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Business Plan Tools for level, Startups and Small Businesses. Have a killer business idea? A killer business plan can help you turn it into a successful business. Creating a well-crafted business plan is no easy task, however. Famous? You#39;ll need to not only flesh out your idea, make some educated guesses and level strategies, have a deep understanding of the different aspects of differences between running a business before you even start one. Level? Figuring out meaning, how to do this correctly is level strategies, hard enough, but there are several tools available to make this arduous task a little bit easier for would-be entrepreneurs. Essay About Critically The Pecking Order Theory Of Capital? Instead of starting from scratch, here are a collection of business plan templates, software, apps and corporate strategies, services to help you start a business the right way with a professional business plan. Business plan templates show you exactly what a business plan is consumption spending, supposed to strategies look like and differences and confucianism, what goes in each section. Corporate Level Strategies? You can find them as downloadable sample business plans that you can copy and disillusionment, modify to strategies fit your business, or as fill-in-the-blank or question-and-answer forms. Spending? There are also different types of strategies business plans: simple business plans that cover the disillusionment, essentials, comprehensive ones that cover every aspect of a business, and corporate, those designed for a specific purpose, such as to 1920s raise funding or find business partners. Here are some business plan templates worth considering.

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Divulgation Extra-Terrestre aux USA : compte rendu de l Audience des Citoyens info! Ajou t yves Herbo avec juste raison puisque larticle viendrait de lui, demande son lien source, donc nous le remettons , a savoir que la presse galactique et neo trouve ne mentionnent nulle part la source de Yves Herbo.Donc logique de remettre les choses en ordre, en tant que partenaire du site de yves herbo et aussi pour respecter le travail dautrui nous mettons le lien en esperant egalement un retour si cela se produit dans le sens inverse nous serons vigilents ! Et mea culpa , sylv1 adm . Dommage encore une fois ( cela ne fera qu’un de plus me direz-vous! ) que nous sommes la cible des carences des autres alors que de note cote nous mettons en avant a la moindre occasion les partenaires ou sites interessants et meme les sources images et video .Tout le monde ne peut pas en dire autant.. Strategies? sylv1 adm investigations ufoetscience. Un congres exceptionnel, l audience des citoyens sur la Divulgation. The Woman In White Analysis? s est tenu a Washington, DC au National Press Club du 29 Avril au 3 Mai dans lequel un puissant groupe de chercheurs et de temoins militaires/agents ont temoigne pendant 30 heures sur 5 jours devant des ex-membres de la Chambre Americaine et du Senat -La devise pour cet evenement etait Si le Congres ne fait pas son travail, le peuple le fera. Corporate Strategies? 29-04-2013 : Le Membre du Congres Bartlett : Quil y ait des ovnis ou des extraterrestres nest pas la question cest une question constitutionnelle plus quautre chose. The Rocky Relationship Essay? Dans son discours public final quand il a quitte ses fonctions, Eisenhower a mis en garde le public contre le complexe militaro-industriel, mais son discours original la appele le complexe militaro-industrielCongressiste, puis il a enleve le mot Congressiste. Corporate? Je pense que le Congres doit au peuple americain une audience a ce sujet.

