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Sample Reviews from the Mental Measurements Yearbook. Below are three sample reviews like the ones you will find in the pages of the Mental Measurements Yearbook or online through Test Reviews Online. Most tests will have two reviews by two independent reviewers, and will contain descriptive information and an evaluation of the test's technical properties. All Mental Measurements Yearbook test reviews are copyrighted by the Buros Institute. New England Vs Chesapeake? Reviews may be printed for individual use only, and may not be otherwise duplicated or distributed without consent. Information on citations of test reviews can be found on the Buros website under FAQ.

Draw-A-Person Intellectual Ability Test for Children, Adolescents, and Adults. Purpose: Designed to estimate intellectual ability from merton's strain, a human figure drawing. Administration: Individual or group. Price Data, 2006: $99 per vs chesapeake colonies complete kit including examiner's manual (75 pages), 50 administration/scoring forms, and 50 drawing forms; $45 per Vavasor Essay examiner's manual; $40 per 50 administration/scoring forms; $25 per 50 drawing forms. Authors: Cecil R. Reynolds and Julia A. Hickman.

Review of the Draw-A-Person Intellectual Ability Test for Children, Adolescents, and Adults by JONATHAN SANDOVAL, Professor of Education, University of the Pacific, Stockton, CA: DESCRIPTION. Vs Chesapeake? The Draw-A-Person Intellectual Ability Test for Children, Adolescents, and Adults (DAP: IQ) consists of the evaluation of 23 features of a human figure drawing produced in response to the instruction draw a picture of yourself (examiner's manual, p. 5). Examples Of Pull Factors? Examinees are asked to draw a full figure from a frontal view. Each of the drawing features (e.g., eyes, clothing, arms) is individually scored from 0 to 1, 0 to 2, 0 to 3, or 0 to 4 points. A maximum score of 49 points is possible.

Raw scores may be converted into a single standard score, an new england, IQ with a mean of 100 and standard deviation of 15, a T-score, a z-score, or a stanine. Examples? The manual also provides percentile ranks, age equivalents and grade equivalents. The test may be individually or group administered to new england colonies individuals from jungian archetypes, age 4 years to 89 years and 11 months and is untimed. The time to administer and score the test is from 8 to 15 minutes. Administration requires a pencil with eraser and drawing form. The administration/scoring form is used to record test information and the scoring of each drawing feature. The authors recommend that examiners using the measure be formally trained in vs chesapeake, assessment and combustion have knowledge of current theories of cognitive development and neuropsychology. The examiner's manual is straightforward and new england colonies provides technical information, normative data, and scoring examples. The test is not intended to punker look provide a comprehensive evaluation of cognitive ability. The developers claim it offers a lower bound estimate that may supplement, and have less cultural specificity than, other intelligence tests.

It may be inappropriate for use with examinees who have visual or motor impairments. DEVELOPMENT. New England? The DAP: IQ is the latest in punker look, a long line of measures aimed at new england vs chesapeake, using human figure drawings as estimates of cognitive ability. In the past, these measures have focused on children, and men themes the authors of this test wished to extend the applicability to adults. New England? Additionally, the of pull, authors hoped to develop a single set of criteria to new england colonies be used across the age span with both genders. Strain? Another goal was to produce current norms, and to reduce the influence of motor skill on the scoring of vs chesapeake colonies figure drawings. TECHNICAL.

Norms for the test were based on 2,295 individuals matched to U.S. Census data from 2001 with regard to geographic area, gender, race, Hispanic origin, family income, educational attainment of parents, and disability status. The normative sample was obtained by soliciting volunteer examiners from the publisher's customer files and setting up additional sites throughout the country with a focus on Texas. More protocols were collected than used in scoring, so the match to census information could be obtained. Samples were obtained at each age from 4 to 16 and thereafter in age ranges (10-year groupings from combustion of alcohol, 19 to vs chesapeake colonies 40, a 15-year grouping from 40 to 55, a 5-year grouping from 60 to merton's strain theory 75, and a 15-year grouping from 75 to new england vs chesapeake colonies 90). These age brackets of scores were developed from a continuous norming procedure and are consistent with cognitive developmental theory. There is some evidence of internal consistency and stability of the DAP: IQ score. The coefficient alpha estimates for the age groupings varied from .74 at age 4 to .87 at age 30-39, with a mean and median value of .82. The standard errors of measurement vary between 4 and jungian 5 points.

Alphas calculated by gender, ethnicity, and colonies handedness indicate the same range of 12 angry men themes coefficients. The manual reports as evidence of reliability, correlations with scoring systems by new england, Koppitz and Goodenough-Harris by three scorers. Punker Look? These correlations are .85, .86, and .86. Colonies? This information is more usually considered evidence of Powell Essay concurrent validity. Stability estimates over new england vs chesapeake colonies a short 1-week period yielded a test-retest correlation of .84 (n = 45).

Interscorer reliability was estimated at punker look, .95 for protocols selected from across the sample, and at .91 for the more difficult-to-score age group of 6 to 11. In all, the estimates of reliability are acceptable and comparable with the new england, reliabilities found for other human figure drawing tests. The test developers provide validity information based on theory, on content, on merton's, response processes, on new england colonies, internal structure, and on relationship to other constructs. The scoring on the tests across ages parallels the theoretical progress of the expression of fluid ability across the lifespan. The content of the test has been used historically to estimate general mental ability in several other measures. The partial point-biserial correlations between each item and the adjusted total are sufficient to suggest the items are tapping the same construct, as do the alpha statistics. A rationale for the test is that everyone regardless of culture or economic background commonly experiences the human figure. The content is also less influenced by education and the task is simple.

External evidence of validity includes total score correlations with scores derived from other scoring systems, and correlations with other established measures of intellectual functioning and achievement. Correlations between DAP: IQ total score and the Detroit Tests of Learning Aptitude-Primary: Second Edition scores (all corrected for theory, unreliability) are .60 for Nonverbal, .42 for new england vs chesapeake, Verbal, and .54 for General Mental Ability. For the Wechsler Intelligence Scale for Children-III correlations are .33 with Verbal, .49 with Performance, and archetypes .46 with Full Scale. The DAP: IQ correlates .39 with Woodcock Johnson-Revised (WJ-R) Broad reading, and .36 with Wechsler Individual Achievement Test (WIAT) Reading. Correlations with Math are .46 with WJ-R Broad math and .43 with WIAT Math. The authors report additional moderate correlations in colonies, the same range for other subject scores on these achievement measures for children between 6 and 11 years of age. Both convergent and divergent validity data are reported. The DAP: IQ has moderate correlations (around .40) with the Developmental Test of Visual Perception-Adolescent and Adult, a measure of visual and jungian archetypes motor perception administered to standardization sample participants 11 years of age and up, and new england vs chesapeake colonies lower correlations (between .36 and .25) with the Developmental Test of Visual-Motor Integration and Bender-Gestalt Test using the Koppitz scoring system for children ages 4 through 10, suggesting the test shares some variance with visual perceptual skill. Vavasor Powell Examples? The low correlation of colonies .18 with a measure of motor speed, the composite score of the Comprehensive Trail Making Test, is evidence that the test does not tap rapid motor skill or sequencing ability.

Very small correlations with scores from the strain theory, Rey Complex Figure Test and Recognition Trial indicate that copying skill alone is not assessed by the DAP: IQ. The examiner's manual also presents data on subgroup performance. In the normative sample, there were no differences in means above the 4-point SEM for gender, handedness, or four of the five ethnic groups examined. However, the African American mean was 6 points below average. A group from the standardization sample labeled mildly mentally retarded had a mean score of 77 and a group labeled learning disabled had a mean of 92 on new england vs chesapeake colonies, the DAP: IQ. The test developers addressed potential fairness issues by examining differential item functioning on the test by ethnicity and gender.

The results showed moderate or large effect sizes for four items on gender, although they balanced each other, and no moderate or large effect sizes in the race and ethnic comparisons. COMMENTARY. Human figure drawing measures offer a useful adjunct to the assessment of punker look intellectual functioning. Vs Chesapeake? The DAP: IQ has a large normative base, is quick to administer, and is easy to score. The norms would only seem to approximate roughly the geographical distribution of the population, because much of the data are from Texas, and many samples of convenience were combined to punker look produce them. However, the norms are based on a larger sample than other similar measures, have been examined with sophisticated psychometric methods, and are more current. Much more evidence on vs chesapeake colonies, reliability and validity will be needed, as the men themes, manual reports only the vs chesapeake colonies, minimum necessary to meet standards. For example, studies could be done testing multiple drawings done at the same time (Draw yourself and someone of the opposite gender) and across somewhat longer spans of Vavasor Powell Essay time. The test developers have not mentioned why they have excluded parallel forms of the test as are found on other drawing tests.

Most of the validity information to date has been collected on children up to new england vs chesapeake colonies age 12. More studies with other age groups and with other well-validated verbal and jungian archetypes nonverbal measures of intellectual functioning need to vs chesapeake be done before the test may be confidently used with adolescents and adults. A major use of the test may be with English language learners because of punker look its nonverbal nature. The language status of the Latino and new england Asian children in the standardization sample and men themes other research samples was not discussed. Studies of the performance of the DAP: IQ with English language learners would be welcome to justify this application of the test.

The test developers claim that the estimate of new england vs chesapeake colonies intellectual functioning on men themes, this test is a lower bound estimate, but this assertion will need to be validated, as some children and adults may have domain specific skill in drawing that exceeds their general cognitive ability. SUMMARY. The DAP: IQ authors have succeeded in providing a successor to colonies the Goodenough Harris Drawing Test (T7:1084) and others. It can be used for rough screening and verifying other test results, particularly when language is an issue. It has been developed using modern constructs and modern psychometric methods. The reliability and validity information, although somewhat limited, justify the combustion, cautious and judicious use of the test. All Mental Measurements Yearbook test reviews are copyrighted by the Buros Institute. Reviews may be printed for individual use only, and may not be otherwise duplicated or distributed without consent. Information on citations of test reviews can be found on the Buros website under FAQ.

Purpose: To measure visuo-spatial learning and recall. Scores, 5 : Learning Index, Displacement Score, Total Displacement Score, Delayed Recall, Delayed Recognition. Price Data, 2006 : L113.50 per complete kit including manual (15 pages), 25 scoring sheets, test grids, practice grids, and picture cards; L35.50 per 50 scoring sheets. Authors: Romola S. Bucks, Jonathan R. Willison, and Lucie M. T. Byrne. Publisher: Harcourt Assessment [England]. Review of the colonies, Location Learning Test by ANITA M. HUBLEY, Associate Professor of Measurement, Evaluation, and Vavasor Powell examples Research Methodology, University of British Columbia, Vancouver, British Columbia, Canada: DESCRIPTION.

The Location Learning Test (LLT) is an individually administered measure of visuospatial learning, recall, and new england colonies recognition designed for older adults. The authors claim it will be particularly useful to professionals interested in the effects of aging, dementia, or drugs/alcohol. Combustion Of Alcohol? There are two forms of the test. Each begins with a practice trial; if the examinee fails the practice trial, testing stops. Otherwise, the examinee is shown a 5x5 grid on which 10 common objects are pictured. The examinee observes the new england colonies, layout of the punker look, objects for 30 seconds before he or she is provided with a blank grid and asked to place cards showing the objects, one by one, in the correct squares of the colonies, grid. There are five learning trials, although testing may stop earlier if the examinee scores perfectly on punker look, two consecutive trials. After a 15-minute interval, either delayed recall or recognition may be administered, but not both. For the delayed recognition task, the examiner combines the 20 cards showing the common objects from Versions A and B and, one by one, asks whether each picture was on the grid or not.

The administration instructions are clear and easy to follow. New England Vs Chesapeake? The authors do not describe how long it takes to administer the test, but it should take about 30 minutes (including the delay interval). Recording performance and computing displacement scores (i.e., the total number of combustion of alcohol squares away from correct placement for objects) for each trial is quick and easy. Four key scores are computed. The Total Displacement Score is the sum of the colonies, displacement scores on each trial. The Learning Index shows the Vavasor, rate of improvement across the learning trials.

A calculator is needed to avoid errors in computing the ratios used to obtain the average improvement. The Delayed Recall Score shows the amount of information forgotten over the delay interval. Finally, the Discrimination Index reflects the ability to discriminate target items from distractors on new england vs chesapeake, the recognition task. No information is of alcohol, provided about how long it takes to vs chesapeake score performance. DEVELOPMENT. In developing the LLT, the authors wanted a visuospatial test that would (a) assess learning and recall of visuospatial information, (b) be appropriate for older adults, and (c) not require complex or fine motor control, drawing ability, or verbal ability. The authors trace the origins of the LLT to some informal work (manual, p. 3) by Shallice and Warrington in the early 1980s and an experimental version developed by a Master's student of one of the authors in 1986.

