluative, us the name of Jesus Christ” on way to do that is by serving others. DC 20:18-19 (read) We see here that we, as man and woman, from creation have been commanded to serve the Lord. Mosiah 2:17 King Benjamin stated in when we serve others we are in the service of God. Christ, speaking to his Disciples in -Mat 16:24-26 taught… Deny your selfish interests and serve others **President Thomas S. Monson taught Brigham Young University students that their student days should include “the matter of college board ap world spiritual preparation,” including service to others. “An attitude of love characterized the ingilizce yazma, mission of the college essay questions, Master,” “He gave sight to the blind, legs to the lame, and life to the dead. Perhaps when we [face] our Maker, we will not be asked, ‘How many positions did you hold?’ but rather, ‘How many people did you help?’ In reality,” “you can never love the Lord until you serve Him by serving His people.” As we put others before ourselves we began to college tuition research, develop the Attributes of Christ and transform ourselves into true active Christians and board history questions followers of the Master.

Church itself fulfills the commandment of. Words: 372 - Pages: 2. . ----------------------- CODE OF CONDUCT 1. CODE OF CONDUCT: Rules of good conduct must take place and be honored by doesn't the security officers of a shift if it is to function effectively. All security officers will adhere to certain rules in order to enhance a climate of harmony and teamwork. Personal background qualities that need to exist in order to essay questions, accomplish this are: a. School? Self discipline b. Self respect c. Loyalty d. Professionalism e. Team spirit f. College Board? Cooperation g. Good humor h. Pride 2. PERSONAL CONDUCT: Security officers are to conduct themselves in a professional manner while on essay questions duty. The following is board essay questions a list of things that employees should not do: a. Use bad language b. Make abusive or demeaning remarks about race, religion and must make an intorduction immediate apology if offence is taken by any listening party c. Make physical contact with any other employee which may cause offence 3. COMPLIANCE WITH THE LAW: Exercise compliance with all laws of Iraq. Immediate dismissal and appropriate prosecution will happen to all who do not. Board Ap World History? 4. MEDIA: Security guards are not to make any statements to the media. Any approach from the media must immediately be reported to a supervisor. 5. BRIBES: You are not allowed to college paper, accept or offer commissions or benefits from or to any supplier or third party. Ap World History Essay? 6. Middle School Essays? DISCIPLINE: Security officers are required to conform to high disciplinary standards and to. Words: 511 - Pages: 3. . Session | Date | Time | 1. | 03 October 2013 (Thu) | 10am- 1pm | 2. College Board Essay? | 04 October 2013 (Fri) | 10am- 1pm | 3. | 09 October 2013 (Wed) | 10am- 1pm | * Each team can decide how they wish to homework doesn't help, organize the presentation in terms their presentation outline and the audio-visual aids that are used.

All team members must present and participate in the QA. College History Essay Questions? Teams are encouraged to be creative in their presentations. * Group presentations require formal dressing, power-point and professional standard presentation. (See requirements below) * All students must be in intorduction formal attire: Business Shirt/Tie and Shoes (no sandals, sneakers or boots) for male students and Formal Blouse/Skirts/ Pants or dresses (no flat sandals/thongs, sports shoes) for female students. * Your PPT Slides: Should be about 25 to 30 slides per board ap world history essay group; * Title page: Topic / Group members’ names/Date * Introduction / Opening * Body / Main points * Summary * Conclusion and Recommendation(s) if any Assessment 2: Individual Written Assignment- 30% Delivery Quality Tourism Services (Learning outcomes from Chapter 2: Structure of the Travel Tourism Industry, Chapter 3: Travel Intermediaries and Chapter 8: Delivering Quality Tourism Services) * Answer ALL the following questions in an essay format. * Submit a written report of 1800- 2 000 words. Yazma Teknikleri? Question 1: Choose a local service provider (a hotel service. Words: 911 - Pages: 4. . The five characteristics for human service professionals are: Self-awareness, Ability to communicate, Empathy, Responsibility/commitment, and Flexibility. Self-awareness is the ap world, deep understanding of one's own self, this includes comprehending self-knowledge about beliefs, attitudes, values, stereotypes, biases, cultural and college research paper gender differences, and behaviors.

Self-awareness is beneficial in diminishing preconceptions and opinions, allowing one to modify or change their self toward a client's perspective. Empathy is the ability to see or feel what the client has experienced. Similar to self-awareness, empathy furthers the board questions, progression of essay questions understanding oneself and enables a provider to college board ap world, put their feet into questions, the client's shoes. Providers who have experienced as well as relate to the client's situation have an college board ap world essay questions easier time expressing empathy. Responsibility/Commitment are ideal promises to a client. The provider shall support the client in whichever possible way is needed through responsibility and tuition research paper will offer the highest quality of board ap world history essay service through commitment.

A provider displays a strong presence of professionalism and acts to the best of essay intorduction their abilities. College History Questions? They will adhere to a code of ethic or conduct and will remain honest with their client throughout their service. Yazma Teknikleri? Flexibility provides versatility to college board ap world history, a provider’s service. They may need to change, abandon, or revise plans if the homework doesn't, program suddenly becomes difficult or unusual. Flexibility allows a provider to learn new. Words: 312 - Pages: 2. . The Biophysical Foundations of questions Indian Cities Imagining Bangalore What do we not see on this map (or any other map)? Bangalore (like any other city) is school a living organism • This is from my nephew’s 1st grade science book – Living things breathe – Living things need food – Living things excrete – Living things grow (usually only for a part of their lives) – Living things die The Problem • We understand a lot about Bangalore’s circulatory system – The flow of rupee and (especially) dollar through the city. Board Ap World History? – The circulatory system is what economics and business is interested in. • However, what about the digestive system? – What does Bangalore consume? – What does Bangalore excrete?

What are these metabolic flows? • • • • Food (Organic waste and sewerage) Energy (air pollution) Water (BWSSB) Metals and plastic (recyclable waste) • Metabolic flows share a two-way relationship with the circulatory system Three ways to characterise metabolism • Social Justice – How are the flows distributed between different people in the city? • Ecological sustainability – What volume of tuition research paper flow is sustainable? • Economic Efficiency – How are the flows distributed between different activities in the city? • Bangalore as a living organism is college ap world history sick and unhealthy on all three counts – The political economy of distribution is fraught with all sorts of inequity – Most metabolic flows are not physically sustainable – The flows are often not economically. Words: 3575 - Pages: 15. . sequence to evaluative essays, archive 1420 Current log sequence 1420 SQL shutdown immediate; Database closed. Database dismounted. ORACLE instance shut down. College Ap World? SQL startup mount ORACLE instance started. Total System Global Area 419430400 bytes Fixed Size 2021280 bytes Variable Size 117442656 bytes Database Buffers 293601280 bytes Redo Buffers 6365184 bytes Database mounted. SQL alter database archivelog ; Database altered. SQL alter database force logging; Database altered. SQL alter database open; Database altered.

SQL SQL SQL select log_mode, force_logging from tuition research, v$database; LOG_MODE FOR ———— — ARCHIVELOG YES Step 4 : Create a password file Due to new log transport security and authentification features, it is board essay madatory that every database in a Dataguard configuration utilize a password file. Doesn't? In addition, the password for the sys user must be identical on every system for log transport services to function, If the primary DB does not currently have a password file, create one with the following steps : [[email protected] ]$ orapwd file=/u00/oracle/product/10.2.0/db_1/dbs/orapwarcdb01 password=orawiss entries=5 force=y Once the board ap world history essay questions, password file is created, you must set the following parameter in the spfile while the database is in nomount state : alter system set remote_login_passwordfile=exclusive scope=spfile; Tansfer the password file to questions, the standby DB : [[email protected] dbf]$ cd /u01/app/oracle/oracle/product/10.2.0/X06/oracle/dbs/ [[email protected] dbs]$. Words: 2998 - Pages: 12. . Egstrand 1 Alyssa Egstrand Professor Sewell ENG: The Literary Experience 1331 28 September 2011 Investigating the Impact of History on Modern Society within Natasha Trethewey’s Native Guard Rooted in the shadows of history, Native Guard by Natasha Trethewey intertwines personal and historical accounts to scrutinize the impact of the past on the present. Trethewey’s Native Guard is divided into three sections, which chronicle her mother’s life and death, the college ap world history, erased history of the homework doesn't, Louisiana Native Guard, and college board ap world Trethewey’s childhood in Mississippi.

These different stories amalgamate, and open a dialogue about the tuition paper, impact of history on today’s world. Throughout Native Guard Trethewey infuses emotion into these untold stories by ap world essay including personal reflections regarding each event that transpired. The third and u.s history questions final section of the book though, is the most important component to the overall work; it details Trethewey’s connections to her memories of growing up in Mississippi. This section synthesizes each unique focus of Native Guard, and consequentially forms one united theme: the importance of remembering of the past—the recorded, the biased, and the erased—due to its impact on the future. The final poem, “South” of Natasha Trethewey’s Native Guard, specifically highlights this theme by utilizing extended metaphors, integrating of memories with historical details, and college ap world questions infusing irony to essay teknikleri, illustrate racial conflicts. Trethewey begins the poem “South” with an extended metaphor. Words: 1552 - Pages: 7. . E-Guard: Customer Acquisition Plan Target Segmentation and Fraud Risk Analysis Considering the past cases of insider trading viz. Rajaratnam case (Galleon Group), Rajat Gupta case (Goldman Sachs) and accounting fraud like that of Satyam Computer Services or Enron Group, the target sectors to be aimed are Financial (hedge fund, mutual fund, trading, investment banking firms, etc.) and ap world history questions big corporate houses like Energy and science in the news coursework driving Steel. * Market study of amount of Data handled in respective sectors and college board ap world their Fraud Risk Analysis * Information assimilation of similar competitive products and their customers * Segmentation on the basis of scale, new or old, if already using similar products, price vs quality sensitivity parameters. Cost of Acquisition vs Customer Retention It is one most important Business Metric which would help in deciding how much to be spent on the respective targets in the acquisition process. College? * The various heads to be included Marketing, Meetings, Infrastructural, Promotional and college Miscellaneous costs * Customer Life Time Value (LTV) to be calculated using Subscription period and Pricing * Marketing Budget to be prepared and if needed share of Retention budgets of the Retail Educational Suits to middle school evaluative essays, be used Customer Engagement The communication is to be done in the following sequential manner: * Key Opinion Leaders (KOL), Stakeholders in each target company to be recognized and approached * Frequency and. Words: 435 - Pages: 2. . in recent years. The Revealed Comparative Advantage (RCA) analysis, at both the aggregated and disaggregated levels, shows that while Korea has been specialising in a few, high value-added manufacturing products, India’s exports have been more diversified.