Il peut ny rien avoir avec les ovnis, mais vous avez le droit dadresser des petitions au gouvernement a ce sujet. About Critically The Pecking Theory Of Capital? Le Dr Steven Greer a ouvert la seance de lapres-midi en decrivant comment il est passe dun medecin de salle durgence a un militant de premier plan pour la divulgation sur les UFO-ET. Corporate Level? Greer est egalement producteur executif dun nouveau documentaire, Sirius, qui se concentre sur ses allegations concernant les technologies existantes qui pourraient changer le monde. Sirius est egalement sur le devoilement de lanalyse de lADN dun humanoide de 6 pouces de hauteur decouvert il y a 10 ans dans le desert dAtacama, au Chili. The Rocky Relationship Essay? Surnomme Ata, il y a controverse quant a son origine et ce que exactement lADN revele, selon un rapport final de Greer : smg-report-4-22-2013-final-revised.pdf. Tout ce que les extraterrestres montrent deux-memes ressemble a de la magie pour nous si vous avez affaire avec des civilisations qui sont effectivement arrivees ici dailleurs, elles ont probablement du le faire plus vite que la vitesse de la lumiere peut-etre a la vitesse de la pensee la conscience et lesprit sont la veritable frontiere finale pas lespace . Level Strategies? Nous ne sommes pas seuls dans lunivers et nous avons besoin davoir une paix interplanetaire, une initiative interstellaire. Consumption? Nous avons besoin de comprendre comment nous allons avancer . LActiviste politique Stephen Bassett a parle de la facon dont les medias ont mal rapporte les nouvelles importantes sur les OVNI. Corporate Level Strategies? Si quelques journalistes tres apres pouvent sortir et poser les bonnes questions, ca va devenir vraiment interessant Le chercheur Grant Cameron discute sur 1.000 documents quil a recu via le Freedom of spending, Information Act sur la facon dont Rockefeller a essaye dobtenir de ladministration Clinton de se pencher sur les ovnis, en particulier le crash dOVNI en 1947 a Roswell, NM, et comment le president Clinton a lance un defi en disant que si il y avait un OVNI a Roswell, il na jamais rien ete dit a ce sujet. Corporate Strategies? Cameron parle de la facon dont Bill et Hillary Clinton ont rencontre Rockefeller dans son ranch pour discuter des OVNIS. Joan Of Arc Famous? Il y a des documents cles de 1995 qui soulignent comment Hillary et son personnel ont aide a la redaction dune lettre dinformation sur les UFO qui serait envoye au president. Corporate Strategies? Le temoignage de Grant Cameron sur ladministration Clinton et ses tentatives infructueuses pour trouver des informations UFO Linda Moulton Howe a signale des enlevements (abductions) et une manipulation possible de lesprit humain. Spending? Elle raconte lhistoire dun militaire qui lui a dit quil etait dans une equipe qui, en 1978, a ete chargee denqueter sur une ville qui aurait ete inondee par des extraterrestres. 30-04-2013 : Le comite des anciens membres du Congres est a lecoute des temoignages de temoins oculaires de l incident celebre de 1980 en foret de Rendlesham en Angleterre qui a implique de nombreux militaires. Plus tard dans la journee, le comite a entendu des temoignages de temoins oculaires, plus de militaires encore, sur l activite OVNI au-dessus des sites americains de missiles nucleaires . Temoignage de James Penniston sur sa rencontre rapprochee avec un OVNI.

Le Cong. Corporate? Roscoe Bartlett a engage le Sgt. The Woman In White Analysis? James Penniston (voir images ci-dessous) a faire un rapport sur lOVNI quil a approche sur le terrain pendant les annees 1980 et les multiples temoignages de rencontre dans la foret de Rendlesham en Angleterre : Bartlett : Vous etiez la quand lengin a decolle? Penniston : Lengin a genere plus de luminosite et cela me preoccupait. Strategies? Je netais pas sur quil nallait pas exploser, donc jai pris une position quelque peu defensive. The Pecking Of Capital? Il a rase le sol, est alle a niveau de larbre, a momentanement plane, puis a decolle en un clin d?il. Level? Les choses quil na pas faites etaient tout ce quil aurait du faire.

Jattendais un deplacement dair tous les avions le font. Consumption Spending? Jesperais le son des avions tous les avions font cela . La session de lapres-midi se concentre sur les nombreux cas dovnis observes dans le voisinage des sites americains de missiles nucleaires. Level? Un des temoins, retraite de la Force aerienne, le Capitaine Bruce Fenstermacher decrit avoir vu un OVNI en forme de cigare au-dessus dune base nucleaire au Wyoming en 1976 . Lhistorien sur les UFO Richard Dolan a parle de la facon dont la loi sur la liberte de linformation a donne des documents importants lies a des affrontements militaires avec les ovnis . Le C ong. Differences Between And Confucianism? Roscoe Bartlett devient un peu grincheux sur la couverture mediatique jusquici sur cette semaine dAudition citoyenne sur la divulgation : (au sujet dallegations dans la presse disant quils etaient achetes 20000 $ pour enregistrer ce quils voulaient : () Cest tout simplement insultant de dire que nous pouvons etre achete pour $ 20,000 cest ridicule ! Il poursuit en disant que lancien membre Roscoe Bartlett, dans une allocution douverture, M. Strategies? Bartlett a declare quil navait pas rempli son devoir a son bureau par ce quil tenait des audiences sur des extraterrestres: Je nai jamais dit cela ! Je nai jamais dit que je croyais aux extraterrestres. Consumption? Je crois quil y a des observations la-bas qui ne peuvent etre facilement expliquees. Corporate Level Strategies? () 01-05-2013 : La Chercheuse Linda Moulton Howe a discute de ses nombreuses annees dinstruction sur detranges mutilations danimaux qui ont ete lies a des observations dovnis . Le premier rapport mondial des medias sur ce phenomene etait en Septembre 1967 , quand une jument nommee Lady a ete retrouve morte dans un ranch dans le sud du Colorado. Joan? Lensemble du crane du cheval et son long cou avaient ete depouilles de chair et tous les organes dans la poitrine de ce cheval avaient ete excises, selon un medecin. Corporate Level Strategies? Il ny avait pas de sang du tout pas sur lanimal, et pas autour de lanimal et nulle part a proximite La deuxieme table ronde de la journee, composee de (de gauche a droite dans limage ci-dessous) Grant Cameron, Stanton Friedman, Linda Moulton Howe et Robert Wood presentent un temoignage actuel sur une serie de documents, connus sous le nom Majestic , qui revelent auraient lhistoire de la presidentielle et autorisation militaire et cover-up des ovnis et des extraterrestres possibles occupants.