An early version of the test (Bucks Willison, 1997) consisted of a single form with 10 colored line drawings of common objects (9 of which differed from the objects in the current LLT) and a 30-minute delayed recall. A recognition trial was administered after the first learning trial. Jungian? The 5x5 grid was selected because it could not be easily divided into quadrants by examinees; objects were placed randomly with the restriction that none would be placed in the corners. The locations of new england vs chesapeake objects for Version B are the same as for Version A, but have been rotated 180 degrees. Examples? Overall, however, little detail is provided about the development of the LLT. For example, no information is provided about why 10 objects were used, how specific objects were selected for the test, whether objects in new england colonies, both versions are equally common, why a 30-second observation period was selected, why five learning trials were selected, why a 15-minute delay interval was selected, how the scoring approach (i.e., displacement scores) was developed, and strain how the final set of scores was selected. TECHNICAL. The standardization sample for LLT Version A consisted of 186 community-dwelling men and women ages 50 to 96 years living in England. The majority of the sample was from the Bristol area (n = 128). No information is provided about race/ethnicity of the sample and, although the authors tried to obtain a sample from a range of social classes and obtained National Adult Reading Test (NART) estimates of IQ, the sample is not necessarily representative of the larger population. Normative data are provided separately by age group (50-69, 70+ years) and NART-IQ group (85-99, 100-114, 115+).

A 2 x 3 x 4 (gender x NART-IQ group x age decade) ANOVA was conducted to colonies determine the normative groups to be used; however, it is unclear how many men and women were obtained in each age decade and the small sample size raises concerns about the statistical power of the analyses and thus the selection of normative groupings. As the punker look, authors noted, the new england vs chesapeake colonies, norms are not appropriate for individuals with NART-IQs less than 85 and caution should be exercised when using the norms for individuals with NART-IQs in the 85-99 range. Norms are provided in Vavasor Powell, the form of percentile ranks for Total Displacement Score, Learning Index, and Delayed Recall Score and a 5% cutoff score for the Delayed Recognition Discrimination Index. Although the entire standardization sample completed all five trials of the LLT, the norms for Delayed Recall and new england vs chesapeake Delayed Recognition are based on very small groups as participants only completed one of merton's these tasks. Meaningful estimates of new england colonies reliability for memory tests are often difficult to obtain due to features such as item interdependence within and punker look between trials and practice or recall effects. In the present case, parallel forms reliability was sought using LLT Version B, which was completed by a subsample of only 49 individuals and could not be examined by new england colonies, age and NART-IQ group.

The majority of this group (n = 31) completed Version A first and Version B 1 week later; the rest completed the tests in archetypes, the reverse order. Colonies? The two versions correlated .71 for the Total Displacement Score and .49 for the Learning Index. The correlation of the two versions at delay was not reported. Very limited validity evidence is provided to support inferences made from the LLT. The test manual reports that correlations between the LLT Learning Index and two visual tasks (the Design Learning subtest of the Adult Memory and Information Processing Battery [Coughlan Hollows, 1985] and the Shapes test from Doors and People [Baddeley, Emslie, Nimmo-Smith, 1994]) were in the low moderate range (rs = .49 and .44, respectively) but were higher than the correlation (rs = .22) with the Hopkins Verbal Learning Test (Brandt, 1991) in theory, a sample of 47 older adults. Correlations between the LLT Displacement Score and both the Design Learning subtest and the HVLT were similarly low (rs = -.24 and -.29) whereas the correlation with the Shapes test was slightly higher (rs = -.37). This is colonies, fairly weak evidence. Further validation work is needed, including contrasted or known groups validity that shows LLT performance differs between cognitively intact and impaired samples. For example, some promising preliminary work conducted with an earlier version of the LLT showed performance differed between small groups of cognitively intact elderly and dementia patients (Bucks Willison, 1997), but this needs to be shown with the current version of the test. COMMENTARY.

The LLT is a brief and easy test to administer that shows a great deal of promise. Its key strengths are that it has ecological validity for examples, older adults and does not rely on complex or fine motor control, drawing ability, or verbal ability. Scoring is not too difficult but does require a calculator. Vs Chesapeake? The norms need to be strengthened using a larger and perhaps more ethnically and geographically diverse sample. The evidence supporting the jungian archetypes, parallel forms reliability of Versions A and B is not convincing enough to recommend using the norms with Version B. In future development of the LLT, the authors might consider using statistical equating procedures to equate performance on Versions A and B. Most critically, however, validity evidence is extremely limited. New England Vs Chesapeake? It is surprising that a test that the 12 angry men themes, authors describe as particularly useful to . those concerned with the effects of dementia and ageing, as well as the effects of drugs and stressors such as alcohol, benzodiazepines and cholinesterases (manual, p. 4) is presented without any validity evidence to new england vs chesapeake back up these claims. Once appropriate validity evidence is obtained, the manual would benefit from the addition of strain specific recommendations to colonies assist test users with interpretation of the results (e.g., case studies with different profiles of performance or different clinical groups). SUMMARY. The LLT was designed to jungian be an individually administered measure of visuospatial learning, recall, and recognition for older adults that would be of particular use to professionals interested in the effects of aging, dementia, and drugs/alcohol.

The test meets its goal of new england vs chesapeake assessing visuospatial learning, recall, and recognition in 12 angry, an ecologically valid manner and stands out from the majority of visuospatial tests in that it does not rely on complex motor control or drawing ability. Unfortunately, very little validity evidence is provided to support the inferences to be made from the LLT and the lack of known groups validity evidence, in particular, means the LLT cannot be recommended for clinical use at this time. All Mental Measurements Yearbook test reviews are copyrighted by the Buros Institute. Reviews may be printed for individual use only, and new england may not be otherwise duplicated or distributed without consent. Essay? Information on citations of test reviews can be found on the Buros website under FAQ. Purpose: Designed for adult probation and parole risk and needs assessment. Colonies? Population: Adult probationers and parolees. Scores: 8 scales: Truthfulness, Alcohol, Drugs, Resistance, Aggressivity, Violence, Antisocial, Stress Coping Abilities. Price Data: Available from publisher. Comments: Both computer version and paper-pencil formats are scored using IBM-PC compatibles; audio (human voice) administration option available.

Author: Risk Needs Assessment, Inc. Publisher: Risk Needs Assessment, Inc. Cross Reference: For a review by Tony Toneatto, see 12:338. Review of the SAQ--Adult Probation III by ROBERT SPIES, Associate Director, Buros Institute of Mental Measurements, University of merton's strain Nebraska--Lincoln, Lincoln, NE, and MARK COOPER, Training Specialist, Center on Children, Families the Law, University of vs chesapeake colonies Nebraska--Lincoln, Lincoln, NE: DESCRIPTION. The Substance Abuse Questionnaire--Adult Probation III (SAQ) is a 165-item test, administered either by paper-and-pencil or computer.

All items are of the selection type (predominantly true/false and multiple-choice). Risk levels and recommendations are generated for examples of pull factors, each of vs chesapeake eight scales: Alcohol, Drug, Aggressivity, Antisocial, Violence, Resistance, Stress Coping, and Truthfulness. Theory? The Truthfulness scale is meant to identify test-takers who attempt to minimize or conceal their problems. Nonclinical staff can administer, score, and new england interpret the SAQ. Examples Of Pull? Data must be entered from an answer sheet onto a PC-based software diskette. The computer-generated scoring protocol produces on-site test results--including a printed report--within several minutes. New England Vs Chesapeake Colonies? For each of the punker look, eight scales, the report supplies a percentile score, a risk categorization, an explanation of the risk level, and (for most scales) a recommendation regarding treatment or supervision. The percentile score apparently is based on the total number of new england problem-indicative items that are endorsed by the test-taker.

According to the Orientation and Training Manual, each raw score then is truth-corrected through a process of combustion of alcohol adding back into each scale score the amount of error variance associated with a person's untruthfulness (p. 8). The adjusted percentile score is colonies, reported as falling within one of four ascending levels of risk (low, medium, problem, severe problem). The responsible staff person is expected to combustion of alcohol use information from the report, along with professional judgment, to identify the severity of risk and needs and to develop recommendations for intervention. DEVELOPMENT. This SAQ is the latest version (copyright, 1997) of a test that has been under development since 1980. The original SAQ, intended for assessment of adult substance abuse, has been adapted for use in risk and needs assessment with adult probation and parole clients. Two scales--the Antisocial and Violence scales--have been added since development of the SAQ in 1994.

Materials furnished by the developer (including an Orientation and Training Manual and An Inventory of vs chesapeake colonies Scientific Findings) provide minimal information regarding initial test development. The definitions provided for each scale are brief and relatively vague. The constructs underlying several scales appear to overlap (e.g., the Aggressivity and Violence scales), but little has been done to theoretically or empirically discriminate between these scales. Merton's Strain Theory? No rationale is offered in new england colonies, the manual for how these scales fit together to measure an examples of pull factors, overarching construct of substance abuse. The developer cites no references to new england vs chesapeake colonies current research in the area of substance abuse. TECHNICAL. Information describing the norming process is vague. The Orientation manual makes reference to archetypes local standardization, and annual restandardization, but does not provide details. In one section the developer claims to have standardized the SAQ on the Department of Corrections adult offender population (p.

7). In another report, standardization is new england vs chesapeake colonies, said to have eventually incorporated adult probation populations throughout the merton's, United States (An Inventory of Scientific Findings, p. 5). One might assume, based on new england vs chesapeake, the citing of SAQ research studies involving literally thousands of probationers that the 12 angry men themes, recency and new england vs chesapeake relevance of norms is beyond question. The developer, however, has not provided the punker look, documentary evidence needed to justify this assumption. The developer has investigated--and found--gender differences on some scales with certain groups to whom the test has been administered. In response, gender-specific norms have been established for those groups (usually on a statewide basis). Vs Chesapeake? There is no evidence that other variables such as ethnicity, age, or education have been taken into account in the norm-setting process. The items selected for use in merton's, the test have several commonalities. Most items focus on personal behaviors, perceptions, thoughts, and attitudes and are linked in a direct and very obvious way to the content of new england vs chesapeake associated scales (e.g., I am concerned about Powell Essay my drinking, from the Alcohol scale). Almost all items are phrased in new england vs chesapeake, the socially undesirable direction; agreeing with the item points to the existence of a problem or a need for intervention.

The developer acknowledges that the items may appear to some people as intrusive, and that clients are likely to factors minimize or under-report their problems. In the SAQ, the response to new england this concern has been the inclusion of the Truthfulness scale and calculation of truth-corrected scale scores. Unfortunately, the statistical procedures underlying this important score correction are neither identified nor defended. Internal consistency for the individual subscales of the SAQ has been well-established by a large number of developer-conducted studies that report Cronbach alpha estimates generally in the .80s to .90s. These high values for internal consistency may in part be explained by the similarity of the items within each scale (i.e., repetition of the examples of pull factors, same basic question, using slightly different words or context). Evidence of other reliability estimates (other than for internal consistency) to support this instrument generally are lacking. The Inventory of Scientific Findings cites only one study in which a test-retest reliability coefficient was reported. Administering an early version (1984) of the SAQ to a small sample of 30 college students (not substance abusers or legal offenders), a test-retest correlation coefficient of .71 was found across an interval of one week.

Evidence to support the validity of the SAQ is limited. New England? Some concurrent validity evidence is presented, in of pull, the form of multiple studies showing modest correlations between some SAQ scales and subscales of the Minnesota Multiphasic Personality Inventory (MMPI). The developer indicates that the MMPI was selected for this validity study because it is the most researched, validated and new england widely used objective personality test in theory, the United States (Inventory of Scientific Findings, p. 14). This explanation, however, does not suffice as a rationale for vs chesapeake colonies, use of the MMPI to support concurrent validity; and no theoretical framework is provided about how the SAQ subscales relate to the personality constructs underlying the MMPI. In other reported studies, the SAQ is shown to be modestly correlated with polygraph examinations and the Driver Risk Inventory (DRI). Again, the developer does not adequately specify how any correlation between these measures advances the efforts at jungian, validation. New England? The studies cited, and the validation process in general, do not meet accepted psychometric standards for substantiating validity evidence established in the Standards for Educational and Psychological Testing (AERA, APA, NCME, 1999). Of Alcohol? These same deficiencies were noted in new england colonies, the prior review of the SAQ (12:338), but no corrective action appears to have been taken. COMMENTARY.

The value of the SAQ as a measure of substance abuse severity with criminal justice populations seems to be compromised on a number of levels. Examples? First, the vs chesapeake, test lacks a clear focus. Only two of combustion eight scales deal directly with substance abuse, and the developer has made no attempt to combine the scale scores into some form of aggregate substance abuse severity score. Given this, the test name is a bit misleading, and the test itself probably is most wisely judged on the basis of the eight individual scales. Second, there are concerns--previously noted--about the individual scales and vs chesapeake items selected for strain theory, the scales.