The analysis also indicates that both the college history essay, countries have comparative advantages in different products in the same industry, revealing the opportunity for intra-industry trade (IIT). Moreover, the increasing trade complementarity index (TCI) shows that Indian and Korean trade gradually has become more compatible over time, indicating that any agreement between the two countries is u.s history essay questions likely to enhance trade flows. Ap World Essay Questions? The trade intensities between the two countries reveal that Korea is doing much better and there is scope for ingilizce yazma teknikleri, India to improve its export intensity with Korea. Board Ap World History? The study also suggests the areas where there is essay teknikleri huge scope for increased investment and technological collaboration between the two countries. Further, there is college board history huge potential for u.s history questions, trade in services in areas such as information technology, science and technology, pharmaceutical industry, broadcasting, tourism, healthcare and human resource development. Removal of tariff and non-tariff barriers, especially sector specific barriers, will give a major boost to history, bilateral trade and investment relations. U.s History Essay Questions? India and South Korea are the college essay, third and fourth largest economies in intorduction Asia.

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Engineering in a Nuclear Power Plant. Huge clouds of steam rise above the heat exchangers of the power plant. The reactor building is to the right; the square shaped building. From August 2003 to college history essay January 2003 I worked as a Co-Op Student for Systems Engineering at Entergy Nuclear?s Vermont Yankee Power Station. During those brief 5 months I was called upon to tuition paper perform various tasks, ranging from board history essay, in-plant ultrasonic pipe wall thickness measurements to middle school computer programming and preparing presentations. This report outlines some of the experiences I had in that job, how they related to, and furthered, my education and essay questions, how what I learned there will help me in the future as a professional Engineer. Working for Vermont Yankee was my first job ever and it has taught me more about what Engineering is all about then I could expect to learn from 4 years of evaluative essays schooling. Vermont Yankee Nuclear Power Plant, now a division of Entergy Nuclear (thus the college board ap world history essay new name ENVY: Entergy Nuclear Vermont Yankee), is a Boiling Water nuclear Reactor (BWR).

BWRs work by harnessing the energy contained in atoms of Uranium 235, present in fuel rod bundles inside the nuclear reactor at a concentration of 3%. U235 is an unstable atom, and as such is prone to splitting apart (fissioning), releasing neutrons, which will go on to strike more uranium atoms, which will split releasing more neutrons, at a nearly exponential rate, producing enormous amounts of heat and radiation. By controlling the position of neutron absorbing rods inside the fuel assembly the neutron flux can be controlled, and thus the power of the reactor can be regulated (1)(2). Once the energy of the fuel is released, it is used to boil water inside the ingilizce nuclear reactor to college board ap world essay questions produce steam, which is then dried and used to tuition research paper turn a series of 3 turbines, which run a generator, producing electrical power for the grid. The steam is then condensed on river-water-cooled heat exchangers and returned to the nuclear reactor as water in a closed loop operation (4). Vermont Yankee utilizes a GE reactor and GE turbines, has been in operation since 1972 and board history questions, produces a maximum dependable output of 535 Megawatts; enough to supply 80% of the state of Vermont with clean power (3). Although they are very simple conceptually, nuclear reactors in practice employ a myriad of subsystems which must all work flawlessly, in unison, for school essays, a period of at least 18 months, when the board ap world questions reactor is shut down for ingilizce, refueling and most systems are serviced.

In order to accomplish the large task of monitoring and troubleshooting all the systems in a nuclear power station a specialized department exists, termed ?Systems Engineering?, where various engineers are assigned different sub systems of the power plant and are responsible for overseeing those systems and ensuring their continuing performance. Tasks performed by the Systems Engineering department include performing tests, predicting component life spans and scheduling maintenance, repairs and upgrades. I was a Co-Op student for the Systems Engineering department. Larry Lukens, my mentor, is history questions a Nuclear Engineer in charge of pump and valve in service testing (IST) for Systems Engineering. Aside from working at IST, I also worked for various other engineers under various other systems, such as Service Water (SW), Heating Ventilation and essay, Air Conditioning (HVAC), Service Air (SA), 115kV line, Offgas (OG) and essay, others. This gave me an appreciation for the complexity of the school plant, the large number of systems and allowed me to see how different tasks were performed in different systems by engineers and technicians of various disciplines. As a Co-Op my main job objective was to assist system engineers with their jobs. My fixed assignments were few, which meant that I had the freedom to work for college board ap world history, different systems and thus learn much more than I would have from spending all 5 months assisting with only one sub system. Essay. In order for engineers to college board essay monitor system performance in a nuclear power plant a lot of middle data must be gathered from tests and this data has to be presented in an easy to read, comprehensible manner. Data collection at ENVY is done through periodic tests performed by maintenance personnel, direct readings of instruments inside the plant, or by a computerized monitoring system termed ?ERFIS?, which gathers essential data and college board history essay, records it.

All collected data, regardless of source, ends up in the plant?s network, under various access levels. System Engineers have access to all system engineering data. Once the needed data is found it is placed in an Excel spreadsheet and then graphed in charts, usually in the form of help Presented Data Vs. Predicted Values, or Presented Data Vs. Maximum and Minimum acceptable Values. During the period I worked at college board history essay questions VY I was responsible for collecting data for various systems from different sources and presenting it in various forms. This data collection was periodic and scheduled at times, but there were occasions in which I also had to gather data out of schedule in order to assist in finding a particular component problem.

These assignments were always very exciting because I found myself working alongside engineers, not as a student, but as part of the engineering team, facing the essay intorduction same challenge of locating a problem, and using the same tools they used in order to do so. Board Questions. I found the extensive Excel training provided during ENG 1101 and essay, Math Classes crucial for college board history essay, those tasks. Chemistry, Physics and Materials Science were also very helpful in allowing me to understand the functioning of the various systems in essay the plant and college board history questions, thus be able to make more educated decisions as to how to college research look at the data and present it. One example of a time critical assignment I had was when unidentified leakage inside the nuclear reactor?s drywell suddenly began to increase from 0.1gpm to ap world questions 0.2gpm overnight. We had experienced two leakage events in the months prior to that; one due to a valve packing failure, and the second one due to the failure of one of the stages of science in the a water recirculation pump seal. These failures forced an unscheduled plant shutdown, which prompted engineers to work overtime to locate and repair the problems as quickly as possible. College Board Essay. During this time I was given the unique opportunity to escort a pump seal specialist who came on site to assist with the repairs; a job which, on top of my regular work hours, resulted in me working a 72 hour workweek and being given entrance to essay the reactor drywell. When this 3 rd increase in leakage began everyone was racing around the clock to identify and locate the cause of the leakage. I worked closely with the system engineer responsible for the drywell, trending temperature data for the past months, days and hours at every available point of the drywell and presenting it with various levels of college board essay questions resolution, and at essay intorduction various elevations and orientations; this allowed us to find one particular area of the drywell where temperatures were rising faster than their surroundings.

Looking at the drywell plans I printed out we were able to board ap world find a valve located in that area and postulate that the leakage was due to a valve packing failure, as evidenced by a temperature rise around that valve. Once the leak had been identified measures were taken to correct it (appendix 1; memo concerning valve leakage and valve leakage over time graph, at the end of this essay). Aside from large amounts of essay data collection and trending, I was also responsible for re-making the college ap world essay questions entire Fire Protection webpage of the plant, and merging it with the Safety webpage. My skills in web design -self thought as I designed and worked on my own personal web page- allowed me to put together a complete page in 2 days which listed all the college tuition safety and fire protection topics, personnel, equipment and indexed relevant documents for both those pages. My supervisor said this is one of the best pages on site! Another computer task I performed was the creation of an college board ap world questions, Access database where system engineers were given a form to essay yazma enter all relevant data for board, their respective systems. This database gathered system health report data and essay, presented it in various forms, graphic and ap world history essay questions, textual. I worked closely with my mentor, other co-ops, and various engineers to put together the database and debug it. Working on a program for the department proved to be both a technological challenge ?as I had to learn how to use the computer program Microsoft Access at the same time that I was using it to create a database- and a challenge in communication skills, since in order to create a useful database I had to know exactly what system engineers expected from essay, it, and how it should present the data contained in it.

I got to interact with other co-ops and various system engineers who helped me answering my questions and explaining to me what was required from the database and suggesting ways in which I could accomplish it. Hands-on experiences at the power plant were always my favorite, and by making myself available for all sorts of in-plant work I got to do a lot of it! From photographing plant equipment for analysis. to escorting visitors into radiation areas, to switchyard work: I learned about ultrasonic transducers and ultrasonic wall thickness measurements and got to measure pipe wall thicknesses in college history the plant?s service water systems. I was also trained for confined space work (on top of radiation worker training and all other training required for unescorted access to the insides of the plant) and got to go down into the service water intake structure with my mentor to take pump flow readings for middle evaluative essays, pump performance trending (another one of the many trends I updated as part of my job). This trend allows us to see when a pump?s performance is deteriorating (due to decreasing flow) and schedule preventive maintenance accordingly. In short, there was never a dull moment during the 5 months I worked at college ap world questions ENVY. I was constantly motivated and excited to go to work, always willing to stay extra hours, fascinated by the fact that in a system as large and complex as a nuclear reactor, there is *always* something happening, something being measured, service being performed, data being collected. This was my first job and science coursework drink driving, if given the opportunity I would love for it to become my permanent job.

I firmly believe that this work experience has educated me in various areas of college ap world engineering and essay yazma, will make me a better worker in the future; whatever field I choose to work on. I feel privileged to college ap world history essay have been given such a unique opportunity by MTU?s Co-Operative education program and by Vermont Yankee. 1- How have your MTU co-op assignments adequately prepared you to essay enter the industry you plan to pursue upon graduation? 2- How can the MTU co-op program be improved to history essay meet the demands of industry and yazma, our students? I believe the Co-Op program is excellent as it is. I just wish that there were more opportunities for college essay questions, students to work on a Co-Op. I believe everyone should be given this opportunity, and if possible it should even be required that all students do at least one semester of co-op. 3- Describe how cooperative education has enhanced your understanding of professional and ethical responsibility. At Vermont Yankee Engineering ethics are paramount.

All workers are required to read and u.s history essay, understand the Engineering code of ap world history essay ethics and to sign a yearly conflict of interests agreement. College Tuition Research Paper. The level of seriousness and ap world history questions, professionalism shown by all at essay intorduction ENVY demonstrated to me just how important engineering ethics are, especially in a field such as nuclear power. 4- How has cooperative education influenced your ability to ap world essay identify, formulate, and solve problems? I was fascinated by how seemingly very difficult problems can be simplified into very basic solutions. When a leakage was found in the drywell it could have come from tuition research, thousands of different places, but breaking it down into levels and monitoring temperature rise simplified the location of the problem into just a couple of charts and some hours of engineering analysis. 5- Describe how your co-op experience exposed you to the use of techniques, skills, and modern tools necessary for your career. Which of these items were you exposed to college board at MTU, and which were you only homework doesn't, exposed to through your co-op experiences? A lot of the tools and skills used at board history ENVY are thought in in the MTU courses, such as graphing, thermodynamics, CAD design and college ap world history essay questions, others. I was already very familiar with Excel from my ENG 1101 course and this proved crucial in the execution of school my job. History Essay. On the doesn't other hand, what I learned about board essay ultrasonic transducers and their uses for essay, wall thickness and flow rate measurements I could not have gotten from a class. 6- How has your co-op experience helped you to develop social, team building, and written and oral communication skills?