Wood , a la retraite apres une carriere de 43 ans chez McDonnell Douglas Aerospace Corp , a passe plus de 30 ans a enqueter sur les ovnis, y compris des annees de recherches pour authentifier les documents Majestic : Lidentification dun aspect dun document mis en question comme etant des resultats souvent anormaux permet a un sceptique de naccepter rien du reste du document, meme si cela peut etre rempli avec des informations exactes. Essay About Assess Order Theory Structure? Cela semble etre accepte dans la communaute du renseignement qui a truque les documents habituellement si ce nest pas souvent quils contiennent beaucoup dinformations valables pour aider a le faire accepter comme authentique partout . La conclusion a laquelle je parviens est incroyablement sauvage : que les responsables ont reussi a garder secrete la plus grande histoire de lhumanite alors que secretement ils depensaient des sommes stupefiantes pour creer des ressources souterraines cachees et de la technologie inversee. Corporate Level? Jusqua ce que nous pouvons quantifier la menace alien, comment pouvons-nous savoir si ces actions sont bonnes ou mauvaises ? Esperons, peut-etre avec laide dune race de bons aliens, que Dieu va peut-etre faire la bonne chose Je pense que le peuple americain merite [la verite] -. Essay Critically Assess The Pecking Order Structure? Nous avons paye pour cela . Plusieurs personnes composent le panel de temoignages sur les evenements entourant le crash dun OVNI presume a lexterieur de la ville de Roswell, NM en 1947. Le jury est compose de (de gauche a droite dans limage ci-dessous) Denice Marcell, Jesse Marcel III, Col. Corporate Strategies? / Dr. Essay Assess Theory Of Capital? Jesse Marcel Jr., le Ret. Level Strategies? USAR lieutenant-colonel Kevin Randle, lancien physicien nucleaire Stanton T. In White? Friedman et le chercheur / auteur Donald Schmitt. Marcel Jr. Corporate Strategies? a une brillante carriere a la fois comme un officier de la marine et de la garde nationale ainsi que detre un chirurgien militaire de vol. About Assess Order Theory Structure? Il a dit au comite Washington CHD sur la nuit en 1947 (alors quil etait age de 11 ans), lorsque son pere Jesse Marcel , officier de renseignement de la Roswell Army Air Field, est revenu a la maison avec des debris de toute sorte de lobjet qui sest ecrase dans un ranch a proximite : Jai ete reveille par mon pere qui revenait dune mission de recueillir des debris dorigine inconnue dun ranch de Roswell. Level Strategies? Sachant quil avait vu quelque chose de tres special, il voulait que ma mere et moi-meme regardions ca aussi et a dit: Vous ne verrez jamais cela a nouveau . In White Analysis? Il nous a dirige dans la cuisine ou il y avait ces etranges debris sur le plancher de la cuisine quil avait pre-positionnes.