Included within those concerns are lack of construct articulation, lack of construct differentiation among scales, the predominance of items that are phrased in a socially undesirable direction, and homogeneity of item content within scales. Item phrasing and the bluntness of the items (e.g., I am a violent person, from the Violence scale) would appear to invite problems with response sets. The use of truth-corrected scores to handle problems with test-taker denial cannot be fairly evaluated due to insufficient information from the developer. Last, caution in the interpretation of reported risk levels and new england vs chesapeake risk level recommendations must be advised. The developer, for example, has determined that percentile scale scores falling within a given percentile interval represent a medium risk level, whereas scale scores falling within a contiguous but higher interval of scores qualify for 12 angry, a problem risk level. There is no clarification, however, of the meaning of the vs chesapeake, labels medium and problem. Further, there are no statements regarding how the two risk levels are to be discriminated from combustion of alcohol, one another, and no identification of new england vs chesapeake colonies outcomes (or probabilities of punker look outcomes) that are tied to the levels. The categorization of scores into risk levels essentially amounts to implementation of new england colonies three cut scores on each scale. Given the developer's failure to ascertain or cope with errors of examples of pull factors measurement, the risk level interpretations and their corresponding recommendations are substantially compromised.

SUMMARY. The developers, to their credit, have produced a risk assessment instrument that can be administered, scored, and interpreted in a relatively efficient and cost-effective manner. They have considered thorny issues such as denial on the part of test-takers and gender differences in the norming process, but the differential impact of ethnicity and age has not been addressed. An earnest attempt has been made to vs chesapeake provide risk assessment information and recommendations that are pertinent to of pull factors the demands of the criminal justice practitioner. On balance, however, the SAQ falls far short of the mark. Insufficient reliability or validity evidence exists to assert that the test consistently or accurately measures any of its associated constructs. New England Colonies? There is continued doubt, in the words of the prior reviewer of the merton's strain theory, SAQ, that the test conveys any useful information additional to simply asking the client if they have an alcohol-drug problem, if they are violent, and colonies how they cope with stress (Toneatto, 1995, p. 891).

Readers seeking an alternative test for a substance abusing population may wish to consider tests such as the Substance Abuse Subtle Screening Inventory (SASSI).

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30 Amazingly Creative Examples of Designer Resumes. It#8217;s extremely hard to find a job these days! The market is slow, the economy is bad, and the competition is fierce. Vs Chesapeake Colonies? To get a job you will have to stand out of the crowd. The following resumes go against theory, everything my business teacher taught me. She taught us to never place a picture of yourself, use clip art, use icons, graphics, or make it colorful. Basically keep it as dull and ugly as you can. Please keep in mind that if you apply to companies that have nothing to vs chesapeake, do with the design field, they wont appreciate your artfulness. What they want to archetypes, see is a plain and new england boring white paper that has your experience, awards, education, and info in black ink.

However, I think if you are in the design field you need to men themes, show off your creativity. The employer will go through hundreds of resumes, so you have to new england colonies, demonstrate that you can think out side the box. For this exact reason you should take some time and perfect your resume. Once its finished, you will have it saved and archetypes ready to print whenever the vs chesapeake opportunity strikes! To help you out on this mission we have collected some of the best designer resumes we could find. We hope these beautiful resumes will get your creativity fluids flowing. Resume is a French word that means summing up.

A resume packages your assets into a convincing advertisement that sells you. The main purpose of the jungian archetypes resume is to win the interview. Thus beating the competition for new england vs chesapeake colonies, the job you are applying for. Two critical aspects of a resume is appearance and content. Below we have compiled a useful guide to follow when working on your resume. The tips can be use for both, a professional and merton's strain theory design based resume. Write it Yourself Brief, Concise, Action-Oriented Rewrite/Revise Accurate (Not Puffed Up) Emphasize Strengths Deemphasize Weaknesses Have your resume professionally edited.

Photos or Illustrations ( In the Design Field you can go against this rule) Reasons You Left Past Jobs Salary Feelings About Travel or Relocation Testimonials Politics or Religion. New England? Personal Data/Contact Information Education Experience (Appropriate Volunteer Work) Achievements, Skills, and Qualifications. Objective References Awards and Honors Job-Related Outside Interests Professional and Social Organizations. Cleanly clearly typed or typeset Logically and simply organized Simply laid out, with as much white space as the information will allow Short and concise Targeted to the prospective employer Designed to emphasize strengths and de-emphasize weaknesses In format that is most appropriate to the education, experience and skills of 12 angry each person. Remember: Stay away from being boring and try to new england vs chesapeake, tackle this task creatively. Note: The following resumes are all linked to a bigger version. We hope the information and inspiration above will allow you to create your mind-blowing CMYK resume!

Please dont forget to subscribe to the RSS-feed and 12 angry follow Inspirationfeed on Twitter+ Facebook(100% Spam Free!) If you enjoyed the following article please let us know if you disagree or agree with this subject in the comment section below, and help us spread the word. Vs Chesapeake? I'm a digital nomad and entrepreneur bouncing around South East Asia. When I'm not working here, I'm out taking photos. Follow me on Instagram: @igorovsyannykov. Nice collection, enjoyed it.

But when you are a webdesigner isnt it smart to design your resume as a website? Not only can you give the needed information, in of alcohol, a readible and clean layout, but you instantly give insight in your qualities as a webdesigner? .. its just a thought? I have done this and new england vs chesapeake colonies have experienced it was a good move! Wanna see my online CV [in Dutch]: Thanks for sharing, cheers ciao .. Great collection and of alcohol variation of resumes. Thanks for sharing #128578; Very creative and very original. These styles, however, would not work for most job seekers. Consider your audience! Very creative. Easy to understand, complex to make.

Easy to understand, lots of work in conceptualization and making. Thank you. These CV#8217;s would end up in the bin to most employers. A CV should be clear and concise, not a piece of artwork. You can show off your work at the interview stages. Employers have 3-5 secs attention span when looking at CVs. If yours is complicated to read then it will be discarded and the person below may get the new england colonies interview. 12 Angry? Excellent examples. One item I would add to the #8220;do#8221; list is to new england vs chesapeake, have your resume professionally edited. It#8217;s amazing how well a resume can read when #8220;touched#8221; by a professional editor.

You are right, this would be a smart move before sending it out. It would be much better if resume#8217;s were always in this format. You would see the creativity in every person. Combustion? Some of these are really great. However#8230; the one in Comic Sans. Really? COMIC SANS? WHY IS THAT EVEN INCLUDED?

Who ever put this page together must not know what really makes a decent graphically designed resume. thanks for sharing. Vs Chesapeake? amazing collection. Archetypes? Wow, looks awesome! Great inspiration also for the company resume company profile of a design studio should be fun and vs chesapeake interesting to review as well. Jungian Archetypes? fabulous list! for colonies, so many of jungian archetypes these designs, i had to knock myself on the head and say, #8220;now why didn#8217;t think of that?#8221; rather than creating something completely new, some of the best ideas, it seems, are just fresh ways of handling everyday, easy-to-overlook concepts. i especially love the classified ads design (first on your list). New England Vs Chesapeake? Some great work. exciting ideas. Comic Sans, #8230;. really? #8230;. *facepalm. Holy cow, the vast majority of these are rubbish! It#8217;s good to think outside the box, but function over style when it comes to a resume.

Well Dorris, if you read the title of the page, you would realize that he did consider the audience that he was trying to jungian archetypes, attract. Great collection, never even occured to me to write a CV in this way! Lee Yue Mei misspelled #8216;experience#8217;. /facepalm. Great blog, thx Igor Ovsyannykov. Hope to see some more! Good to look at , but like what some others agreed, they would probably end up in the bin of most HR managers. HR managers typically go through at least 10s to hundreds of vs chesapeake colonies resumes for merton's strain theory, a particular job opening in a respectable firm, the last thing they wanna do while skimming through is to new england colonies, learn your color coded graphics and pie charts to figure out what you#8217;re good at and what you#8217;re not. But otherwise, this list is a nice show of creative artwork. oh I am so redoing my CV.

I love the concepts, would make great posters for combustion of alcohol, sale framed for employment agencies. #128578; Been there, done that is a more subtle way in the fashion/textile area decades ago. When I was young and naive. Problem is vs chesapeake colonies, that the punker look one opening the envelope is usually of the totally bland, non creative and administrative type. Your chances are slim, as clever and creative it looks, there is big chance it ending in the bin or in the stack that will not get a reply. New England Vs Chesapeake? I see hundreds of jungian archetypes CVs for designers each day, and although there are some here which do work, many don#8217;t. There are some simple rules: make your CV clear and consise, think of how you present your skills instead of just pure aesthetics. No photos of yourself (EVER). And the resume on the coffee table, with cup stains, pens etc has been done to DEATH.

I always suggest that your CV should be a way of showcasing your typographic ability, as well as layout skills. Clean, elegant and simple is best just like any classic design. I#8217;m a graphic designer. I believe that our resumes need to new england vs chesapeake colonies, be different and jungian archetypes show that we are creative. However, the vs chesapeake resume selection that you have shared, as Neil has said, would 100% percent of the time end up in the trash. You want to land the job not to turn the company off so the never look at you again. HR employees are not interested in punker look, being blasted with craziness when they are trying to conduct a search. Your resume as boring as it may sound, should look like a resume. Adding a punch of color or play with font a little is vs chesapeake, fine but don#8217;t over do it! Honestly: I don#8217;t want to read a single one of 12 angry men themes these especially if they come in bulk!

They are all pretty and vs chesapeake awesome and retro and stuff #8230;and they are all totally off the track. The person who has to read all this probably gets these by the pound daily. Vavasor Powell Essay Examples? The faster these can be processed, the better. Among all these, a simple legal,clean and easy to read could be a real hero here. Please don#8217;t waste people#8217;s time, be creative where needed and where it counts. Nice collection, Igor. Keep it coming.

There#8217;s not a single CV here that works. Vs Chesapeake? be simple, clear, and to jungian, the point. its about new england vs chesapeake, what#8217;s on combustion of alcohol the page that will get you the new england vs chesapeake job. not the crazy graphical background or unreadable grid structure. BE SIMPLE. Great collection and Vavasor Powell examples great tips Igor. Vs Chesapeake? They look really cool. Here is my approach of a cv design. 12 Angry Men Themes? Ok, I admit those are amazing websites, however I get the feeling it#8217;s a bit complicated and not user friendly to browse. These are fun to look at as designs, but they don#8217;t work as resumes. Most of them would not reproduce in a copier, for one thing. For another, as has been pointed out, they are unlikely to colonies, appeal to an overworked HR person tasked with sorting through hundreds of resumes to find five people to interview. They would not be amused. Archetypes? You don#8217;t want to new england colonies, come across as so different that you wouldn#8217;t fit in.

Unless you#8217;re applying for the hottest agency in the coolest city on Vavasor Powell Essay earth, the chances are you#8217;d be working for (even with) fairly conservative people. Also, don#8217;t a lot of HR and headhunter outfits use software to scan for key words? How would most of these resumes work with that? These are all really, really bad as resumes, and a lot of them are bad from a graphic design point of vs chesapeake view. Don#8217;t encourage people to turn in resumes like this. Men Themes? Thanks for vs chesapeake colonies, sharing the article. Jungian? Well, most of them are usability nightmares, to be honest Great, thanks for vs chesapeake colonies, share this. What are you thinking about my first. As a Designer Lee Yue Mae should know better than to Vavasor Essay, use Comic Sans, even if you are imitating handwriting! She#8217;ll never live it down. Vs Chesapeake Colonies? I did something similar. feed back welcome at @obabar !! Great article!

Also, if you#8217;re considering writing your own resume you can view examples of resumes on where over 50 professional resume writers have uploaded their resume examples to view and download. Combustion Of Alcohol? My piece of work: I am very much grateful to vs chesapeake colonies, you for posting such an innovative concept of creative resume. This stuff is really helpful. How do you manage to create it and jungian from where you got these ideas.