Since my job was to assist various engineers with their jobs I was constantly working with various individuals; this allowed me to improve on my communication skills, work in teams, prepare presentations and also make friends with interesting and college board ap world history essay, intelligent individuals. 7- Would you recommend cooperative education to a sophomore student? Why or why not? Yes! I believe that in the competitive job market of today one can never have too much work experience, and the best way to gain experience is to start as soon as possible. (1) General Physics Corporation, Nuclear Power Plant Steam Mechanical Fundamentals. ( 2) ?Investigating Nuclear Stability with a Graphing Calculator?:

(3) ?Entergy Nuclear Vemont Yankee corporate site?: (4) ?Boiling Water Reactor?. Proprietary Information Disclaimer: People have visited this page since 11/02/10 . Copyright ? 2006 by Sam Barros. School Evaluative. All rights reserved.

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42 Amazing Resume Tips That You Can Use in 30 Minutes [Examples] Maybe you’ve finished writing your resume, maybe you’re just starting. Either way, you could probably use some quick resume tips. What are the best tips for board history essay, writing a resume? It’s easy to overlook things when you’re worried about finding a job. The best tips help you remember the smallest details of resume writing. So, here are 42 of the best resume tips we could find for every step of the resume writing process. For your convenience, we’ve divided the tips into two , five , and thirty-minute tips . Research. Next to each tip you will also see a star rating that ranks the tips in importance on a scale from one to essay, five.

Our five-star tips are those that we highly recommend every job seeker use especially if you don’t have time for anything else. Ingilizce Teknikleri. These Resume Tips Will Take Two Minutes Tops. 1. Create a professional email address. Out of all of the resume tips listed, this may seem too obvious. But it’s worth mentioning because the college board essay use of an unprofessional email address will get you rejected 76% of the time. So, if you haven’t already done so, ditch that email address you’ve been using since high school. Choose a professional email provider like Gmail or Outlook. Use your name. Tuition Paper. 2. Update your contact information. After you change your email address, make sure the rest of your contact information is up to date.

You don’t want to miss an interview because you put the board ap world history wrong phone number on homework help, your resume. Also, exclude information like your birth date or marital status. You do not have to respond to questions about religion, race, or gender on an application. US employers cannot take these aspects into consideration when accessing you. If you’re applying for a job out of college board history essay, state or country, also consider omitting your current address. That way a hiring manager won’t think you’re confused about the location of the job.

3. Set your font size to middle evaluative, 10-12 points. While choosing a font is important, making sure that it is the right size is paramount. Keep your font size between 10-12 points so that a hiring manager can easily read it without squinting. For your education section, put your highest degree first. College Board Ap World History Essay Questions. For your experience section, put your current job first. 5. Align your content to the left to tuition paper, make it skimmable. Board Ap World History Questions. The first thing a hiring manager is going to do is skim your resume for relevant keywords from the job description. Aligning your text to the left makes this easier for them to do. 6. Make strategic use of bold, caps, and italics.

Be consistent with your choices. If you’ve made one of your subheadings bold - make them all bold. Try not to overuse anything. The point is to make important information easier to find. 7. Choose an attractive and readable font.

You may think fonts are trivial in the larger scheme of ingilizce essay yazma, things, but the right font is going to do a lot for your resume. College Ap World History Questions. Stick to fonts that sound like the ingilizce names of hipster children: If you choose a font that is hard to college, read or childish, a hiring manager might toss your resume in the trash. 8. College Paper. Only add jobs you’ve had in ap world the past 10-15 years. You do not need to list every job you’ve ever had on your resume. Make sure that every job you have added was a job you held in the last 10 or 15 years. 9. Give your sections simple subheadings. Regardless of what layout you choose, make sure your sections are visible and u.s history easy to find. You can do that by giving them simple subheadings. You’ll want to write simple subheadings for all sections. That way Applicant Tracking System (ATS) software can find them.

Pro Tip: Deciding what skills to put on college board questions, your resume is one of the biggest tasks that lie ahead of new resume writers. Make sure that they are easy to find and easy to skim as well. 10. Essay Intorduction. Include URLs to social media profiles, personal websites, and your blog. If you have a professional website or blog, take a moment to include the URL in your contact section. Add any relevant social media handles as well.

For most professionals, that will include your LinkedIn URL and college board history essay questions your Twitter handle. Creative professionals could also consider adding relevant links to Instagram, Youtube, or Pinterest profiles. Take an extra couple of minutes to make sure that your URLs are live and to hyperlink them in the text so they are accessible. 11. Choose a resume format that works for you. What are the best formats for college, a resume? Well, that depends. There are three types of resume formats: Reverse-chronological Combination Functional or Skills-based. Most of you will opt for ap world essay, the reverse-chronological format . It’s the most common and you can play with the layout. In almost every situation, the tuition research functional resume format is not a good choice because it kills your experience section.

And even if you don’t have experience, that’s not the ap world best way to handle it. Science In The News Drink. Pro Tip: Consider a format that gets your strongest information closest to college ap world essay questions, the top of your resume where hiring managers will be sure to see it right away. 12. Consider using a professionally designed template. Templates can save you a lot of essay, time and effort. Imagine not having to fool around with margins in Word. Pick one out, and you’re ready to go. 13.

Consider putting your education section first. Once you’ve chosen a format, it’s a good idea to make a quick decision about the layout. How do you build a strong resume? After your contact information , start your resume with either a resume summary or a resume objective . More on that later. College Ap World History Essay Questions. But what should come next? Your education or your experience section? If you’re a professional with tons of essay intorduction, experience , your experience should come first. But let’s say you’re a student and your educational background is your strongest selling point. In that case, consider putting your education section first.

14. Lose the college history essay questions phrase “References Available Upon Request.” It is no longer necessary to place this phrase at the bottom of your resume, as hiring managers know that they can request your references. Adding it only takes up valuable space that you could use for middle essays, something else. Only Have Five Minutes? Here are the Best Resume Tips. 15. Read the job description and then read it again. Okay, reading the job description may sound like one of the most obvious resume tips ever. Of course, you’ve read the job description.

Right? In fact, most people spend an board ap world questions, average of 76 seconds reading a job description. And that’s why hiring managers find that 50% of applicants are unqualified for the job. You’ve got to make sure you have the tuition paper skills necessary for the job in the first place. Read the job description. Make sure you’re qualified. Read it again. Mine it for board, keywords. Put it through a cloud generator. Take it on a date.

Buy it Tiffany’s. Middle. Get married to it. Because that job description is your best friend when it comes to building a great resume. College Board History Essay. Seeing a job title that sounds right, sending your resume immediately. Reading a job description is as close as you’re going to get to reading the recruiter’s mind. 16. Make sure you’ve created margins. Margins are important.

That’s because resumes with text crammed edge to edge look messy and unprofessional. Do you know where messy resumes go? You know. If you do need a little more space, it’s okay to drop your bottom and news drink driving top margins to 0.5” and your side margins to 0.75”. Anymore and you’re resume will suffer. 17. Balance your text and college board history questions white space. Balancing your text and white space is the same thing as adding margins.

It makes your resume aesthetically pleasing and in the news coursework easy to read. Do not sacrifice white space in the name of college board ap world history, fitting everything onto drink driving one page. There are other ways. 18. Consider adding a coursework description. This is one of the board ap world history essay questions best resume tips for students. If you’re learning how to make a student resume , adding a coursework description is a good start. Ingilizce Essay Yazma Teknikleri. Your education is still your strongest asset. Listing or describing courses can show recruiters that you have skills related to the job. Board Ap World History Essay Questions. Coursework descriptions can also benefit professionals who are making a career change.

It shows that you’ve got relevant knowledge that goes beyond your past work experience. It is important to doesn't, name your files properly. Your resume could end up in an inbox with hundreds of other resumes. And if they’re all named “ resume ,” then the chance of college board history questions, your resume standing out is essay slim to board ap world history essay questions, none. 20. Match your cover letter to your resume. The two best cover letter tips are: Write a cover letter. Match the tuition research content of your cover letter to your resume. Yes, you still need to write cover letters . And yes, they need to match your resume so that you’re telling the hiring manager one cohesive story.

If there was something you feel needs an explanation, write about it in college essay questions your cover letter. 21. Essay Yazma Teknikleri. Draw attention to history, your promotions. Make sure you’ve mentioned any promotions you’ve received. You don’t have to list the name of the company more than once in the case of internal promotions.

Write the doesn't help name of the board company once. Then list your various titles with their accompanying responsibilities. 22. Cut the fluff in college tuition paper your experience section. Is your resume is a bit longer than the recommended length for resumes (one to ap world history questions, two pages)? Then an science in the coursework drink, easy way to college ap world history, cut fluff is to middle school evaluative essays, start by deleting bullet points in your experience section. Limit yourself to around six bullet points. List responsibilities that demonstrate the skills and experience you’ll need for your new job. Also, consider listing responsibilities that you can illustrate with achievements. Don’t list every responsibility you had at previous jobs. 23.

Write explanations for board ap world history questions, large gaps in u.s history essay your career history. Address significant gaps in your career history by college board history writing brief explanations next to the jobs where the gaps occur. Gaps can happen for all sorts of reasons. A brief explanation will reassure recruiters that it was unintentional or beneficial for you. As in the case of a layoff or a break to have a child or go back to school. 24. Essay Intorduction. Insert action verbs wherever possible. College Essay Questions. Take a quick glance at your resume. How many times have you used the phrase “ responsible for ?” A million?

It’s not uncommon. The good news is that it only takes five minutes to replace that sad phrase with action-packed verbs . Using action verbs as often as possible is one of the best resume tips out there. Middle School. Remember, not all verbs are action verbs. Try to avoid weak verbs like “ managed ” or “ communicated. ” Here are some alternatives: The person interviewing you may not be familiar with the technical jargon that goes with your territory. Especially if you are in college history a jargon-heavy industry such as engineering, law, or medicine. Try to use layman’s terms or simplified equivalents wherever possible. Wrong: Dramatically cloudify viral innovation. Right: Create digital backups for popular campaigns. 26.

Run your job description and resume through a cloud generator. Before you start writing, run your job description through a cloud generator. Which words are the most prominent? You can use the words that appear as a content guide while writing your resume. When you’re finished writing, send your resume through the cloud generator. Do the same words appear? A cloud generator is a quick way to check that you’ve tailored your resume to meet the needs of the hiring manager.

27. Consider saving a copy of your resume as a PDF. Saving your resume as a PDF is science in the drink driving one of those resume tips that might not work for college board history essay, everyone. The benefit of essay intorduction, saving your resume as a PDF is college history essay that the formatting will not change when it’s opened. Yazma. The downside is that if a company is using ATS, a PDF might not be the best format for your resume. Pro Tip: It’s often best to college board history questions, save your resume in a couple of file formats so you can send whatever is more suitable. It’s up to you to decide. These Resume Tips Take 30 Minutes, But They’re So Worth It. Middle School. 28. Tailor your resume to the job description. You do that by identifying keyword skills in board ap world the offer and college tuition research then add these skills throughout your resume.

It sounds like a lot of work, but these keywords are what you should put on your resume above all else. That’s because keywords are what hiring managers are looking for when they scan your resume. 29. Add achievements to your experience section. If tailoring your resume to the job description is the king, adding achievements is the queen of college ap world essay, resume tips. Illustrating a skill or responsibility with an ingilizce essay teknikleri, achievement puts you five steps ahead of candidates with the same skill set. That’s because you’re showing what it looks like when you put your skills to college essay questions, work. To generate user engagement , I performed multiple A/B tests , resulting in college tuition a 20% decrease in bounce rates and college ap world questions a 15% increase in sales conversions . I won an employee of the year award.

30. Add numbers and ingilizce essay yazma teknikleri details where possible. Adding numbers and details to emphasize skills is by far one of the board ap world essay best resume tips you can follow. Anytime you can illustrate an achievement or skill with numbers or details - do it. Responsible for sales. Numbers draw the eye of the recruiter and details give them a tangible sense of what it looks like when you use a skill. Maybe you increased sales, efficiency, or user engagement. Maybe you slashed costs. Intorduction. Whatever it is that you’ve achieved try to college ap world history questions, make it quantifiable.

31. Make good use of the top third of your resume. Think of the top third of your resume and “the penthouse.” It’s here that you want your best skills, experience, and achievements to appear. Try to middle essays, put the best stuff at the top. Because when a recruiter scans your resume, they will focus on the top third of the document. If they don’t find what they’re looking for in a few seconds of scanning, they will reject your resume as irrelevant. Board Essay. 32. Include a resume summary or objective.

So, how do you get your best information in the top third of your resume? Include a resume summary or a resume objective. It’s three sentences of who you are, where you’re going, and essay why you’ll bring value to the company. Dedicated Sales Manager seeking fulfilling work in children’s retail sector. Dedicated Sales Manager with 5+ years of questions, experience in the retail industry. Wishing to decrease returns for PeaPod Babywear by 15%. 33.

Use a proofreading tool like Grammarly. Doesn't. You cannot afford to board ap world questions, have typos or grammar errors in your resume. The majority (61%) of research, recruiters will throw out a resume immediately if they see typos. Microsoft Word or Google Docs will do a good job of detecting spelling errors, but the Grammarly app or Language Tool will catch grammar mistakes and typos. You need to college board history, proofread your resume before sending your resume, and middle school an app will help you catch things you can’t see. 34.

Have a human proofread your resume. Apps are great for catching mistakes, but another human being is college board essay questions priceless. Grab whoever you can find with the patience to read through your resume. Science In The News Coursework. They can also give you feedback about college board history questions, your tone and science news driving how you’re selling yourself. College Ap World. It’s not always enough to write a great resume and ace an school evaluative, interview. The show isn’t over board essay questions, until you’ve also written a thoughtful thank-you email. When you’re just learning how to create a resume , you may forget that hiring managers also search for you online.

Make sure that you’ve cleaned up “public” information on your Facebook and Twitter accounts. Change your Facebook privacy settings to “Friends” to keep future posts from becoming public. And do a quick sweep to make sure nothing else unsavory is lurking out there on the Internet. Enter your name into Google and tuition see what turns up in the results. 37.

Create a professional persona for yourself. A professional persona is a two or three-word description of yourself that should stick in the head of the recruiter when your name doesn’t. It’s like when you try to describe someone from last night’s party. College Board Ap World Essay. Remember the girl who graduated from science driving Harvard and board ap world history questions talked about goat cheese for an hour? It’s like that except less goat cheese.

38. Reinforce your professional titles by essay showing career progression. Putting a bunch of flashy titles on your resume isn’t the most impressive thing you can do believe it or not. Ap World Essay. What is impressive is the college tuition research paper telling the ap world history essay questions story of your career progression . See, you can be a social media manager for your cousin’s pizza place without any prior experience. But when you can show that you progressed to that position through hard work, that’s impressive.

The trick is trying to make each past role reinforce your place in the next one. Planned and implemented promotional campaigns. Cooperated with interactive agencies. Conducted market research. Assisted during promotional campaigns . 39.

Consider adding a Hobbies and Interest section to your resume. That’s because companies are beginning to emphasize work culture . Which makes finding a candidate with a fitting personality increasingly important. Just be sure to research your company. Choosing hobbies and interests that match the company’s culture is school evaluative essays a good strategy. Work Culture: Corporation participates in board ap world charity marathons. Hobbies and Interests: Volunteer Work and Athletics. Religious, political, or sexual hobbies. If the person reading your resume has an opposite opinion, it could hurt your chances of getting an help, interview. 40. College History Essay Questions. Trim any unnecessary fat from your resume. Having problems keeping the length of your resume in check?

You will want to essay intorduction, trim the fat: Make sure every word you’ve used is college board history essay necessary. Keep your bullet points to six at most. Ingilizce Teknikleri. Trim your resume summary or your skills section without killing the value. And kill any extra sections that aren’t mandatory. 41. Try to find the college board questions personal email address of the ingilizce essay hiring manager.

You can always attach your resume to a generic email and send it to a generic inbox. Or you can attach your resume to a personalized email and send it to your hiring manager. Some hiring managers may not appreciate receiving unsolicited resumes. Board Essay. At the same time, if you know how to homework, send an email to a hiring manager you know that you aren’t sending it unannounced. You establish contact via a referral or LinkedIn before sending your resume. Sending a cold-call email to an unknown hiring manager. Board History Essay. Instead of waiting around for a phone call, track your email so that you know the moment a hiring manager opens it. You can use a free tool like Mixmax to see if a hiring manager has read your resume. That give you a better idea of when to send follow-up or thank you emails. It can be easy to forget small details when you’re trying to figure out how to write a great resume.

But if you follow these resume tips and homework help tricks you can rest assured that you’re on the right track. Always take the time to check your resume. Can you think of any more quick resume writing tips that we forgot? What are some little-known resume tips you can share? Let us know in college board ap world history essay the comments. Natalie is essay a writer at Uptowork.

She loves writing about board history questions, resumes and eating tacos more than life itself. She spends her free time reading complicated novels and binge watching TV series.

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Ap world history essay questions

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 history other Resources. Four days following two-vessel coronary artery bypass graft (CABG) procedure and replacement of help a mitral valve, this 69-year-old woman presented with a chief complaint of college board questions shortness of breath, inability to lie supine, oliguria, and essay, 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 board ap world essay questions 2.7 L/minute. Both the prothrombin and in the news drink driving, the partial thromboplastin times were elevated. Medical Disease and ap world history essay questions, Differential Diagnosis What is the differential diagnosis of low cardiac output (CO) postoperatively? A. Essay! Medical Disease and Differential Diagnosis. A.1. What is the differential diagnosis of low cardiac output (CO) postoperatively? CO is determined by the product of college questions stroke volume (SV) and 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 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 ingilizce teknikleri explore whether there has been a change in the preload, the board ap world essay questions, afterload, and/or the contractile state. Either too much preload (ventricular overdistention) or too little preload can lower the CO. Similarly, a significant reduction in homework afterload (vasodilators, anesthetics, sympatholysis) or an college history 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 bacterial endotoxins). A combination of hemodynamic disturbances can coexist in the same patient. For example, a patient can have both a decrease in contractility and doesn't, a reduced preload to account for 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, 1999:1155–1191. A.2. What is cardiac tamponade? Enumerate the common etiologies of college board ap world history questions cardiac tamponade. Cardiac tamponade is yazma teknikleri defined as significant compression of the heart by ap world history questions, 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 one extreme may be clinically insignificant whereas on another extreme presents as a life-threatening condition requiring emergent surgical attention. Essays! Clinical tamponade is history essay questions frequently associated with marked increase in pericardial pressure relative to intracardiac pressures (atrial and college paper, 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. 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. Pathophysiology of cardiac tamponade. Chest 1998:113:1372–1378. A.3. What is the difference between acute and delayed cardiac tamponade? In the setting of cardiac surgery, cardiac tamponade can occur acutely over minutes, hours, or after a few days postoperatively. The reported incidence of acute cardiac tamponade is ap world history 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 middle school evaluative, 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 college history essay questions, is often misdiagnosed because of a low index of suspicion and because the clinical signs and symptoms can be comparable to those of congestive heart failure, pulmonary embolism, and generalized fatigue (i.e., failure to thrive postoperatively). Questions! The most common culprit in delayed cardiac tamponade is anticoagulant therapy with coumadin, heparin, and/or platelet inhibiting agents.

Effusion after cardiac surgery is college board ap world questions common. Using echocardiography, Weitzman et al. evaluated consecutive patients postoperatively and demonstrated that 103/122 (84#37;) had pericardial effusions. Generally, effusions reach their maximum size by the tenth postoperative day and ingilizce yazma teknikleri, regress spontaneously thereafter. D'Cruz IA. Overton DH. Pai GH. College Board History! Pericardial complications of cardiac surgery: emphasis on intorduction, the diagnostic role of echocardiography.

J Card Surg 1992:7:257–268. Nelson RM. Jeson CB. Smoot WM. College Board History Essay! Pericardial tamponade following open-heart surgery. J Thorac Cardiovasc Surg 1969:58:510–516. Weitzman LB. Tinker WC. Kronzon I, et al.The incidence and natural history of homework doesn't help pericardial effusions after cardiac surgery: an echocardiographic study.

Circulation 1984:69:506. A.4. How is the diagnosis of postcardiotomy cardiac tamponade made? The diagnosis of cardiac tamponade following cardiac surgery is often difficult and requires a high degree of clinical suspicion, proficient knowledge of pulmonary artery catheter (PAC) derived measures, physical examination, and diagnostic tools such as echocardiography and chest x-ray film. Often, the diagnosis is college ap world history essay questions made in the operating room whereby evacuation of u.s history essay questions clot and blood from the mediastinum is 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 such limitations.

The classical teaching of equalization of diastolic blood pressures in college ap world history essay questions cardiac tamponade [central venous pressure (CVP) = pulmonary artery diastolic pressure (PAD) = pulmonary artery occlusion pressure (PAOP)] is u.s history essay infrequently observed postoperatively because the college board ap world essay questions, pericardium is research paper left open. As such, blood or clot or both do not distribute around the heart homogeneously to ap world essay questions produce equalization of science in the coursework drink driving pericardial diastolic pressures. Board Essay Questions! Generally, the CVP is elevated but the PAD and ingilizce essay, 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 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 college board ap world history, diagnosis of essay cardiac tamponade had right heart catheterization findings that reflected equalization of diastolic blood pressures. 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 CO or blood pressure or both are not readily responsive to conventional management. Ap World History Essay Questions! Furthermore, in in the coursework drink driving delayed tamponade the complaints tend to be vague and less hemodynamic data is available (i.e., PAC) to allow prompt diagnosis of tamponade.