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

On examination, she appeared anxious and diaphoretic with the following vital signs: respiratory rate 38 breaths/minute, heart rate (HR) 120 beats/minute [normal sinus rhythm (NSR)], and new england vs chesapeake systemic blood pressure 115/66 mm Hg. A pulmonary artery catheter (PAC) was placed and revealed: pulmonary artery (PA) pressures, 55/15 mm Hg; pulmonary artery occlusion pressure (PAOP), 14 mm Hg; central venous pressure (CVP), 23 mm Hg; and a cardiac output (CO) of 2.7 L/minute. Both the prothrombin and the partial thromboplastin times were elevated. Medical Disease and Differential Diagnosis What is the differential diagnosis of low cardiac output (CO) postoperatively? A. Medical Disease and Differential Diagnosis. A.1. What is the differential diagnosis of jungian archetypes, low cardiac output (CO) postoperatively? CO is determined by the product of stroke volume (SV) and heart rate (HR) during 1 minute (CO = HR x SV). 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). New England Vs Chesapeake! To more accurately determine the etiology of a reduced SV, it is necessary to explore whether there has been a change in the preload, the afterload, and/or the contractile state. 12 Angry! Either too much preload (ventricular overdistention) or too little preload can lower the CO. Similarly, a significant reduction in afterload (vasodilators, anesthetics, sympatholysis) or an increase in afterload (arterial resistance) can diminish SV. 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 vs chesapeake colonies, contractility and a reduced preload to account for the low output state. Correcting one problem alone may not produce the optimal hemodynamic condition.

Fontes ML. Punker Look! Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:11551191. A.2. What is cardiac tamponade? Enumerate the vs chesapeake colonies, common etiologies of cardiac tamponade. Cardiac tamponade is defined as significant compression of the heart by accumulating pericardial contents. These include blood and clots (postcardiotomy, chamber perforation, dissecting aortic aneurysm, trauma, anticoagulant therapy), exudative effusions (malignant states, infective pericarditis, idiopathic pericarditis), nonexudative effusions (uremia, systemic lupus erythematous, rheumatoid arthritis, idiopathic, radiation), and air. How significant cardiac tamponade is jungian, 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. New England! Clinical tamponade is frequently associated with marked increase in punker look, pericardial pressure relative to intracardiac pressures (atrial and ventricular) such that SV progressively declines resulting in systemic hypotension and in cardiogenic shock. Braunwald E, Heart disease: a textbook of colonies, cardiovascular medicine 6th ed. Philadelphia: WB Saunders, 2001:1498. Fowler NO. Gabel M. Buncher CR. Of Alcohol! 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 1998:113:13721378. A.3. What is the difference between acute and delayed cardiac tamponade? In the setting of cardiac surgery, cardiac tamponade can occur acutely over minutes, hours, or after a few days postoperatively. The reported incidence of acute cardiac tamponade is 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 new england vs chesapeake colonies, chest tubes may become clogged by blood clots impeding mediastinal drainage. Delayed tamponade has been arbitrarily defined as cardiac tamponade occurring greater than 5 to merton's theory, 7 days after pericardiotomy. Vs Chesapeake Colonies! The incidence is 12 angry, 0.3#37; to 2.6#37; and is often misdiagnosed because of colonies, a low index of examples of pull factors, suspicion and because the clinical signs and symptoms can be comparable to new england, those of congestive heart failure, pulmonary embolism, and jungian archetypes generalized fatigue (i.e., failure to thrive postoperatively). New England Colonies! The most common culprit in delayed cardiac tamponade is anticoagulant therapy with coumadin, heparin, and/or platelet inhibiting agents.

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

J Card Surg 1992:7:257268. Nelson RM. Examples Factors! Jeson CB. Smoot WM. Pericardial tamponade following open-heart surgery. J Thorac Cardiovasc Surg 1969:58:510516. Weitzman LB. Tinker WC. Kronzon I, et al.The incidence and natural history of pericardial effusions after cardiac surgery: an 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 new england vs chesapeake colonies, clinical suspicion, proficient knowledge of examples factors, pulmonary artery catheter (PAC) derived measures, physical examination, and diagnostic tools such as echocardiography and chest x-ray film. Often, the diagnosis is made in the operating room whereby evacuation of clot and blood from the new england colonies, mediastinum is strain theory, associated with drastic improvement in hemodynamics. Relying on one modality alone for diagnosis can lead to vs chesapeake, 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 Vavasor Powell examples, cognizant of such limitations.

The classical teaching of equalization of diastolic blood pressures in cardiac tamponade [central venous pressure (CVP) = pulmonary artery diastolic pressure (PAD) = pulmonary artery occlusion pressure (PAOP)] is vs chesapeake colonies, infrequently observed postoperatively because the factors, pericardium is left open. As such, blood or clot or both do not distribute around the vs chesapeake colonies, heart homogeneously to produce equalization of 12 angry men themes, pericardial diastolic pressures. Generally, the CVP is new england vs chesapeake, elevated but the PAD and the PAOP can be normal, elevated, or, in some cases, reduced. With significant compression of the right heart, reduced blood flow to merton's strain, 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 diagnosis of 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. Furthermore, in new england, delayed tamponade the complaints tend to be vague and less hemodynamic data is jungian archetypes, available (i.e., PAC) to allow prompt diagnosis of tamponade.

Whenever, the patient is not progressing as expected postoperatively with some signs of new england vs chesapeake colonies, end-organ dysfunction [fall in urine output and or increase blood urea nitrogen (BUN) and creatinine], an of pull factors, echocardiogram should be obtained to rule out cardiac tamponade. Russo A. O'Connor W. Waxman H. Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery. Chest 1993:104:7178. Spodlick D. Pathophysiology of cardiac tamponade. Chest 1998:113:13721378. A.5. What is regional cardiac tamponade? Regional cardiac tamponade occurs when one or more cardiac chambers become compressed by blood or blood clot or both compromising forward flow.

Postcardiotomy, diastolic regional collapse of the right atrium or the right ventricle is the most common echocardiographic finding in early cardiac tamponade. Postoperative right atrial hematoma often become localized to the anterior and new england 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 examples of pull, right heart becomes adherent or tethered to the anterior chest wall. As discussed in the previous answer, the diagnosis of tamponade is often misdiagnosed because classical features of tamponade are often absent because of uneven distribution of blood and blood clots around the heart. Vs Chesapeake Colonies! The clinical presentation may be mistaken for congestive heart failure, acute left or right ventricular infarction, septic shock, or pulmonary embolism. Chuttani K. Examples Of Pull Factors! Pandian NG. Mohanty PK, et al.Left ventricular diastolic collapse. An echocardiographic sign of regional cardiac tamponade. Circulation 1991:83:19992006. Fowler NO. Gabel M. Regional cardiac tamponade: a hemodynamic study.

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

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

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

Refractory postoperative hypoxemia associated with regional cardiac tamponade and patent foramen ovale. Crit Care Med 1997:25:16081611. A.6. What is pulsus paradoxus? What is Kussmaul's sign?

Normally, there is an inspiratory fall of less than 10 mm Hg in the arterial systolic pressure and an accompanying inspiratory fall in the venous pressure. However, a paradoxical pulse differs from the normal situation in two aspects: (a) the 12 angry, inspiratory fall of the arterial pressure exceeds 10 mm Hg and (b) the inspiratory venous pressure remains steady or increases (Kussmaul's sign). Echocardiographic studies of new england, patients with cardiac tamponade by D'Cruz et al. described phasic respiratory changes whereby both left ventricular and mitral valve excursion decreased during inspiration. In contrast, right ventricular dimensions increased in Vavasor Powell examples, association with a shifting of the interventricular septum toward the left ventricle. Of importance, pulsus paradoxus is not unique to cardiac tamponade.

The phasic respiratory changes in ventricular dimensions with exaggerated decrease in new england vs chesapeake, systemic systolic arterial pressure during inspiration can be present in a variety of clinical conditions whereby intrapleural pressure is combustion of alcohol, significantly diminished. That is, the magnitude of paradoxical pulse is directly proportional to colonies, the inspiratory decrease of left ventricular dimension, diastolic volume, and SV. This physiologic process is often present in respiratory distress, airway obstruction, chronic obstructive pulmonary disease (COPD), and pulmonary embolism. Although a prominent feature of cardiac tamponade, pulsus paradoxus may not be present at all in patients with chest wall trauma, neuromuscular disease, and of alcohol 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 vs chesapeake colonies patients with severe aortic regurgitation do not exhibit pulsus paradoxus. D'Cruz IA. Overton DH. Pai GH. Punker Look! Pericardial complications of cardiac surgery: emphasis on the diagnostic role of new england vs chesapeake colonies, echocardiography.

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

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

Ventricular interaction is extremely important for maintenance of merton's theory, adequate cardiac performance. Under normal conditions, the average SV of the right ventricle equals the SV of the left ventricle; however, cyclical respiratory differences in left and 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 increase in new england vs chesapeake, right ventricular filling causes the interventricular septum to bulge leftwardly reducing left ventricular dimension and altering its compliance and filling (ventricular interaction). During exhalation, the Powell, reverse process occurs. In the case of cardiac tamponade, ventricular interaction also involves the new england colonies, interventricular septum but it can involve other chamber and 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 of pull factors, rising pressure. Because of the fixed space within the pericardium, cardiac chamber dimensions become smaller. New England Colonies! First, the thin-walled and more compliant atriums progressively get compressed followed by the right ventricle and lastly the left ventricle.

Overall, the physiology of 12 angry, ventricular interaction in clinical cardiac tamponade becomes complex as the pressure-volume relationship of mediastinal and chest structure alters with each heartbeat and colonies from respiratory and neuroendocrine influences. Spodlick D. Pathophysiology of cardiac tamponade. Chest 1998:113:13721378. A.8. How is coronary blood flow affected in cardiac tamponade? In the absence of coronary artery disease, coronary blood flow is reduced in jungian archetypes, cardiac tamponade but this reduction is not sufficient to add an vs chesapeake, ischemic injury to the myocardium because there is a proportionate decrease in (a) ventricular preload (underfilled) and (b) ventricular afterload (underafterloaded). Consequently, both myocardial work and oxygen consumption are reduced. In contrast, patients with coronary artery disease may be at increased risk for 12 angry men themes, myocardial ischemia or infarction or both. Reddy PS.

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

J Am Coll Cardiol 1985:6:296299. A.9. What are the electrocardiographic abnormalities associated with cardiac tamponade? Electrocardiographic changes may occur in the settling of cardiac tamponade. New England Vs Chesapeake! These include nonspecific ST-T wave abnormalities, low voltage QRS complex, signs of myocardial ischemia and strain theory pericarditis, and electrical alternans ( Fig. Colonies! 15.1A ). Vavasor! The latter is seen in patients with large effusions and is characterized by interbeat shifts in electrical axis. This beat-to-beat alteration may be due to new england vs chesapeake, increased distance between the jungian archetypes, heart and vs chesapeake colonies the chest wall resulting in a pendulum like motion of the heart. However, it has been shown that with minimal amount of pericardial fluid removal, the presence of electrical alternans can be abolished while the pericardial space remains enlarged. Thus, the electrocardiographic change of of alcohol, 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 vs chesapeake colonies, 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. Jungian Archetypes! Electrical alternans. N Engl J Med 1999;341:2060, with permission.) Figure 15.1. Depiction of new england, 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. 12 Angry! Images in clinical medicine. New England! Electrical alternans. N Engl J Med 1999;341:2060, with permission.) Fox JJ. McHarg JL. Strain Theory! Gilmour RF Jr. Ionic mechanism of electrical alternans. New England Vs Chesapeake! Am J Physiol Heart Circ Physiol 2002:282:H516530.

Kosta E. 12 Angry Men Themes! Kronzon I. Electrical alternans in cardiac tamponade. Echocardiography 2000:17:(6 Pt 1)575576. Kronzon I. Cohen M. Winer H. Contribution of echocardiography to the understanding of the pathophysiology of cardiac tamponade. New England Vs Chesapeake Colonies! J Am Coll Cardiol 1983:1:11801182. Longo MJ. Jaffe CC. Images in clinical medicine. Electrical alternans. N Engl J Med 1999:341:2060. A.10. What roentgenographic and echocardiographic findings are noted in cardiac tamponade?

On standard anterior-posterior chest roentgenography, the cardiac silhouette may appear normal in size or extremely enlarged depending on the acuity and chronicity of the tamponade process. Normally, the pericardial fluid amounts to 15 to 25 mL. Acute tamponade physiology can arise with as little as 150 mL of effusion, whereas chronic effusions may exceed 1,000 mL before clinical signs and symptoms of cardiac tamponade manifest. On chest x-ray film, the cardiac silhouette will appear widened with or without features such as obscuring of the 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 combustion of alcohol semiquantitated. Colonies! Likewise, pericardial blood clots can be demonstrated to examples of pull factors, compress the respective chamber. Additional echocardiographic signs observed in tamponade include (a) diminished left ventricular dimension and mitral valve excursion during inspiration, (b) shifting of the interventricular septum toward the left ventricle, (c) changes in transvalvular (mitral and aortic) flow characteristics seen by vs chesapeake colonies, Doppler techniques, (d) diastolic posterior motion of the right ventricular wall, and (e) in some cases, a systolic notch on the right ventricular epicardium ( Fig. 15.1B and C ). Although many of the findings of both x-ray film and echocardiogram can be suggestive of cardiac tamponade, no one sign is 100#37; sensitive and specific. Braunwald E, Heart disease: a textbook of cardiovascular medicine 6th ed. Philadelphia: WB Saunders, 2001:1490. Kaplan JA, Cardiac anesthesia 4th ed. Philadelphia: WB Saunders, 1999:932, 1250.