Whenever, the patient is board essay 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 ingilizce teknikleri 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 1993:104:71–78. Spodlick D. Questions! Pathophysiology of cardiac tamponade. Chest 1998:113:1372–1378. A.5. What is regional cardiac tamponade? Regional cardiac tamponade occurs when one or more cardiac chambers become compressed by school essays, blood or blood clot or both compromising forward flow.

Postcardiotomy, diastolic regional collapse of the right atrium or the right ventricle is the most common echocardiographic finding in 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 ap world history essay questions, right heart becomes adherent or tethered to the anterior chest wall. College Tuition Research! As discussed in the previous answer, the diagnosis of tamponade is ap world history 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 news coursework drink driving congestive heart failure, acute left or right ventricular infarction, septic shock, or pulmonary embolism. Chuttani K. Pandian NG. Mohanty PK, et al.Left ventricular diastolic collapse. An echocardiographic sign of regional cardiac tamponade. Circulation 1991:83:1999–2006. Fowler NO. Gabel M. Regional cardiac tamponade: a hemodynamic study.

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

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

J Am Coll Cardiol 1990:16:511–516. Russo A. O'Connor W. School Evaluative Essays! Waxman H. Atypical presentations and college board history essay questions, echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery. Homework! Chest 1993:104:71–78. Sandifer DP. Gonzalez JL.

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

Normally, there is an homework doesn't inspiratory fall of less than 10 mm Hg in board ap world history the arterial systolic pressure and homework help, an accompanying inspiratory fall in the venous pressure. However, a paradoxical pulse differs from the normal situation in two aspects: (a) the inspiratory fall of the arterial pressure exceeds 10 mm Hg and (b) the inspiratory venous pressure remains steady or increases (Kussmaul's sign). Essay Questions! Echocardiographic studies of essay intorduction patients with cardiac tamponade by D'Cruz et al. College Board Ap World History Essay Questions! 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 homework, interventricular septum toward the left ventricle. Of importance, pulsus paradoxus is not unique to cardiac tamponade.

The phasic respiratory changes in college ap world history essay questions 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 magnitude of college paper paradoxical pulse is directly proportional to the inspiratory decrease of left ventricular dimension, diastolic volume, and SV. This physiologic process is often present in respiratory distress, airway obstruction, chronic obstructive pulmonary disease (COPD), and pulmonary embolism. College History! 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 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 the diagnostic role of echocardiography.

J Card Surg 1992:7:257–268. Frey B. Freezer N. Diagnostic value and pathophysiologic basis of homework doesn't pulsus paradoxus in infants and children with respiratory disease. Pediatr Pulmonol 2001:31:138–143. Jay GD. Onuma K. Board Ap World Essay Questions! Davis R, et al.Analysis of physician ability in the measurement of homework pulsus paradoxus by sphygmomanometry. Chest 2000:118:348–352. McGregor M. Pulsus paradoxus. N Engl J Med 1979:301:480.

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

Ventricular interaction is extremely important for maintenance of adequate cardiac performance. U.s History! Under normal conditions, the average SV of the right ventricle equals the SV of the left ventricle; however, cyclical respiratory differences in left and 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 the following reasons: (a) lung expansion increases its reservoir for blood and (b) the history essay, increase in right ventricular filling causes the interventricular septum to intorduction bulge leftwardly reducing left ventricular dimension and altering its compliance and filling (ventricular interaction). During exhalation, the reverse process occurs. In the essay questions, case of science drink driving cardiac tamponade, ventricular interaction also involves the interventricular septum but it can involve other chamber and college board ap world history questions, 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. Because of the fixed space within the pericardium, cardiac chamber dimensions become smaller. Homework Doesn't! First, the thin-walled and more compliant atriums progressively get compressed followed by college ap world history essay, the right ventricle and lastly the left ventricle.

Overall, the physiology of homework help ventricular interaction in clinical cardiac tamponade becomes complex as the college history essay, pressure-volume relationship of mediastinal and chest structure alters with each heartbeat and from respiratory and neuroendocrine influences. Spodlick D. Pathophysiology of cardiac tamponade. Yazma Teknikleri! Chest 1998:113:1372–1378. A.8. How is college essay 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 ingilizce yazma teknikleri not sufficient to add an ischemic injury to the myocardium because there is a proportionate decrease in college board essay questions (a) ventricular preload (underfilled) and (b) ventricular afterload (underafterloaded). Consequently, both myocardial work and oxygen consumption are reduced. Homework! 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 1978:58:265–272. Spodlick DH. College Board Ap World History Essay! Threshold of ingilizce essay teknikleri pericardial constraint: the pericardial reserve volume and auxiliary pericardial functions.

J Am Coll Cardiol 1985:6:296–299. A.9. What are the electrocardiographic abnormalities associated with cardiac tamponade? Electrocardiographic changes may occur in the settling of cardiac tamponade. Board Essay Questions! These include nonspecific ST-T wave abnormalities, low voltage QRS complex, signs of myocardial ischemia and pericarditis, and doesn't help, electrical alternans ( Fig. 15.1A ). College Ap World Essay Questions! The latter is seen in patients with large effusions and is characterized by interbeat shifts in electrical axis. Homework Doesn't! 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. College Board History Essay Questions! Thus, the u.s history essay, 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 essay 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. School Evaluative! (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 clinical medicine. Electrical alternans. N Engl J Med 1999;341:2060, with permission.) Fox JJ. College Ap World History Essay Questions! McHarg JL. Questions! Gilmour RF Jr. Ionic mechanism of electrical alternans. Am J Physiol Heart Circ Physiol 2002:282:H516–530.

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

On standard anterior-posterior chest roentgenography, the cardiac silhouette may appear normal in homework doesn't size or extremely enlarged depending on the acuity and chronicity of the tamponade process. Normally, the college history, pericardial fluid amounts to 15 to 25 mL. Acute tamponade physiology can arise with as little as 150 mL of effusion, whereas chronic effusions may exceed 1,000 mL before clinical signs and symptoms of cardiac tamponade manifest. On chest x-ray film, the cardiac silhouette will appear widened with or without features such as obscuring of the pulmonary vessels at 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 college research paper, respective chamber. College Board Essay Questions! 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 transvalvular (mitral and aortic) flow characteristics seen by Doppler techniques, (d) diastolic posterior motion of the ingilizce essay, right ventricular wall, and college board ap world questions, (e) in some cases, a systolic notch on the right ventricular epicardium ( Fig. 15.1B and C ). Although many of the 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. U.s History Questions! Philadelphia: WB Saunders, 2001:1490. Kaplan JA, Cardiac anesthesia 4th ed. Board Ap World Essay Questions! Philadelphia: WB Saunders, 1999:932, 1250.

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

Procedures that require CPB are known to adversely affect the college board ap world history, hemostatic mechanisms including vascular endothelium, fibrinolytic and coagulation factors, platelet, plasminogen, and inflammatory pathways ( Fig. Ingilizce Essay Yazma Teknikleri! 15.2 ). Under normal settings, these systems (and others yet unknown) act in concert and in opposition with one another (a) to prevent bleeding by promoting clot formation at college essay 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 fibrinogen. Tuition! The potential for postoperative bleeding will depend on 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 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 college board essay questions, 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 school, thrombosis: basic principles and clinical practice, 2nd ed. Philadelphia: JB Lippincott, 1987:1052, with permission.) Figure 15.2.

The coagulation cascade, illustrating the college board essay questions, coagulation factors required for evaluative 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. College History Questions! Hemostasis and thrombosis: basic principles and clinical practice, 2nd ed. Philadelphia: JB Lippincott, 1987:1052, with permission.) Platelets play an important role in the coagulation process.

Once activated, they secrete several types of granules. College Tuition! Granules, containing peptides such as fibrinogen, thrombospondin, factors V and VIII, and -thromboglobulin, are reduced in both number and content during CPB. Of greater importance is the loss of board history questions 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 a quantitative platelet defect, (b) factor deficiency, and (c) surgical bleeding. The latter can arise from either venous or arterial sources that were undetected before closure of the college tuition research, chest. Attentive and meticulous effort to surgical hemostasis can significantly reduce the incidence of ap world history bring-backs. Despotis GJ. Science In The News Coursework Drink! Avidan MS. Hogue CW Jr. Mechanisms and college ap world history essay, attenuation of hemostatic activation during extracorporeal circulation. Ann Thorac Surg 2001:72:S1821–1831.

Harker L. Malpass TW. Branson HE. Research! 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 history questions, after cardiopulmonary bypass surgery. Thromb Res 2001:104:301–307. Levy JH. Pharmacologic preservation of the ingilizce yazma teknikleri, hemostatic system during cardiac surgery. Ann Thorac Surg 2001:72:S1814–1820. A.12.

What is the college board, mechanism of action of low molecular weight heparin (LMWH)? LMWHs are fragments of essay unfractionated heparin produced by controlled enzymatic or chemical depolymerization processes yielding chains having molecular weight of college board ap world history questions about 5,000 daltons. The parent compound is a heterogeneous mixture of polysaccharide chains with molecular weight of 3,000 to 30,000 daltons. The mechanism of action is similar for both unfractionated heparin and LMWH. Middle School Essays! Binding of the pentasaccharide to antithrombin (antithrombin III) results in a conformational change in antithrombin that accelerates its interaction with thrombin and factor X (factor Xa) by 1,000-fold. Whereas unfractionated heparin causes a comparable inhibition of factor Xa as LMWH, its inhibition of thrombin is much more profound than LMWH. To inactivate thrombin, heparin has to bind to board ap world history questions both antithrombin and thrombin forming a ternary complex. Heparin pentasaccharide sequences (randomly distributed along heparin chains) of 18 units or more is required for the formation of this ternary complex. Approximately 50#37; of LMWH lack the adequate length necessary for binding antithrombin and thrombin. Furthermore, only 15#37; to 25#37; of 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 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. Research! Zacharias J, et al.Effect of low molecular weight heparin (fragmin) on bleeding after cardiac surgery. Ann Thorac Surg 2000:69:762–765. Danielsson A. Raub E. Lindahl U, et al.Role of ternary complexes in questions which heparin binds both antithrombin and in the, proteinase, in the acceleration of the reactions between antithrombin and thrombin for factor Xa. J Biol Chem 1986:261:1546–1573. Gohlke-Barwolf C. Anticoagulation in valvar heart disease: new aspects and college board ap world history essay, management during non-cardiac surgery.

Heart 2000:84:567–572. Harenberg J. Pharmacology of research low molecular weight heparins. Semin Thomb Hemost 1990:16:12–18. Kondo NI. Maddi R. Ewenstein BM, et al.Anticoagulation and board ap world history essay, hemostasis in cardiac surgical patients.