Singh SM. Wann LS. Schuchard GH, et al.Right ventricular and right atrial collapse in patients with cardiac tamponade. Circulation 1984:70:996. A.11. What is in examples, the differential diagnosis of postcardiopulmonary bypass (post-CPB) bleeding? Significant bleeding following cardiac surgery requiring surgical exploration bring-back occurs in new england vs chesapeake, approximately 3#37; of punker look, cases. Often, the new england vs chesapeake colonies, 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 hemostatic mechanisms including vascular endothelium, fibrinolytic and coagulation factors, platelet, plasminogen, and inflammatory pathways ( Fig. 15.2 ). Under normal settings, these systems (and others yet unknown) act in concert and in opposition with one another (a) to prevent bleeding by promoting clot formation at the site of endothelial injury (procoagulant effects) and (b) to prevent or destroy clot formation (anticoagulant effects#151;either directly or indirectly via inhibitory mediators). Once blood elements come in contact with a nonendothelialized surface (bypass circuit), the procoagulant system becomes activated resulting in consumption of platelets, coagulation factors, and of pull fibrinogen. 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 coagulation factors required for colonies, 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. Of Pull! (From Coleman RW, Hirsch J, Marder VJ, et al, eds. Hemostasis and thrombosis: basic principles and clinical practice, 2nd ed. Philadelphia: JB Lippincott, 1987:1052, with permission.) Figure 15.2.

The coagulation cascade, illustrating the coagulation factors required for various screening tests. HMWK, high molecular weight kininogen; PK, prekallikrein; PL, phospholipid by new england vs chesapeake colonies, 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 punker look thrombosis: basic principles and colonies clinical practice, 2nd ed. Jungian Archetypes! Philadelphia: JB Lippincott, 1987:1052, with permission.) Platelets play an important role in the coagulation process.

Once activated, they secrete several types of granules. Granules, containing peptides such as fibrinogen, thrombospondin, factors V and VIII, and -thromboglobulin, are reduced in both number and content during CPB. Of greater importance is the loss of new england, 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. Strain Theory! The latter can arise from either venous or arterial sources that were undetected before closure of the chest. Vs Chesapeake Colonies! Attentive and jungian meticulous effort to surgical hemostasis can significantly reduce the incidence of vs chesapeake, bring-backs. Despotis GJ. Men Themes! Avidan MS. Hogue CW Jr. Mechanisms and attenuation of vs chesapeake, hemostatic activation during extracorporeal circulation. Ann Thorac Surg 2001:72:S18211831.

Harker L. Malpass TW. Jungian! Branson HE. Mechanism of abnormal bleeding in patients undergoing cardiopulmonary bypass: acquired transient platelet dysfunction associated with selective alpha-granule release. Blood 1980:56:824. Kojima T. Gando S. Morimoto Y, et al.Systematic elucidation of new england, effects of examples factors, tranexamic acid on fibrinolysis and new england colonies bleeding during and after cardiopulmonary bypass surgery. Thromb Res 2001:104:301307. Levy JH. Pharmacologic preservation of the hemostatic system during cardiac surgery. Ann Thorac Surg 2001:72:S18141820. A.12.

What is the mechanism of action of low molecular weight heparin (LMWH)? LMWHs are fragments of unfractionated heparin produced by controlled enzymatic or chemical depolymerization processes yielding chains having molecular weight of about 5,000 daltons. The parent compound is a heterogeneous mixture of archetypes, polysaccharide chains with molecular weight of 3,000 to 30,000 daltons. The mechanism of action is similar for both unfractionated heparin and LMWH. 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 vs chesapeake colonies, much more profound than LMWH. 12 Angry Men Themes! To inactivate thrombin, heparin has to bind to both antithrombin and thrombin forming a ternary complex. Heparin pentasaccharide sequences (randomly distributed along heparin chains) of 18 units or more is required for the formation of this ternary complex. Approximately 50#37; of LMWH lack the adequate length necessary for binding antithrombin and thrombin. Furthermore, only 15#37; to vs chesapeake, 25#37; of chains of strain theory, LMWH contain pentasaccharide sequences. Therefore, LMWH has greater inhibitory effect of vs chesapeake, 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. Punker Look! This complex in turn inactivates factor VIIa. Clark SC. Vitale N. Zacharias J, et al.Effect of low molecular weight heparin (fragmin) on new england colonies bleeding after cardiac surgery. Ann Thorac Surg 2000:69:762765. Danielsson A. Raub E. Merton's Strain! Lindahl U, et al.Role of ternary complexes in which heparin binds both antithrombin and proteinase, in the acceleration of the reactions between antithrombin and thrombin for factor Xa. J Biol Chem 1986:261:15461573. Gohlke-Barwolf C. Anticoagulation in vs chesapeake, valvar heart disease: new aspects and management during non-cardiac surgery.

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

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

The plasma half-life of LMWH is two to colonies, four times longer than unfractionated heparin, which undergoes a dose-dependent elimination by the liver and 12 angry the kidneys. A significant amount of unfractionated heparin is bound to plasma proteins, vascular endothelium, and macrophages resulting in less bioavailability and an unpredictable anticoagulant effect. Consequently, careful laboratory monitoring is required. Additional benefits of LMWH over unfractionated heparin include less bleeding (less platelet inhibition and less propensity for increasing microvascular permeability). Several clinical trials have demonstrated both improved efficacy and safety of LMWH over unfractionated heparin.

Of note, LMWH is not recommended in the setting of renal failure, and its anticoagulant activity may be measured by assaying factor Xa levels. There are, however, many different types of LMWH available in 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 new england vs chesapeake, be dismissed. Alban S. Gastpar R. Plasma levels of merton's, total and free tissue factor pathway inhibitor (TFPI) as individual pharmacological parameters of various heparins. Thromb Haemost 2001:85:824829.

Cohen AT. New England! Bailey CS. Punker Look! 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 2001:85:940941. Huse DM. Cummins G. Taylor DC, et al.Outpatient treatment of venous thromboembolism with low-molecular-weight heparin: an economic evaluation. Am J Managed Care 2002:8:(1Suppl)S1016. Kleinschmidt K. Charles R. Pharmacology of low molecular weight heparins [Review]. Emerg Med Clin North Am 2001:19:10251049. A.14.

What is heparin-induced thrombocytopenia (HIT)? How is the new england, 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 the presence of examples factors, heparin. Other immunoglobulins may also potentiate HIT. HIT exists in two forms. A benign form of HIT, type 1, is new england, observed in approximately 10#37; to 20#37; of patients receiving unfractionated heparin. This mild form of factors, thrombocytopenia (rarely less than 100 x 10 3 / L) occurs after 1 to 4 days of therapy and vs chesapeake colonies 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 combustion 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 new england vs chesapeake, 30#37;. Although there is no randomized prospective study looking at the true incidence of 12 angry men themes, HIT, the colonies, expected incidence is estimated to be less than 5#37;. Those patients who have had a previous exposure to heparin (recent and in some cases remote history) may develop HIT earlier after institution of heparin therapy as compared with those with no previous exposure. Combustion! The frequency of HIT is vs chesapeake, also higher in patients receiving porcine mucosal heparin compared with bovine lung heparin. The diagnosis of HIT should be entertained in any patient with a significant fall in platelet count while on 12 angry men themes heparin therapy (less than 150 x 10 3 / L or a 50#37; or greater decrease in platelet count after 5 days of therapy). The definitive diagnosis requires the following steps: (a) thrombocytopenia while on heparin, (b) exclusion of other etiology of thrombocytopenia, (c) improvement in platelet count following cessation of heparin therapy, and (d) presence of heparin-dependent platelet antibody by an in new england, vitro test.

In most cases, the men themes, diagnosis is made on vs chesapeake clinical findings. Gerotziafas GT. Elalamy I. Merton's! 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 2001:12:511520. Robitaille D. Carrier M. Cartier R, et al.Successful management strategy for mechanical assistance and heart transplantation in patients suffering from heparin-induced thrombocytopenia type II. J Heart Lung Transplantation 2001:20:12371240. Shea SI.

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

What is the therapy for HIT? Because HIT type II is of alcohol, a potentially lethal condition, the vs chesapeake colonies, most effective therapy is discontinuation of heparin. The thrombocytopenia should improve progressively. Although tempting, the need for platelet transfusion is discouraged because bleeding occurs infrequently and vascular thrombosis may be potentiated. Several agents have been recommended for examples, use in HIT. These include direct thrombin inhibitors (hirudin, argatroban), LMWH, LMW heparinoid, ancrod, and antiplatelet agents. Most of new england, these agents are not available in Powell Essay, the United States for use; others are under clinical investigation. Hirudin has been extensively used in colonies, Europe with demonstrable benefit and safety. Examples Of Pull Factors! 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 the United States) extracted from the Malayan pit viper and is immunologically distinct from heparin. New England Vs Chesapeake! It acts by cleaving fibrinopeptide A from fibrinogen and its activity can be measured by assaying for plasma fibrinogen concentration. Lastly, in the setting of factors, HIT, a synthetic analogue of prostacyclin (iloprost#151;a potent inhibitor of platelet activation) has been used successfully during cardiac surgery to prevent further reduction of platelet count. Cheng-Lai A. Cardiovascular drug highlight: hirudin. Heart Dis J Cardiovasc Med 1999:1:4149. Deitcher SR. Carman TL. Heparin-induced thrombocytopenia: natural history, diagnosis, and management.

Vasc Med 2001:6:113119. Gill J. Colonies! Kovacs MJ. Successful use of danaparoid in treatment of heparin-induced thrombocytopenia during twin pregnancy. Obstet Gynecol 1997:90:(4 Pt 2)648650. Koster A. Meyer O. Fischer T, et al.One-year experience with the platelet glycoprotein IIb/IIIa antagonist tirofiban and heparin during cardiopulmonary bypass in patients with heparin-induced thrombocytopenia type II.

J Thorac Cardiovasc Surg 2001:122:12541255. Robitaille D. Archetypes! Carrier M. Cartier R, et al.Successful management strategy for mechanical assistance and heart transplantation in patients suffering from heparin-induced thrombocytopenia type II. J Heart Lung Transplantation 2001:20:12371240. Warkentin TE. Dunn GL. New England Colonies! Cybulsky IJ. Off-pump coronary artery bypass grafting for acute heparin-induced thrombocytopenia. Ann Thorac Surg 2001:72:17301732. A.16. Can HIT be caused by LMWH?

Based on confirmed laboratory tests, the prevalence of HIT is 2#37; for patients receiving unfractionated heparin. Although the incidence of men themes, HIT is infrequent in the setting of new england colonies, 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. Jungian Archetypes! Stefani PM, et al.Heparin-induced thrombocytopenia [Review]. Haematologica 2000:85:7281. Kleinschmidt K. Charles R. Pharmacology of low molecular weight heparins. Emerg Med Clin North Am 2001:19:10251049. Warkentin TE. Sheppard JA. Horsewood P, et al.Impact of the patient population on the risk for heparin-induced thrombocytopenia. Blood 2000:96:17031708.

A.17. What is the mechanism of heparin antagonism by new england, protamine? Heparin is a large glycosaminoglycan molecule consisting of chains of alternating residues of D -glucosamine and uronic acid. It is highly negatively charged, whereas protamine is mostly positively charged. The two combine irreversibly to 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 punker look, eliminated. Kimmel SE. Sekeres M. New England! Berlin JA, et al.Mortality and merton's theory adverse events after protamine administration in patients undergoing cardiopulmonary bypass. Anesth Analg 2002:94:14021408.

A.18. What is heparin rebound? The ACT is vs chesapeake colonies, used to Essay examples, confirm adequacy of heparin neutralization by protamine. New England Vs Chesapeake! The concept of heparin rebound and coagulopathy following protamine reversal may occur as follows: first, heparin that is sequestered in 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 mobilized back into circulation it can inhibit thrombin formation and predispose post-CPB bleeding. Jungian Archetypes! Studies in which 1 mg of protamine is given per 100 units of heparin (total dose) found no evidence of heparin rebound. Thus, bleeding in the postoperative cardiac surgical patient is unlikely to new england vs chesapeake, be from heparin rebound. Heller EL. Punker Look! Paul L. Anticoagulation management in a patient with an vs chesapeake colonies, acquired antithrombin III deficiency. J Extra Corpor Technol 2001:33:245248.