J Card Surg 1994:9:443–461. Weitz JI. Drug therapy: low molecular weight heparins. N Engl J Med 1997:337:688–698. A.13. Describe the advantages of tuition research paper LMWH over standard heparin therapy. There are several clinical and pharmacologic advantages of LMWH over unfractionated heparin.

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

Of note, LMWH is not recommended in the setting of renal failure, and its anticoagulant activity may be measured by assaying factor Xa levels. There are, however, many different types of ap world history questions 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 essay total and free tissue factor pathway inhibitor (TFPI) as individual pharmacological parameters of various heparins. Thromb Haemost 2001:85:824–829.

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

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

In contrast, type II HIT is a life-threatening condition that develops 5 to 10 days after initiating heparin therapy and is associated with devastating thromboembolic processes (most commonly arterial thrombosis resulting in limb ischemia, cerebrovascular events, and myocardial infarction). The platelet count falls to less than 50 x 10 3 / L and in severe cases to less than 5 x 10 3 / L. The incidence of HIT in patients receiving full-dose heparin ranges between 0#37; to 30#37;. Questions! Although there is no randomized prospective study looking at the true incidence of HIT, the expected incidence is estimated to be less than 5#37;. Those patients who have had a previous exposure to u.s history essay heparin (recent and in college some cases remote history) may develop HIT earlier after institution of heparin therapy as compared with those with no previous exposure. The frequency of HIT is essay also higher in patients receiving porcine mucosal heparin compared with bovine lung heparin. The diagnosis of HIT should be entertained in college board essay any patient with a significant fall in platelet count while on 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 essay questions, (d) presence of heparin-dependent platelet antibody by an in college board essay questions vitro test.

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

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

What is the therapy for HIT? Because HIT type II is a potentially lethal condition, the most effective therapy is discontinuation of history essay heparin. The thrombocytopenia should improve progressively. Tuition Paper! Although tempting, the need for platelet transfusion is discouraged because bleeding occurs infrequently and vascular thrombosis may be potentiated. Several agents have been recommended for board essay 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 use; others are under clinical investigation. Hirudin has been extensively used in Europe with demonstrable benefit and safety. Ingilizce Essay Teknikleri! The LMWH have been shown to have cross reactivity with unfractionated heparin approaching 100#37; [C-serotonin release or by heparin-induced platelet aggregation (HIPA) assays] and should not be used in the setting of HIT unless there are demonstrable negative cross reactivity assays with standard heparin.

The ancrod is a defibrinogenating agent (not available in college ap world history questions the United States) extracted from the Malayan pit viper and is immunologically distinct from essay intorduction, heparin. It acts by cleaving fibrinopeptide A from fibrinogen and its activity can be measured by history questions, 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 1999:1:41–49. Deitcher SR. Carman TL. Heparin-induced thrombocytopenia: natural history, diagnosis, and management.

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

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

Based on confirmed laboratory tests, the prevalence of board ap world HIT is 2#37; for questions patients receiving unfractionated heparin. Although the college history essay, incidence of HIT is infrequent in the setting of LMWH, it is not zero and avoidance of the latter is recommended for patients demonstrating signs of HIT while receiving unfractionated heparin. Fabris F. Luzzatto G. Stefani PM, et al.Heparin-induced thrombocytopenia [Review]. Science News! Haematologica 2000:85:72–81. Kleinschmidt K. College Board Ap World History Essay! Charles R. Pharmacology of low molecular weight heparins. Emerg Med Clin North Am 2001:19:1025–1049. Warkentin TE. Evaluative Essays! Sheppard JA. Board History! Horsewood P, et al.Impact of the doesn't, patient population on the risk for heparin-induced thrombocytopenia. Blood 2000:96:1703–1708.

A.17. College Board Ap World History Essay Questions! What is the yazma teknikleri, mechanism of heparin antagonism by protamine? Heparin is history questions 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 form a heparin-protamine complex that does not have the ability to bind to thrombin or factor Xa. Once neutralized, the complex of heparin and protamine is eliminated. Kimmel SE. Sekeres M. Homework Doesn't! Berlin JA, et al.Mortality and adverse events after protamine administration in patients undergoing cardiopulmonary bypass. Anesth Analg 2002:94:1402–1408.

A.18. What is heparin rebound? The ACT is used to confirm adequacy of heparin neutralization by protamine. The concept of heparin rebound and coagulopathy following protamine reversal may occur as follows: first, heparin that is college board ap world sequestered in tuition paper tissues that are poorly perfused (i.e., fat) may not undergo neutralization by protamine and second, the half-life of heparin is longer than that of protamine (45 minutes) such that as heparin is college board ap world essay questions mobilized back into circulation it can inhibit thrombin formation and predispose post-CPB bleeding. Studies in which 1 mg of intorduction protamine is given per 100 units of heparin (total dose) found no evidence of heparin rebound. Thus, bleeding in college board ap world history 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 2001:33:245–248.

Subramaniam P. Skillington P. Tatoulis J. School Evaluative Essays! Heparin-rebound in the early postoperative phase following cardiopulmonary bypass. Austr N Z J Surg 1995:65:331–333. Woodman RC. Harker LA. Bleeding complications associated with cardiopulmonary bypass. Blood 1990:76:1680. A.19. How does coumadin affect the coagulation system? What is the 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 presence of other comorbid conditions. Board Ap World History Questions! On average, it takes several days of therapy to achieve the desired INR (2 to 4); consequently, administration of 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 u.s history essay questions, hemorrhage). To reverse its effect, coumadin should be discontinued several days (more than 3 days) to allow levels of the aforementioned factors to normalize. Acute reversal is achieved with FFP. Administration of vitamin K is often necessary to accelerate the synthetic process. Erban S. Initiation of warfarin therapy: recommendations and college board ap world history, clinical pearls. J Thromb Thrombolysis 1999:7:145–148. Henderson MC.

White RH. Anticoagulation in the elderly. Curr Opin Pulm Med 2001:7:365–370. Horton JD. Bushwick BM. Warfarin therapy: evolving strategies in anticoagulation. Essay Intorduction! Am Fam Physician 2002:65:172. Keller C. Matzdorff AC. Kemkes-Matthes B. Pharmacology of warfarin and ap world questions, clinical implication. U.s History Essay Questions! Sem Thromb Hemost 1999:25:13–16. A.20.

What do the following measure: prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time, activated clotting time (ACT), bleeding time? PT measures the activity of the extrinsic pathway: factors I (fibrinogen), II (prothrombin), V, VII, and X ( Fig. 15.2 ). Deficiencies of factors V, VII, and X (50#37; of normal) significantly prolong the board ap world essay, PT. Much lower concentrations of fibrinogen and prothrombin are required to prolong the essay questions, 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 college board ap world history questions, activity of the intrinsic pathway: factors XII, XI, IX, VIII, V, X, prothrombin, and fibrinogen ( Fig. 15.2 ). The aPTT is prolonged by concentrations of essay less than 20#37; to 30#37; of these factors. Board History! 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. Science! 15.2 ). The thrombin time is decreased in the presence of board ap world history essay questions low concentrations of fibrinogen and thrombin. Heparin prolongs the thrombin time, whereas coumadin has little effect. Normal values are less than 10 seconds. Activated Clotting Time.

ACT measures the college paper, general function of the coagulation system. It is used primarily to measure the ap world questions, adequacy of heparinization during CPB and protamine reversal of heparin following CPB. Prolonged ACTs may be due to heparin, low levels of science news coagulation factors, or thrombocytopenia. College Essay Questions! It is, however, not particularly specific for intorduction platelet or factor deficiencies. Normal values are 110 to 140 seconds. Bleeding time measures platelet activity, including both platelet number and aggregation.

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

New York: McGraw Hill, 2001:354–358. Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and thrombosis: basic principles and clinical practice 2nd ed. Philadelphia: JB Lippincott, 1987:1048. A.21. How is the science in the coursework, anticoagulant effect of LMWH monitored? There is college board essay no evidence that monitoring the dose improves the clinical efficacy. In contrast, any overdose increases the risk of hemorrhage. Because the middle school essays, kidneys play a significant role in the elimination of LMWH, therapeutic use of 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 board ap world history essay bleeding. Boneu B. de Moerloose P. How and when to monitor a patient treated with low molecular weight heparin. Sem Thromb Hemost 2001:27:519–522.

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 u.s history essay questions suspended in a cuvette filled with heated blood. As clot formation proceeds, the college board history, rotation of the piston is affected and characteristic curves are generated ( Fig. 15.3 ). The etiology of a coagulopathy may be obtained by tuition, analyzing these curves ( Fig. 15.4 ). College History Questions! The Sonoclot similarly measures the development of in the drink clot viscoelastic strength. The Sonoclot piston moves vertically and measures the impedance to vibration at the tip of the probe. Sonoclot tracings obtained from college essay questions, platelet-rich plasma and platelet-poor plasma are shown in the Fig.

15.5 . Figure 15.3. Production of normal thromboelastogram and measured parameters. R, reaction time, 7 to 14 minutes; K value, 3 to 7 minutes; , clot formation rate, 40 degrees to essay 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. Board Ap World History Essay Questions! (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 15.3. Production of normal thromboelastogram and measured parameters.

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

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

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

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

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

Adv Exp Med Biol 1998:449:427–438. A.24. What is fibrinolysis? Fibrinolysis is fibrin breakdown in thrombi. Plasmin, derived from 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 broken down before healing. Although elevated concentrations of plasminogen activators are found during CPB, their half-lives are very short after bypass. In cardiac surgery, fibrinolysis is middle school evaluative a rare cause of postoperative bleeding.

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

Aminocaproic acid (Amicar) is an college history 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 tuition the setting of heart surgery, portocaval shunts, hematologic disorders such as aplastic anemia, abruptio placentae, hepatic cirrhosis, and neoplastic diseases. Compared with placebo, both tranexamic acid and aminocaproic acid have been shown to reduce blood loss by essay, 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 essay questions 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 a continuous infusion at a rate of 1 g per hour. History Essay Questions! Higher infusion rates may be used. There are several adverse events that include thrombosis (early graft closure, myocardial ischemia and infarction), agranulocytosis, leukopenia, and thrombocytopenia. Although rare, bradycardia and doesn't help, mild reduction in blood pressure have also been reported. Levi M. Cromheecke ME. College Board Ap World Questions! de Jonge E, et al.Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet 1999:354:1940–1947. A.26. What is aprotinin? Aprotinin is a complex polypeptide molecule belonging to the family of serine protease inhibitors that is extracted from intorduction, bovine lung. After intravenous administration, aprotinin undergoes rapid total extravascular distribution with a plasma half-life of approximately 150 minutes.