Subramaniam P. Skillington P. Tatoulis J. Heparin-rebound in of pull, the early postoperative phase following cardiopulmonary bypass. Austr N Z J Surg 1995:65:331333. Woodman RC. Harker LA. Bleeding complications associated with cardiopulmonary bypass. Blood 1990:76:1680. A.19. How does coumadin affect the coagulation system? What is the therapy for reversing its effect? Coumadin remains the colonies, most commonly used anticoagulant agent in the outpatient setting (atrial fibrillation, prosthetic valves and devices).

Its predominant pharmacodynamic effect is 12 angry, inhibition of synthesis of vitamin K-dependent factors (II, VII, IX, and new england colonies X) in the liver and its clinical efficacy is Essay, 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 new england vs chesapeake colonies presence of other comorbid conditions. On average, it takes several days of therapy to Powell Essay, achieve the desired INR (2 to 4); consequently, administration of new england vs chesapeake, either LMWH or unfractionated heparin may be necessary for initiating anticoagulation. Archetypes! Complications occur either because of new england, inadequate anticoagulation (thrombosis) or because of excessive anticoagulation (bleeding and of pull factors hemorrhage). To reverse its effect, coumadin should be discontinued several days (more than 3 days) to colonies, allow levels of the aforementioned factors to combustion, 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 clinical pearls. J Thromb Thrombolysis 1999:7:145148. Henderson MC.

White RH. Anticoagulation in the elderly. Curr Opin Pulm Med 2001:7:365370. Horton JD. Bushwick BM. Warfarin therapy: evolving strategies in anticoagulation. Am Fam Physician 2002:65:172. Keller C. Matzdorff AC. Kemkes-Matthes B. Vs Chesapeake! Pharmacology of jungian archetypes, warfarin and clinical implication. Sem Thromb Hemost 1999:25:1316. A.20.

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

Activated partial thromboplastin time (aPTT) measures the activity of the intrinsic pathway: factors XII, XI, IX, VIII, V, X, prothrombin, and fibrinogen ( Fig. 15.2 ). The aPTT is prolonged by theory, concentrations of less than 20#37; to new england vs chesapeake, 30#37; of these factors. Punker Look! Normal values are 25 to colonies, 40 seconds. Thrombin time measures the conversion of fibrinogen to fibrin by 12 angry men themes, thrombin#151;the final step in the coagulation cascade ( Fig. 15.2 ). The thrombin time is vs chesapeake colonies, decreased in examples of pull, the presence of low concentrations of fibrinogen and thrombin. Heparin prolongs the vs chesapeake, thrombin time, whereas coumadin has little effect. Merton's! Normal values are less than 10 seconds. Activated Clotting Time.

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

The bleeding time becomes prolonged with platelet counts less than 50 x 10 3 / L and in the presence of combustion of alcohol, inhibitors of platelet aggregation such as aspirin. Colonies! Normal values are less than 5 minutes. Archetypes! The bleeding time has not been shown to be predictive of postoperative bleeding and is no longer performed routinely preoperatively. Barash PG, Cullen BF, Stoelting RK, Clinical anesthesia 4th ed. Philadelphia: Lippincott, Williams Wilkins, 2001:219224. Braunwald E, Fauci A, Kasper DL, et al., Harrison's principles of internal medicine 15th ed.

New York: McGraw Hill, 2001:354358. Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and thrombosis: basic principles and colonies clinical practice 2nd ed. Punker Look! Philadelphia: JB Lippincott, 1987:1048. A.21. How is the anticoagulant effect of LMWH monitored? There is no evidence that monitoring the new england vs chesapeake colonies, dose improves the punker look, clinical efficacy. In contrast, any overdose increases the risk of hemorrhage. Because the kidneys play a significant role in the elimination of LMWH, therapeutic use of these agents should be monitored with an colonies, antifactor Xa assay, especially in patients who have renal insufficiency, are elderly, and have clinical conditions that increase the risk of bleeding. Boneu B. de Moerloose P. How and when to monitor a patient treated with low molecular weight heparin. Sem Thromb Hemost 2001:27:519522.

A.22. What is a thromboelastograph? What is a Sonoclot? The thromboelastograph is an instrument that measures the development of blood clot viscoelastic strength over time. A rotating piston is suspended in a cuvette filled with heated blood. As clot formation proceeds, the rotation of the men themes, piston is affected and characteristic curves are generated ( Fig. 15.3 ). The etiology of new england vs chesapeake, a coagulopathy may be obtained by analyzing these curves ( Fig. 15.4 ). The Sonoclot similarly measures the development of clot viscoelastic strength. The Sonoclot piston moves vertically and combustion measures the impedance to new england vs chesapeake colonies, vibration at the tip of the probe. Sonoclot tracings obtained from Powell examples 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 new england colonies, 60 degrees, MA, maximum amplitude, 50 to 60 mm, A60/MA, amplitude 60 minutes after MA; whole blood clot lysis index, greater than 0.85; F, whole blood clot lysis time, greater than 300 minutes. (From Tumen KJ, Spiess BD, McCathy RJ, et al. Effects of progressive blood loss on coagulation as measured by thromboelastography. Anesth Analg 1987;66:856#150;863.) Figure 15.3. Production of punker look, normal thromboelastogram and new england colonies measured parameters.

R, reaction time, 7 to 14 minutes; K value, 3 to archetypes, 7 minutes; , clot formation rate, 40 degrees to 60 degrees, MA, maximum amplitude, 50 to 60 mm, A60/MA, amplitude 60 minutes after MA; whole blood clot lysis index, greater than 0.85; F, whole blood clot lysis time, greater than 300 minutes. (From Tumen KJ, Spiess BD, McCathy RJ, et al. Effects of progressive blood loss on coagulation as measured by thromboelastography. Anesth Analg 1987;66:856#150;863.) Figure 15.4. Qualitative analysis of thromboelastograms. Figure 15.4. Vs Chesapeake! Qualitative analysis of 12 angry, thromboelastograms. Figure 15.5. Sonoclot tracings of platelet-rich plasma (PRP) and platelet-poor plasma (PPP). Vs Chesapeake! 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 of alcohol, 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). Colonies! A: lag period, B: primary wave, C: shoulder, D: secondary wave, E: peak, F: downward wave. (From Saleem A, Blifeld C, Saleh SA, et al. Viscoelastic measurement of clot formation: a new test of platelet function. Ann Clin Lab Sci 1983;13:115, with permission.) Avidan MS. 12 Angry! Da Fonseca J. Parmar K, et al.The effects of aprotinin on thromboelastography with three different activators. Anesthesiology 2001:95:11691174.

Ellison N, Jobes DR, Effective hemostasis in the cardiac surgery Philadelphia: WB Saunders, 1988:155. Forestier F. Belisle S. Contant C, et al.Reproducibility and interchangeability of the new england colonies, thromboelastograph, Sonoclot and Hemochron activated coagulation time in cardiac surgery. Can J Anaesth 2001:48:902910. Koster A. Hansen R. Schulz J, et al.Assessment of the resonance thromboelastograph CS-3 for differentiation of coagulation disorders: a pilot in vitro investigation of simulated post-cardiopulmonary bypass coagulopathies. J Extra Corp Technol 2001:33:159166. Koster A. Powell Examples! 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 2001:33:153158. 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. New England Vs Chesapeake! Bevan DH, et al.Thromboelastography: a reliable test?.

Blood Coag Fibrinolysis 2001:12:555561. Vorweg M. Hartmann B. 12 Angry! Knuttgen D, et al.Management of fulminant fibrinolysis during abdominal aortic surgery. J Cardiothorac Vasc Anesth 2001:15:764767. A.23. New England Vs Chesapeake! How does desmopressin aid hemostasis? Desmopressin [1-deamino-8- D -arginine vasopressin (DDAVP)] increases von Willebrand's factor and factor VII activity in plasma. von Willebrand's factor, which binds to platelets, is found in subendothelial tissue and is in 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 1998:18:2141. Kondo NI. Powell Examples! Maddi R. Ewenstein BM, et al.Anticoagulation and hemostasis in cardiac surgical patients. J Card Surg 1994:9:443461. Serradeil-Le Gal C. Nonpeptide antagonists for vasopressin receptors. New England! Pharmacology of SR 121463A, a new potent and highly selective V2 receptor antagonist.

Adv Exp Med Biol 1998:449:427438. A.24. What is fibrinolysis? Fibrinolysis is fibrin breakdown in thrombi. Plasmin, derived from plasminogen, is the punker look, enzyme involved in vs chesapeake, this process. Physiologic fibrinolysis involves clot remodeling and punker look removal during the healing process. Pathologic fibrinolysis occurs when fibrin in a thrombus is new england vs chesapeake, broken down before healing. 12 Angry Men Themes! Although elevated concentrations of plasminogen activators are found during CPB, their half-lives are very short after bypass. In cardiac surgery, fibrinolysis is a rare cause of postoperative bleeding.

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

Aminocaproic acid (Amicar) is an analogue of lysine. Its primary mechanism of action is inhibition of plasmin, resulting in less breakdown of vs chesapeake, fibrinogen, fibrin (fibrinolysis), and other clotting components. Aminocaproic acid has been effective in treating coagulopathy in of alcohol, the setting of heart surgery, portocaval shunts, hematologic disorders such as aplastic anemia, abruptio placentae, hepatic cirrhosis, and neoplastic diseases. Compared with placebo, both tranexamic acid and aminocaproic acid have been shown to reduce blood loss by 30#37; to 49#37; as well as reduce homologous blood transfusion. New England Vs Chesapeake Colonies! When compared with aprotinin, in high-risk patients, high dose-Amicar has also been shown to punker look, 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 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 new england vs chesapeake colonies, a rate of 1 g per hour. Higher infusion rates may be used. There are several adverse events that include thrombosis (early graft closure, myocardial ischemia and infarction), agranulocytosis, leukopenia, and thrombocytopenia. 12 Angry Men Themes! Although rare, bradycardia and mild reduction in blood pressure have also been reported. Levi M. New England Vs Chesapeake! Cromheecke ME. de Jonge E, et al.Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of punker look, clinically relevant endpoints. Lancet 1999:354:19401947. A.26. What is aprotinin? Aprotinin is a complex polypeptide molecule belonging to the family of vs chesapeake, serine protease inhibitors that is extracted from bovine lung. Strain! 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 reabsorbed by the proximal tubules. The terminal half-life is approximately 10 hours. The basis for vs chesapeake colonies, its efficacy is not fully understood but consists of a complex activation-interaction of the following systems: kallikrein resulting in kinin generation, complement and factors inflammatory pathways, coagulation (intrinsic and extrinsic), fibrinolytic, angiotensin, and others not yet determined ( Fig. 15.6 ). Vs Chesapeake! Initial contact between blood elements and the nonendothelialized surface of the CPB circuit promote contact activation of both humoral and cellular inflammatory processes. The coagulation system may be the first to be activated by contact generating factor XIIa from Vavasor Powell examples 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 new england vs chesapeake colonies accelerate the generation of bradykinin from HMWK, factor XIIa, angiotensin, and complement activation. Factor XIIa, in turn, also interacts with fibrinogen to produce plasmin ( Fig. 15.7 ). Figure 15.6. Contact activation and the role of the kallikrein system. Factor 12, XII; activated factor 12, XIIa; high-molecular weight kininogen, HK; prekallikrein, PKK; factor 11, XI; activated factor 11, XIa. (From slide set no.

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

3, tryaslol slide library [online]. Bayer, 2000. Available at with permission.) Figure 15.7. Involvement of the new england, various components of jungian archetypes, coagulation including the coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and new england vs chesapeake colonies the fibrinolytic system. C1, complement; HMW, high molecular weight. (From slide set no. 3, tryaslol slide library [online]. Examples Of Pull Factors! Bayer, 2000. Available at: with permission.)

Figure 15.7. New England Vs Chesapeake Colonies! Involvement of the various components of jungian, coagulation including the coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and new england the fibrinolytic system. C1, complement; HMW, high molecular weight. (From slide set no. 12 Angry Men Themes! 3, tryaslol slide library [online]. Bayer, 2000. Available at: 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 new england colonies, platelet surface glycoproteins (IIb/IIIa), which is necessary for platelet-fibrinogen interaction and clot formation. The inflammatory properties of 12 angry men themes, aprotinin (both cellular and vs chesapeake humoral) have been shown in animal and in 12 angry, some human studies; however, clinical outcome trials addressing this effect have not been conducted. In contrast, clinical trials comparing Aprotinin to new england vs chesapeake colonies, placebo and/or to Amicar have consistently shown greater efficacy related to reduction in blood loss and 12 angry men themes transfusions of blood elements. Concerns regarding prothrombotic potentials, including myocardial infarction and renal dysfunction, have since been dismissed. The infarction rate and the incidence of vs chesapeake colonies, 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. Of Alcohol! Rarely, if aprotinin is used in patients with protein C or S deficiency, they may experience life-threatening thrombotic events shortly after protamine neutralization of heparin. Another important aspect of aprotinin use is the type of new england vs chesapeake colonies, reagent used to combustion, monitor adequacy of heparinization (ACT). Kaolin is the recommended agent to new england vs chesapeake, be used to assess ACT when aprotinin is used (greater than 480 seconds). If Celite is used, the ACT value should be more than 750 seconds before initiation of CPB. Of Pull Factors! Aprotinin is not an antithrombotic agent, and, therefore, adequate amount of new england vs chesapeake colonies, heparin must be given.

Because it is a serine protease inhibitor, it interacts with antithrombin III to inhibit the action of all intrinsic and common pathway factors resulting in prolongation of measures of coagulation such as ACT. Aprotinin has a very good safety profile but serious anaphylaxis or shock can occur. This risk is increased in combustion of alcohol, patients who are reexposed to aprotinin within 6 weeks. New England! Most of the cases reported occurred within 200 days of merton's strain, exposure. It is recommended that a test dose of 1 mL be given when it is possible to colonies, 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 jungian archetypes, administered intravenously at new england vs chesapeake, least 10 minutes before the loading dose, followed by close observation for merton's theory, signs of an new england vs chesapeake colonies, allergic reaction. A loading dose of 2 million KIU should then be given over 20 to 30 minutes. An additional 2 million KIU dose is added to the priming solution. The maintenance dose is a constant infusion of Vavasor Powell Essay examples, 500,000 KIU/hour for the duration of surgery. It may be beneficial and colonies cost effective to continue the merton's strain, infusion of the remaining amount of the new england, drug while the patient is transferred and merton's strain theory recovering in the ICU. A half-dose regimen has been proposed and entails reducing the previously mentioned recommendation in new england colonies, half. Cosgrove DM III. Examples Of Pull! Heric B. Lytle BW, et al.Aprotinin therapy for reoperative myocardial revascularization: a placebo-controlled study. Ann Thorac Surg 1992:54:10311038. Dobkowski WB.

Murkin JM. A risk-benefit assessment of aprotinin in cardiac surgical procedures. Drug Safety 1998:18:2141. Fujii S, Kinins V, Part B. Advances in experimental medicine and biology vol 247B: New York: Plenum Press, 1989:3542. Hoffmann H. Siebeck M. Vs Chesapeake! Thetter O, et al.Aprotinin concentrations effective for the inhibition of 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 2001:72:21692175. Murkin JM. Attenuation of neurologic injury during cardiac surgery. Ann Thorac Surg 2001:72:S18381844.

Orchard MA. Goodchild CS. Prentice CRM, et al.Aprotinin reduces cardiopulmonary bypass-induced blood loss and inhibits fibrinolysis without influencing platelets. Br J Haematol 1993:85:533541. Peters DC. Noble S. 12 Angry! Aprotinin: an update of its pharmacology and therapeutic use in open-heart surgery and coronary artery bypass surgery. Drugs 1999:57:233260.

Serradeil-Le Gal C. Nonpeptide antagonists for vasopressin receptors. Pharmacology of SR 121463A, a new potent and highly selective V2 receptor antagonist. Adv Exp Med Biol 1998:449:427438. Wahba A. Black G. New England Colonies! Koksch M, et al.Aprotinin has no effect on platelet activation and adhesion during cardiopulmonary bypass. Thromb Haemost 1996:75:844848. B. Jungian! Preoperative Evaluation and Preparation. B.1. Interpret the hemodynamic findings of this patient. The patient has an adequate blood pressure; however, this appears to vs chesapeake, be maintained via compensatory mechanism including increase in both arterial resistance [systemic vascular resistance (SVR)] and of alcohol HR. The PA systolic pressure is consistent with pulmonary hypertension arising most likely from chronic mitral valvular disease (either stenosis or insufficiency). New England Colonies! Both the PAD and the PAOP suggest that the left ventricular end diastolic pressure#151;a correlate of left ventricular preload#151;is within the 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. A CVP of 23 torr is examples of pull, suggestive of right ventricular or biventricular dysfunction, tricuspid stenosis or insufficiency, or obstruction and compression of the right atrium. The CO is new england, inadequate. The derived SV of 22 mL (CO/HR), combined with the other derangements (elevated CVP and PAOP of punker look, 14 mm Hg), strongly reflect right heart dysfunction. Taking into 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 vs chesapeake cardiac tamponade. An echocardiogram should be performed to assist in punker look, the diagnostic process and clinical management. Fontes ML. New England Vs Chesapeake! Bellows W. Ngo L et al. and McSPI Research Group.

Assessment of ventricular function in punker look, critically ill patients: limitations of pulmonary artery catheterization. J Cardiothorac Vasc Anesth 1999:13:18. B.2. How would you treat the low output status of this patient? Although the HR is elevated, it may be unwise to attempt to vs chesapeake colonies, 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 examples factors, right heart may be excessive (CVP = 23 mm Hg), the preload of the left heart may not be adequate despite a PAOP of new england vs chesapeake, 14 mm Hg.

While waiting for the echocardiogram to of alcohol, be performed, a fluid bolus can be attempted. If there is a positive response (i.e., the blood pressure and vs chesapeake colonies or the CO increase), additional fluid bolus can be administered until the punker look, limit of the preload reserve has been reached (operating on new england the flat end portion of the Frank Starling's curve). In the setting of right ventricular failure, it is customary to fluid load the patient maintaining the CVP in the 20s. It is important to note that fluid challenge alone will not improve cardiac performance without addressing the 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 institute inotropic support (initially, the Vavasor, choice of the inotrope is not that important despite the tachycardia). With regard to the afterload, both systemic and pulmonary afterloads are elevated. On the right side, PA hypertension can be improved with the nitrossovasodilators (nitroglycerin or nitroprusside) but the new england vs chesapeake colonies, associated systemic hypotension would prohibit their use. Merton's Strain! In fact, most vasodilators with the exception of nitric oxide would compromise the systemic pressures. Colonies! Alternatively, an inotrope that has vasodilatory properties (phosphodiesterase inhibitors#151;milrinone or amrinone#151;or dobutamine) would be better choices. Combustion! The SVR is a derived number (mean arterial pressure minus CVP divided by the CO and multiplied by a factor of 80). It is important to new england, identify and archetypes treat the cause of the altered CO (i.e., change in HR or SV) and not to react to changes in SVR.

For example, if the CO is low because of a rhythm issue or a reduced preload, it would be inappropriate to vs chesapeake, administer a vasodilator to correct the high SVR. In summary, a rational management of the hemodynamic findings presented would include administering fluid (crystalloid or blood products as indicated), giving inotropic support, obtaining an echocardiogram, and addressing the other systemic complications (pulmonary, renal, and punker look coagulation). Fontes ML. Hines RL. Cardiogenic shock. Vs Chesapeake Colonies! Murray MJ, Coursin DB, Pearl RG, et al., Critical care medicine: perioperative management New York: Raven Press, 1997:295306. Fontes ML. Merton's Strain! Hines RH.

Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:11551191. B.3. How would you evaluate this patient's coagulation status? A complete blood cell count and a complete coagulation panel should be performed.

Assuming that both the hematocrit and the platelet function are adequate, attention should be directed to the elevated PT and the aPTT. The most obvious etiology for vs chesapeake, 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 the liver. Measuring the jungian, PT and new england vs chesapeake or the INR assesses the status of its anticoagulant effect. Why is the Powell Essay, aPTT also elevated? This coagulation measure reflects the function of the following factors: V, VIII, IX, X, XI, XII, prothrombin, and fibrinogen. New England Colonies! It can also be surmised that the elevated aPTT is archetypes, due to new england vs chesapeake colonies, anticoagulant therapy (e.g., excessive coumadin therapy, use of unfractionated heparin, or a combination of treatment with heparin and coumadin). The latter approach is standard practice in cardiac surgery for patients requiring prolonged anticoagulation (i.e., valvular replacement) and can account for elevations of punker look, 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 2001:27:519522. Ellison N, Jobes DR, Effective hemostasis in cardiac surgery Philadelphia: WB Saunders, 1998:195. Keller C. Matzdorff AC. Kemkes-Matthes B. New England Colonies! Pharmacology of warfarin and clinical implication. Semin Thromb Hemost 1999:25:1316. B.4.

What do fresh frozen plasma (FFP) and cryoprecipitate contain? FFP contains the labile factors V and combustion VIII as well as the stable coagulation factors (II, VII, IX, X, XI). New England! In addition, FFP contains other plasma proteins and lipids normally found in human plasma. Cryoprecipitate is derived by thawing FFP at 4C. 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 Vavasor Powell examples, antithrombin III on the activated coagulation time in patients on new england heparin therapy. Anesth Analg 2000:90:10761079. Nuttall GA. Powell Essay! Oliver WC.

Santrach PJ, et al.Efficacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology 2001:94:773781. , discussion 5A#150;6A. B.5. What are the indications for transfusing FFP, platelet concentrate, and cryoprecipitate? Blood usually coagulates appropriately when coagulation factor concentrations are at least 20#37; to 30#37; of normal and when fibrinogen levels are greater than 75 mg/dL. Although laboratory values such as PT and partial thromboplastin time (PTT) may be abnormal, The American Society of colonies, Anesthesiologist Task Force on Blood Component Therapy discourages conventional use of FFP for jungian archetypes, 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 new england vs chesapeake, task force states that a true dilutional coagulopathy does not ordinarily occur until more than 100#37; of the patient's blood volume has been replaced.

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

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

The American Society of Anesthesiologist's Task Force on Blood Component Therapy recommends the administration of cryoprecipitate for. Prophylaxis in nonbleeding perioperative or peripartum patients with congenital fibrinogen deficiencies or von Willebrand's disease unresponsive to DDAVP (whenever possible, these decisions should be made in new england vs chesapeake colonies, 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 of alcohol, cryoprecipitate per 10-kg body weight raises plasma fibrinogen concentration approximately 50 mg/dL in the absence of new england vs chesapeake colonies, continued consumption or massive bleeding. Bleeding following cardiac surgery without demonstrable abnormalities of coagulation is not considered to be an indication for transfusion of FFP, platelets, or cryoprecipitate. American Society of of pull factors, Anesthesiologists. Guidelines for vs chesapeake colonies, blood component therapy.

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

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

Weinstein SL, et al.Packed red cells in acute blood loss: dilutional coagulopathy as a course of surgical bleeding. Anesth Analg 1995:80:336342. Shore-Lesserson L. Manspeizer HE. 12 Angry Men Themes! DePerio M, et al.Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Randomized controlled. Anesth Analg 1999:88:312319. Stover EP. Siegel LC. Vs Chesapeake Colonies! Parks R, et al.Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study.

Institutions of the Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology 1998:88:327333. Wilhelmi M. Franke U. Cohnert T, et al.Coronary artery bypass grafting surgery without the strain theory, routine application of new england vs chesapeake colonies, blood products: is combustion, it feasible?. Eur J Cardiothorac Surg 2001:19:657661. B.6. What are the complications associated with blood component transfusions? Complications associated with transfusions of new england colonies, blood elements include transmission of infectious agents (e.g., hepatitis, HIV infection), hemolytic and men themes nonhemolytic transfusion reactions, immunosuppression, anaphylactic or anaphylactoid reactions, and new england alloimmunization to platelet-specific antigens and the Rh antigen (resulting from 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. Kam PC. Baldo BA, et al.Anaphylactic or anaphylactoid reactions in punker look, patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2001:15:684688. Frere MC. Rapaille A. Colonies! Bouillenne C, et al.Analysis of 516 reports of merton's strain, reactions after the transfusion of labile blood products. Transfusion Clin Biol 2001:8:333342. Fresh frozen plasma: indications and risks. New England Vs Chesapeake Colonies! 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. N Engl J Med 1995:333:17211725. Nightingale SD. Department of Health and Human Services Advisory Committee on Blood Safety and Availability. Punker Look! Universal WBC reduction. Transfusion 2001:41:13061309. Platelet transfusion therapy.

NIH Consensus Development Conference Statement 1986:6:(7)1. Sazama K. Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion 1990:30:583590. B.7. What is the new england vs chesapeake colonies, risk of Powell Essay examples, acquiring HIV from blood exposure? The risk of HIV infection in the United States is 1/200,000 to 1/2,000,000 per unit transfused. However, with the new england vs chesapeake colonies, implementation of donor screening tests for HIV-1 antigen, there is an combustion, expectation of preventing up to colonies, 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 punker look, blood transfusion is cytomegalovirus.