It is filtered by the glomeruli and history questions, reabsorbed by essays, the proximal tubules. The terminal half-life is approximately 10 hours. The basis for history its efficacy is ingilizce yazma 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 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 board history, 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 college tuition, generation of bradykinin from HMWK, factor XIIa, angiotensin, and complement activation. Factor XIIa, in college ap world questions turn, also interacts with fibrinogen to in the news produce plasmin ( Fig. 15.7 ). Figure 15.6. Contact activation and the role of the kallikrein system. Factor 12, XII; activated factor 12, XIIa; high-molecular weight kininogen, HK; prekallikrein, PKK; factor 11, XI; activated factor 11, XIa. (From slide set no.

3, tryaslol slide library [online]. Bayer, 2000. History Questions! Available at http://www.trasylol.com/slides.htm with permission.) Figure 15.6. Contact activation and ingilizce essay teknikleri, 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. Board Essay Questions! (From slide set no.

3, tryaslol slide library [online]. Bayer, 2000. Available at http://www.trasylol.com/slides.htm with permission.) Figure 15.7. Involvement of the various components of coagulation including the coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and science in the news coursework drink, the fibrinolytic system. Board History Essay Questions! C1, complement; HMW, high molecular weight. (From slide set no. 3, tryaslol slide library [online]. Middle School Evaluative Essays! Bayer, 2000. Available at: http://www.trasylol.com/slides.htm with permission.)

Figure 15.7. Involvement of the various components of coagulation including the college history, coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and the fibrinolytic system. C1, complement; HMW, high molecular weight. (From slide set no. 3, tryaslol slide library [online]. 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 intorduction platelet surface glycoproteins (IIb/IIIa), which is necessary for board ap world questions 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. In contrast, clinical trials comparing Aprotinin to placebo and/or to Amicar have consistently shown greater efficacy related to reduction in blood loss and middle evaluative essays, transfusions of blood elements. Concerns regarding prothrombotic potentials, including myocardial infarction and college essay, renal dysfunction, have since been dismissed. The infarction rate and the incidence of renal dysfunction are comparable to 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 homework patients with protein C or S deficiency, they may experience life-threatening thrombotic events shortly after protamine neutralization of heparin. Another important aspect of aprotinin use is the type of reagent used to monitor adequacy of heparinization (ACT). Ap World History Essay! Kaolin is the recommended agent to be used to assess ACT when aprotinin is used (greater than 480 seconds). If Celite is used, the ACT value should be more than 750 seconds before initiation of science coursework CPB. Aprotinin is not an antithrombotic agent, and, therefore, adequate amount of heparin must be given.

Because it is board essay a serine protease inhibitor, it interacts with antithrombin III to homework 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 college history essay increased in patients who are reexposed to aprotinin within 6 weeks. Most of the cases reported occurred within 200 days of exposure. It is 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 u.s history least 10 minutes before the loading dose, followed by college board ap world history, close observation for signs of an allergic reaction. Yazma Teknikleri! A loading dose of 2 million KIU should then be given over 20 to 30 minutes. College Board Ap World History Essay! 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 the duration of surgery. It may be beneficial and cost effective to drink continue the infusion of the remaining amount of the drug while the patient is board history essay questions transferred and recovering in the ICU. A half-dose regimen has been proposed and entails reducing the previously mentioned recommendation in half. Cosgrove DM III. Heric B. Ingilizce Yazma Teknikleri! Lytle BW, et al.Aprotinin therapy for reoperative myocardial revascularization: a placebo-controlled study. Ann Thorac Surg 1992:54:1031–1038. Dobkowski WB.

Murkin JM. A risk-benefit assessment of aprotinin in cardiac surgical procedures. Drug Safety 1998:18:21–41. Fujii S, Kinins V, Part B. Advances in board questions experimental medicine and biology vol 247B: New York: Plenum Press, 1989:35–42. Hoffmann H. Siebeck M. Thetter O, et al.Aprotinin concentrations effective for homework doesn't help the inhibition of college history essay tissue kallikrein and plasma kallikrein in vitro and in vivo. Abe K, Moriya H, Landis RC, et al., The antithrombotic and antiinflammatory mechanisms of action of aprotinin. Ann Thorac Surg 2001:72:2169–2175. Murkin JM. College! Attenuation of ap world history questions neurologic injury during cardiac surgery. Ann Thorac Surg 2001:72:S1838–1844.

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

Serradeil-Le Gal C. Nonpeptide antagonists for vasopressin receptors. Pharmacology of SR 121463A, a new potent and highly selective V2 receptor antagonist. Adv Exp Med Biol 1998:449:427–438. Wahba A. Black G. Koksch M, et al.Aprotinin has no effect on platelet activation and adhesion during cardiopulmonary bypass. Thromb Haemost 1996:75:844–848. B. Preoperative Evaluation and Preparation. B.1. College Tuition Paper! Interpret the hemodynamic findings of college ap world history essay questions 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 middle school evaluative essays, left ventricular end diastolic pressure#151;a correlate of left ventricular preload#151;is within the college ap world history essay questions, normal limits.

Pressure measurements are more representative of the ventricle's state of compliance than the 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. Essay Teknikleri! A CVP of 23 torr is suggestive of right ventricular or biventricular dysfunction, tricuspid stenosis or insufficiency, or obstruction and college essay, compression of the right atrium. The CO is inadequate. The derived SV of 22 mL (CO/HR), combined with the other derangements (elevated CVP and PAOP of intorduction 14 mm Hg), strongly reflect right heart dysfunction. Taking into college board ap world history questions, consideration the patient's overall presentation (physical examination and laboratory findings), the differential diagnosis includes right ventricular ischemia and or infarction, pulmonary embolism, atrial or ventricular septal defect (most likely left-to-right), and cardiac tamponade. U.s History Essay Questions! An echocardiogram should be performed to assist in the diagnostic process and ap world history, clinical management. Fontes ML. Bellows W. Ngo L et al. and McSPI Research Group.

Assessment of ventricular function in critically ill patients: limitations of pulmonary artery catheterization. J Cardiothorac Vasc Anesth 1999:13:1–8. B.2. How would you treat the low output status of this patient? Although the HR is elevated, it may be unwise to attempt to normalize it before correcting the SV. The latter is a function of the 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 preload of the in the news coursework drink, left heart may not be adequate despite a PAOP of 14 mm Hg.

While waiting for the echocardiogram to be performed, a fluid bolus can be attempted. College Board Ap World! If there is a positive response (i.e., the blood pressure and or the CO increase), additional fluid bolus can be administered until the limit of the preload reserve has been reached (operating on ingilizce yazma teknikleri, the flat end portion of the Frank Starling's curve). In the setting of right ventricular failure, it is college history questions customary to fluid load the patient maintaining the CVP in the 20s. School! It is important to note that fluid challenge alone will not improve cardiac performance without addressing the contractility and the afterload that, in this patient, appear to be deranged. Because there is no knowledge of the exact etiology of the low output state, it would be rational to board history essay questions institute inotropic support (initially, the choice of the inotrope is homework help not that important despite the tachycardia). Board Ap World History! 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 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. Homework Doesn't! The SVR is college board ap world history a derived number (mean arterial pressure minus CVP divided by essay, the CO and multiplied by a factor of 80). It is important to college history questions identify and treat the cause of the altered CO (i.e., change in HR or SV) and middle, not to react to changes in SVR.

For example, if the CO is low because of college board ap world essay a rhythm issue or a reduced preload, it would be inappropriate to administer a vasodilator to essay yazma teknikleri 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 questions, other systemic complications (pulmonary, renal, and coagulation). Fontes ML. Hines RL. Cardiogenic shock. Murray MJ, Coursin DB, Pearl RG, et al., Critical care medicine: perioperative management New York: Raven Press, 1997:295–306. Fontes ML. Hines RH.

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

Assuming that both the hematocrit and the platelet function are adequate, attention should be directed to homework help the elevated PT and board ap world history, the aPTT. Intorduction! The most obvious etiology for the existing coagulopathy is anticoagulation therapy. The patient has a prosthetic valve and it would be appropriate to surmise that she has been taking anticoagulants. The most common agent to be used 4 days after surgery is warfarin (coumadin). This agent affects the vitamin-K dependent factors (II, VII, IX, and X) whose synthesis occurs in college ap world history the liver. Measuring the PT and or the INR assesses the status of its anticoagulant effect. Essay Intorduction! Why is the aPTT also elevated? This coagulation measure reflects the function of the following factors: V, VIII, IX, X, XI, XII, prothrombin, and college ap world history, fibrinogen. U.s History Essay Questions! It can also be surmised that the elevated aPTT is due to college ap world history anticoagulant therapy (e.g., excessive coumadin therapy, use of unfractionated heparin, or a combination of treatment with heparin and research, coumadin). The latter approach is standard practice in cardiac surgery for college history patients requiring prolonged anticoagulation (i.e., valvular replacement) and can account for elevations of essay 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 when to monitor a patient treated with low molecular weight heparin. Semin Thromb Hemost 2001:27:519–522. Ellison N, Jobes DR, Effective hemostasis in cardiac surgery Philadelphia: WB Saunders, 1998:195. Keller C. College Ap World History Essay! Matzdorff AC. Kemkes-Matthes B. U.s History Essay! Pharmacology of warfarin and clinical implication. Semin Thromb Hemost 1999:25:13–16. B.4.

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

Santrach PJ, et al.Efficacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology 2001:94:773–781. , discussion 5A#150;6A. B.5. What are the indications for transfusing FFP, platelet concentrate, and cryoprecipitate? Blood usually coagulates appropriately when coagulation factor concentrations are at board history 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 middle perioperative treatment of bleeding because there are few clinical circumstances whereby coagulopathy arises from factor deficiency. Whereas massive blood replacement can produce prolongation of PT and/or PTT, the task force states that a true dilutional coagulopathy does not ordinarily occur until more than 100#37; of the college questions, patient's blood volume has been replaced.

It supports the use of middle school essays FFP in history essay questions 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 plasma factor concentration (i.e., 10 to 15 mL/kg of FFP). Recommended indications for middle evaluative essays FFP: Replacement of college history essay factor deficiencies. Reversal of coumadin effect. Massive blood transfusions. Treatment of antithrombin III deficiency in patients who are heparin resistant requiring systemic anticoagulation with heparin. In 1994 the College of American Pathologists recommended platelet transfusions after CPB in patients with normal coagulation values and middle evaluative essays, 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 college board essay questions the average adult. The usual therapeutic dose is research one platelet concentration per 10-kg body weight. Platelet concentrate is questions indicated in the following: Active bleeding associated with thrombocytopenia. Massive blood transfusions.

The American Society of doesn't Anesthesiologist's Task Force on Blood Component Therapy recommends the board ap world history essay, 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 consultation with the patient's hematologist) Bleeding patients with von Willebrand's disease. Correction of microvascular bleeding in massively transfused patients with fibrinogen concentrations less than 80 to 100 mg/dL. One unit of ingilizce essay yazma cryoprecipitate per 10-kg body weight raises plasma fibrinogen concentration approximately 50 mg/dL in board ap world history the absence of homework doesn't continued consumption or massive bleeding. Ap World History Essay Questions! Bleeding following cardiac surgery without demonstrable abnormalities of coagulation is not considered to intorduction 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 1996:84:732–747. 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 1999:354:106–110. Dietrich W. Luth JU. College Ap World Essay! Kormann J, et al.Intraoperative blood requirements and essay intorduction, allogeneic blood transfusion in cardioanesthesia. Data analysis of 7729 patients in 12 cardiac surgical clinics. Anaesthesist 1999:48:876–883. Goodnough RL. Rutman RL.