Bartlett JG. Report from IDSA: symposium on healthcare worker issues. The. Hopkins HIV Report: A Bimonthly Newsletter for new england vs chesapeake, Healthcare Providers 2000:12:(1)3, 8. Goodnough LT. Brecher ME. Kanter MH, et al.Transfusion medicine: first of 2 parts#151;blood transfusion. N Engl J Med 1999:340:438447. Lacritz EM.

Sullen GA. Aberle-Grasse J, et al.Estimated risk of men themes, transmission of the human immunodeficiency virus by new england colonies, screened blood in the United States. N Engl J Med 1995:333:17211725. Lowe KC. Farrell K. Ferguson EM, et al.Current perceived risks of transfusion in the UK and relevance to the future acceptance of blood substitutes. Artif Cells Blood Substit Immobil Biotechnol 2001:29:179189.

B.8. Archetypes! 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. Primary fibrinolysis is rarely a cause of new england vs chesapeake colonies, bleeding in the postcardiac surgery patient. Butterworth J. James RL. Lin YA, et al.Gender does not influence epsilon-aminocaproic acid concentrations in adults undergoing cardiopulmonary bypass. Of Alcohol! Anesth Analg 2001:92:13841390. Chauhan S. Kumar BA. Rao BH, et al.Efficacy of aprotinin, epsilon aminocaproic acid, or combination in cyanotic heart disease. Ann Thorac Surg 2000:70:13081312.

Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and vs chesapeake colonies thrombosis: basic principles and clinical practice 2nd ed. Merton's Theory! Philadelphia: JB Lippincott, 1987:1026. Ray MJ. New England Vs Chesapeake! O'Brien MF. Comparison of punker look, epsilon aminocaproic acid and low-dose aprotinin in cardiopulmonary bypass: efficiency, safety and cost. Ann Thorac Surg 2001:71:838843. 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 new england colonies, patient's history, physical examination, and laboratory findings are mandated; second, key areas of theory, concern should be identified and appropriate steps taken to address them; third, an vs chesapeake colonies, anesthetic plan that is tailored to cardiac tamponade is devised; last, communication with the respective medical (surgeons, nurses, perfusionist, blood bank) and combustion of alcohol 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 chest x-ray film, and assessment of arterial blood gasses. Shortness of new england vs chesapeake, breath and the inability to lie supine are frequent symptoms in patients having cardiac tamponade physiology and every effort should be made to provide comfort and 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. Combustion Of Alcohol! The persistent oliguria most likely reflects prerenal or renal (acute tubular necrosis) process secondary to reduced CO and the associated vasoconstrictive state. As described in the previous answer, optimization of hemodynamics should also improve the renal function. New England Vs Chesapeake Colonies! Whereas some may administer diuretics in merton's strain, this setting, such management is strongly discouraged. The most effective management is new england vs chesapeake, surgical evacuation of the pericardial effusion or clot.

The hematologic issues include elevated PT and aPTT, blood loss, and Vavasor Essay examples the potential for further blood loss perioperatively. The coagulopathy should be corrected appropriately, the patient's hematocrit and platelets should be checked and new england vs chesapeake treated accordingly, and sufficient blood (four to six units) will be required in the room before commencing surgery. Fontes ML. Of Pull! Hines RL. New England Vs Chesapeake! Cardiogenic shock. Murray MJ, Coursin DB, Pearl RG, et al., Critical care medicine: perioperative management New York: Raven Press, 1997:295306. Kirklin JK, Barratt-Boyes BG, Cardiac surgery 2nd ed. New York: Churchill Livingstone, 1993:1685. Nelson RM. Jeson CB. Smoot WM.

Pericardial tamponade following open-heart surgery. J Thorac Cardiovascular Surg 1969:58:510516. B.10. What premedication would you prescribe? Although it is important to reduce the emotional stress preoperatively, in the setting of punker look, cardiac tamponade it would be unwise to administer any type of anxiolytic. The most effective approach is communication with the new england, patient. Often, the physical appearance and the hemodynamics can be misguiding and catastrophic consequences can arise from premedicating patients in tamponade. A state of marked sympathoadrenal activation exists to of alcohol, support perfusion to 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 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 vs chesapeake colonies vital signs must be continuously assessed including invasive monitoring of systemic blood pressure, electrocardiogram, and oxygen saturation.

In addition, emergency cardioactive and vasoactive drugs should be available during transport: Oxygen: increase the F IO 2 as needed. All necessary equipment for jungian archetypes, intubation should be present (laryngoscope and several blades, bag-mask units, and vs chesapeake 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 Powell examples, 0.1 g/kg/minute. Calcium chloride: dose 2 to 4 mg/kg. Lidocaine: 1 to 2 mg/kg. Atropine: 0.01 mg/kg. C.2. In this patient, what hemodynamic effects would occur from intravenous induction with ketamine, thiopental, fentanyl, propofol, etomidate, and midazolam?

After intravenous administration, ketamine (1 mg/kg) has a rapid onset of action and 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 new england vs chesapeake, an additional 30 minutes or longer. Some of the hemodynamic effect of ketamine may include small increases in blood pressure, HR, CO, and myocardial oxygen demand. This response is mediated by a direct central sympathetic stimulation and by inhibition of norepinephrine uptake into postganglionic sympathetic nerve endings. Ketamine has also been shown to have intrinsic depressant properties on the myocardium.

In clinical conditions whereby norepinephrine stores are reduced and in the presence of preexisting cardiac dysfunction (mechanical or myocardial), administration of ketamine can produce hemodynamic disturbance. Thiopental (4 mg/kg) has a mild to moderate negative inotropic effect as well as vasodilatory property. The hemodynamic response relates to the dose, coexisting diseases (hypertension, ventricular dysfunction), age, intravascular volume, and intactness of autonomic sympathetic responses. Generally, doses of 1 to 12 angry, 2 mg/kg do not cause significant hemodynamic disturbance; however, in patients with cardiac tamponade, thiopental should not be used for colonies, induction. These patients are, literally, on the edge of cardiovascular collapse. Fentanyl does not possess any depressant effects on myocardial contractility but because of combustion of alcohol, its vagotonic effect (decreases in HR) and mild sympatholytic effect (central sympathetic outflow), a reduction in blood pressure may be noted. This response may be more profound in shock or preshock states and when fentanyl is vs chesapeake colonies, used concomitantly with other induction agents (benzodiazepines, thiopental, propofol).

Propofol produces very similar effects as thiopental. Punker Look! 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 vs chesapeake the atrioventricular (AV) node as well as on merton's strain 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 vs chesapeake, cardiac tamponade is strongly disfavored. Etomidate has a very favorable hemodynamic profile and combustion of alcohol 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 new england colonies, mean arterial pressure but such changes are not attributable to myocardial depression as is typical of propofol and sodium thiopental. Pain at the injection site and involuntary muscle movements are the combustion of alcohol, most common adverse events noted with etomidate. It also appears to reduce seizure threshold and enhance its duration when used during electroconvulsion therapy.

Midazolam may cause mild to new england, moderate systemic vasodilation, particularly when used in combination with narcotics. Overall, of the agents discussed, etomidate would be the jungian archetypes, preferred agent for new england vs chesapeake colonies, induction followed by ketamine, and/or fentanyl; whereas, thiopental and propofol would be the least desired. Kaplan JA, Cardiac anesthesia 4th ed. Philadelphia: WB Saunders, 1999:611626. Tweed WA. Minuck M. Mymin D. Circulatory responses to ketamine anesthesia. 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 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 punker look, this setting remains debatable. The actual induction should proceed ONLY in the presence of a surgical team that is ready and gowned and after the vs chesapeake, patient has been completely prepared and draped. The choice of induction agents is limited to narcotics, muscle relaxant (depolarizing or nondepolarizing), and either etomidate or ketamine. Regardless of the 12 angry men themes, induction technique, the anesthesiologist should expect and vs chesapeake colonies be prepared to men themes, manage ensuing circulatory collapse. Fontes ML. Vs Chesapeake Colonies! Hines RH.

Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Vavasor Essay! Philadelphia: Grune Stratton, 1999:11551191. 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 the management steps required for resuscitating this patient. Cardiac tamponade is caused by new england colonies, significant pericardial pressure from accumulating pericardial contents (fluid, blood, and blood clots) that impede chamber filing resulting in of alcohol, a low CO state. The precipitous fall in blood pressure observed with induction can be accounted for by the following: first; most induction agents will have negative hemodynamic effects that are either direct or indirect; second, sympatholysis reduces arterial resistance as well as chronotropy and inotropy of the heart; third, the physiologic consequences of switching from negative pressure ventilation to positive pressure ventilation will further reduce cardiac filling by increasing intrathoracic pressure and afterload; and new england vs chesapeake colonies 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 combustion, hypotension will require use of vasoactive drugs, cardioactive drugs, and/or fluid challenge. Reducing inspiratory positive pressure (i.e., lowering tidal volume or switching from ventilator-delivered breaths to hand ventilation) may also improve the hemodynamic status.

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

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

C.6. What is myocardial stunning? What is myocardial hibernation? The myocardium can exhibit segmental dysfunction or hypofunction related to injury (i.e., ischemia and infarction). Colonies! It has also been noted that myocardial function can be coupled or uncoupled with tissue perfusion. Jungian Archetypes! For example, following a period of new england, oxygen deprivation and restoration of flow, the archetypes, affected myocardium can resume normal function, diminished function, or no function (dysfunction). The term myocardial stunning represents a state of uncoupling between function and flow whereby myocardial flow is normal but function is diminished or akinetic. In the setting of cardiac surgery, myocardial stunning can be a cause of ventricular dysfunction that generally resolves within the first 6 to 8 hours post-CPB. During this period, inotropic support has been shown to be effective. Myocardial hibernation, on new england 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 lower their metabolic activity and oxygen consumption to survive during states of oxygen deprivation. The definitive diagnosis of punker look, stunning and hibernation may be difficult to make because regional myocardial blood flow is 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 new england vs chesapeake colonies, regional function should follow revascularization. D'Ancona G. Examples! Donias HW. Bergsland J, et al.Myocardial stunning after off-pump coronary artery bypass grafting: safeguards and pitfalls. Ann Thorac Surg 2001:72:21822183. Fontes ML. Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction.

Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:11551191. Lorusso R. La Canna G. Ceconi C, et al.Long-term results of coronary artery bypass grafting procedure in new england vs chesapeake, the presence of left ventricular dysfunction and hibernating myocardium. Merton's Theory! Eur J Cardio Thorac Surg 2001:20:937948. Shah BR. Velazquez E. Shaw LK, et al.Revascularization improves survival in ischemic cardiomyopathy regardless of electrocardiographic criteria for prior small-to-medium myocardial infarcts. Am Heart J 2002:143:111117.

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

Rather than administering antihypertensive agents indiscriminately, the clinician should exclude the jungian archetypes, following conditions as causality of hypertension: hypoxemia, hypercarbia, acid-base derangements, and new england vs chesapeake colonies pain. The occurrence of hypertension is a common phenomenon during the first several hours in Vavasor, the ICU. In most cases, the etiology is uncertain and new england vs chesapeake 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 jungian, used because of its potent effect and titratability. Because the underlying mechanism of the hypertension involves endogenous release of norepinephrine (with minimal epinephrine), the most rational agents to use are the -blockers.

Labetalol antagonizes both - and -adrenergic receptors and is an effective antihypertensive agent. Colonies! Alternatively, metoprolol, atenolol, esmolol, or propranolol can be used particularly if the hypertension is associated with tachycardia. Of Alcohol! Unfortunately, these agents are used infrequently because of theoretical concerns of myocardial depression and bradycardia. Current cardiology practice strongly endorses the use of -blockers in the setting of vs chesapeake, moderate and severe ventricular dysfunction. In addition, the examples factors, cardioprotective effects of -blockers have been shown in several perioperative trials whereby the new england, incidence of myocardial injury and mortality (up to 2 years postoperatively) are significantly reduced in patients treated perioperatively with -blockers. Kotlyar E. Macdonald PS. Keogh AM, et al.Optimization of left ventricular function with carvedilol before high-risk cardiac surgery. Punker Look! J Heart Lung Transplantation 2001:20:11291131. Leslie J. Brister N. Levy JH, et al.Treatment of postoperative hypertension after coronary artery bypass surgery.

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

Crit Care Med 1997:25:18071812. D.2. When would it be appropriate to extubate this patient? The timing of combustion, extubation depends on the following: Clinical stability (stable hemodynamics without need for significant inotropic or vasoactive support) Intact neurologic function (alertness and new england colonies ability to of alcohol, comprehend and execute simple verbal commands) Adequate pulmonary function (acceptable arterial blood gases and acid-base status and adequate weaning parameters#151;tidal volume, respiratory rate, vital capacity, and inspiratory effort) Normal body temperature and new england colonies 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.