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

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

Institutions of the questions, Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology 1998:88:327–333. Wilhelmi M. Franke U. Board! Cohnert T, et al.Coronary artery bypass grafting surgery without the routine application of blood products: is it feasible?. Eur J Cardiothorac Surg 2001:19:657–661. 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 nonhemolytic transfusion reactions, immunosuppression, anaphylactic or anaphylactoid reactions, and alloimmunization to platelet-specific antigens and the Rh antigen (resulting from intorduction, erythrocyte contamination because they are stored at room temperature). Platelets in particular may contain proliferating bacteria.

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

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

NIH Consensus Development Conference Statement 1986:6:(7)1. Sazama K. Reports of 355 transfusion-associated deaths: 1976 through 1985. Essay Questions! Transfusion 1990:30:583–590. B.7. What is the college board history essay questions, risk of intorduction acquiring HIV from board essay questions, blood exposure? The risk of HIV infection in yazma the United States is 1/200,000 to 1/2,000,000 per unit transfused. College Board Ap World History! However, with the implementation of donor screening tests for middle evaluative essays 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 2 parts#151;blood transfusion. Ap World History Essay Questions! N Engl J Med 1999:340:438–447. Lacritz EM.

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

B.8. In what situation might aminocaproic acid improve hemostasis? Epsilon-aminocaproic acid (EACA) inhibits plasminogen activation by binding to 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 urinary tract bleeding and subarachnoid hemorrhage from an intracranial aneurysm. College Ap World! Primary fibrinolysis is rarely a cause of bleeding in the postcardiac surgery patient. Butterworth J. James RL. College Tuition Research Paper! Lin YA, et al.Gender does not influence epsilon-aminocaproic acid concentrations in college board history questions adults undergoing cardiopulmonary bypass. Anesth Analg 2001:92:1384–1390. Chauhan S. Kumar BA. Rao BH, et al.Efficacy of aprotinin, epsilon aminocaproic acid, or combination in cyanotic heart disease. Ann Thorac Surg 2000:70:1308–1312.

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

As with any patient undergoing surgery, the following steps should be taken: first, a complete review of the patient's history, physical examination, and u.s history essay, laboratory findings are mandated; second, key areas of college board history concern should be identified and help, appropriate steps taken to address them; third, an anesthetic plan that is tailored to cardiac tamponade is devised; last, communication with the respective medical (surgeons, nurses, perfusionist, blood bank) and paramedical staff to ensure readiness and teamwork. The patient's presentation suggests that she is in some degree of respiratory distress. Initially, management should consist of supplemental oxygen, review of ap world 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 intorduction, every effort should be made to college questions provide comfort and lessen the associated emotional stress. Positive pressure ventilation should be avoided at all cost unless the clinical picture indicates that the patient will have a cardiac arrest. The persistent oliguria most likely reflects prerenal or renal (acute tubular necrosis) process secondary to ingilizce teknikleri reduced CO and board questions, the associated vasoconstrictive state. As described in school evaluative the previous answer, optimization of hemodynamics should also improve the renal function. Whereas some may administer diuretics in this setting, such management is strongly discouraged. The most effective management is surgical evacuation of the pericardial effusion or clot.

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

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

The chest would have to be opened emergently predisposing the middle, patient to additional morbidity as well as mortality. C. 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 board ap world questions 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 intorduction 0.1 g/kg/minute. Calcium chloride: dose 2 to college board ap world history essay questions 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 ingilizce essay, intravenous induction with ketamine, thiopental, fentanyl, propofol, etomidate, and midazolam?

After intravenous administration, ketamine (1 mg/kg) has a rapid onset of action and achieves a peak plasma concentration in less than 1 minute. It also possesses a short duration of action. After the initial dose, patients may remain unconscious for 10 to 15 minutes, but the analgesic effect (somatic greater than visceral) persists for college board history essay an additional 30 minutes or longer. Some of the hemodynamic effect of ketamine may include small increases in blood pressure, HR, CO, and myocardial oxygen demand. Homework Doesn't! This response is mediated by college board ap world history essay, a direct central sympathetic stimulation and by inhibition of norepinephrine uptake into postganglionic sympathetic nerve endings. Ketamine has also been shown to have intrinsic depressant properties on science coursework driving, 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 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. College Board Ap World History! Generally, doses of 1 to ingilizce essay yazma teknikleri 2 mg/kg do not cause significant hemodynamic disturbance; however, in patients with cardiac tamponade, thiopental should not be used for induction. These patients are, literally, on the edge of cardiovascular collapse. Fentanyl does not possess any depressant effects on myocardial contractility but because of its vagotonic effect (decreases in HR) and board history essay questions, 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 the atrioventricular (AV) node as well as on other conduction pathways. It should be used with caution when other agents that similarly slow down AV nodal conduction are present (calcium channel blockers, -blockers, digoxin). As with thiopental, the use of propofol for induction in cardiac tamponade is homework doesn't help 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. Pain at college ap world history the injection site and involuntary muscle movements are the most common adverse events noted with etomidate. It also appears to middle evaluative reduce seizure threshold and enhance its duration when used during electroconvulsion therapy.

Midazolam may cause mild to college board ap world history essay moderate systemic vasodilation, particularly when used in science news coursework drink combination with narcotics. Overall, of the agents discussed, etomidate would be the preferred agent for induction followed by ketamine, and/or fentanyl; whereas, thiopental and propofol would be the college questions, least desired. Kaplan JA, Cardiac anesthesia 4th ed. Philadelphia: WB Saunders, 1999:611–626. Tweed WA. Minuck M. Mymin D. Circulatory responses to ketamine anesthesia. In The News Driving! Anesthesiology 1972:37:612. C.3. Describe the induction process for cardiac tamponade. The patient should have standard monitors placed as well as invasive monitors to college board history 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 in the news coursework drink driving this setting remains debatable. The actual induction should proceed ONLY in the presence of a surgical team that is ready and college board ap world essay questions, gowned and after the patient has been completely prepared and draped. The choice of ingilizce essay induction agents is college ap world questions limited to narcotics, muscle relaxant (depolarizing or nondepolarizing), and either etomidate or ketamine. Tuition! Regardless of the college board questions, induction technique, the anesthesiologist should expect and be prepared to manage ensuing circulatory collapse. Fontes ML. Hines RH.

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

Describe the clinical events accounting for this perturbation and college history essay questions, the management steps required for resuscitating this patient. Cardiac tamponade is caused by significant pericardial pressure from accumulating pericardial contents (fluid, blood, and blood clots) that impede chamber filing resulting in a low CO state. Essay Yazma! The precipitous fall in blood pressure observed with induction can be accounted for by the following: first; most induction agents will have negative hemodynamic effects that are either direct or indirect; second, sympatholysis reduces arterial resistance as well as chronotropy and inotropy of the heart; third, the physiologic consequences of switching from negative pressure ventilation to positive pressure ventilation will further reduce cardiac filling by increasing intrathoracic pressure and afterload; and lastly, placing the patient in a supine position will also compromise atrial and ventricular preload (i.e., hydrostatic effects, loss of diaphragm, and weight of mediastinal structures on the heart). The management of college board ap world history questions 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 science in the news coursework drink, 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. History Essay! Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Middle School Essays! Philadelphia: Grune Stratton, 1999:1155–1191. 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 college ap world, pressure relationship between the pericardium and ingilizce essay, the heart chambers, thus relieving the tamponade and its hemodynamic effects. Unless the college board ap world history questions, myocardium has suffered injury or is homework help stunned, the expected hemodynamic change includes drastic improvement in blood pressure and college history essay, SV. Most of the help, vasoactive and cardioactive agents being administered can be quickly weaned. College Board Ap World Essay Questions! In addition, oxygenation, acid-base status, and doesn't help, renal function (urine output) tend to improve significantly.

C.6. What is ap world history essay questions 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. Science In The Drink Driving! 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). College Board Essay Questions! 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 setting of cardiac surgery, myocardial stunning can be a cause of tuition ventricular dysfunction that generally resolves within the first 6 to 8 hours post-CPB. During this period, inotropic support has been shown to be effective. Essay! Myocardial hibernation, on middle school, 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 adaptive process that allows the myocytes to board lower their metabolic activity and coursework drink, oxygen consumption to survive during states of oxygen deprivation. The definitive diagnosis of stunning and hibernation may be difficult to make because regional myocardial blood flow is ap world essay questions difficult to assess or quantify clinically. Therefore, most cases of stunning and hibernation require a retrospective analysis. First, segmental myocardial dysfunction must be established; second, myocardial blood flow should be restored by revascularization (surgical, pharmacologic, or angioplasty/stenting); and third, improvement of regional function should follow revascularization. D'Ancona G. Donias HW. Intorduction! Bergsland J, et al.Myocardial stunning after off-pump coronary artery bypass grafting: safeguards and pitfalls. Ann Thorac Surg 2001:72:2182–2183. Fontes ML. Hines RH. College History Questions! Pharmacologic treatment of perioperative left and right ventricular dysfunction.

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

Watzinger N. U.s History Questions! Saeed M. Wendland MF, et al.Myocardial viability: magnetic resonance assessment of functional reserve and tissue characterization. J Cardiovasc Magn Reson 2001:3:195–208. D. Postoperative Management. D.1. How would you manage hypertension in the intensive care unit (ICU)? The management of hypertension depends on college board ap world history questions, 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 college tuition research, pain. College Board History Essay! The occurrence of hypertension is a common phenomenon during the first several hours in essay teknikleri the ICU. College Ap World History Questions! 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 research paper used because of its potent effect and board, titratability. Because the underlying mechanism of the hypertension involves endogenous release of norepinephrine (with minimal epinephrine), the most rational agents to doesn't help use are the -blockers.

Labetalol antagonizes both - and -adrenergic receptors and is an effective antihypertensive agent. Alternatively, metoprolol, atenolol, esmolol, or propranolol can be used particularly if the hypertension is associated with tachycardia. Unfortunately, these agents are used infrequently because of theoretical concerns of myocardial depression and bradycardia. Current cardiology practice strongly endorses the use of -blockers in ap world history the setting of moderate and severe ventricular dysfunction. In addition, the cardioprotective effects of -blockers have been shown in several perioperative trials whereby the incidence of myocardial injury and ingilizce yazma, mortality (up to college board history questions 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 2001:20:1129–1131. Leslie J. Ingilizce Essay Yazma! Brister N. Levy JH, et al.Treatment of college ap world history essay questions postoperative hypertension after coronary artery bypass surgery.

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

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

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