Il a dit: Regardez ca Je pense que cest ce que vous appelez une soucoupe volante ou des restes de celle-ci. Corporate Strategies? Les debris se composaient de trois elements: il y avait une feuille metallique tres dure, il y avait des debris de plastique noir, comme un disque de phonographe casse, mais la chose la plus etrange que jai vu etait une poutre en I dans lepave. Why Was Joan Of Arc Famous? Il y avait des signes decriture le long de la surface a linterieur de celle-ci. Corporate Level? elles etaient dune teinte violacee-violet, semi-reflechissantes a la lumiere. Differences Between Taoism And Confucianism? Marcel Jr. Corporate Level? a continue a raconter comment son pere a ensuite ordonne denvoyer un vol avec le materiel pour le bureau du General Roger Ramey a Fort Worth, Texas. Quand mon pere est rentre, il a demande a ma mere et a moi-meme de nous assoir et a dit: Vous ne parlez jamais de cela cest un non-evenement . In The? Je nen ai jamais discute avec mes amis ou quelquun dautre jusqua ce que Stanton Friedman interroge mon pere en 1978. Le USAF Ret. Strategies? lieutenant-colonel Richard French donne un surprenant temoignage sur Roswell. French a parle au comite au sujet dun incident dont il a ete temoin a la fin des annees 1960 a Alamogordo, alors quil testait les effets de laltitude sur les humains dans une chambre daltitude pour completer son cours de recyclage annuel.

Pendant que jattendais la, jai eu connaissance dun accident a quelques miles de la en direction des White Sands [silos de missiles]. The Woman? Peu de temps apres, jai ete temoin du decollage dun avion de chasse prototype que je ne reconnaissais pas ou su ce que cetait. Lavion a decolle a un taux tres eleve de vitesse et a tire une fusee, de cinq pouces de diametre et denviron six pieds de long, soit environ la meme taille que certains des fusees aeriennes air-air modernes. Ensuite [j’ai entendu] quil y avait un nombre inconnu dhumanoides, tues ou blesses. Level? Les restes des victimes ont ete amenes a la base des operations a Holloman Air Force Base [au Nouveau-Mexique]. Why Was Joan Famous? Les seules parties de lengin que jai ete autorise a voir portaient des marques qui semblaient etre arabe ou une langue que je ne comprenais pas. Plus tard, jai appris que les restes et les victimes ont ete transportes a Wright-Patterson Air Force Base [en Ohio] et remis a la Division des technologies etrangeres.

Ce nest pas la premiere fois que French sest presente pour reveler des informations intrigantes sur les OVNIS. Corporate Level? Lannee derniere, il a dit au The Huffington Post exclusivement quil ny avait pas seulement un OVNI qui sest ecrase pres de Roswell en 1947 il y en avait deux ! 02-05-2013 : le Jour 4 de laudition offre un temoignage international sur le sujet des OVNIS. The Rocky Relationship? le Membre du Comite, le Senateur Mike Gravel (voir ci-dessous) pense que ce sera important: Je pense a la meilleure possibilite que nous avons pour apporter de la visibilite aux peuples du monde sur cette question nous pourrions aller a lONU. Corporate Strategies? Maintenant, je ne pense pas que nous aurions une priere a faire au Conseil de securite, car il est controle par nous et que ca ne pourrait tout simplement pas se produire. Mais quest-ce quil se passerait a lAssemblee generale si nous devions presenter une resolution ? Je vous parie que ca passerait. Analysis? Ils financent une partie de celui-ci le reste du financement pourrait provenir de sources privees, et nous aurions levenement mondial le plus impressionnant sur ce sujet au bout de deux ou trois ans . Les temoignages daujourdhui sont presentes par plusieurs fonctionnaires et des militaires de differents pays, dont le Bresil, lUruguay, le Perou et lArgentine . Certains problemes techniques dans la traduction audio de plusieurs personnes ont empeche une bonne comprehension. Dans la premiere table ronde de la journee, lancien chimie bresilien, le professeur AJ Gevaerd a parle des nombreux cas dOVNI au Bresil , plus precisement dans la region de lAmazonie. Corporate Level? Il a decrit un comite cree en 1977 par larmee de lair bresilienne pour enqueter sur les cas. Mass Culture In The? Le comite etait appele Operation Soucoupe. Corporate Strategies? Gevaerd a presente au Comite un rapport de 440 pages intitule OVNI en Amazonie (voir ci-dessous) Peut-etre le temoignage le plus intriguant offert aujourdhui, jusqua ce moment, est venu dun ancien pilote, combattant de 25 ans de lArmee de lair peruvienne. Spending? Le colonel Oscar Santa-Maria (photo ci-dessous).

En 1980 , on corporate level strategies, lui a ordonne de decoller et dabattre un OVNI en forme de sphere qui se trouvait dans lespace aerien restreint a proximite dune base aerienne. Differences And Confucianism? La rencontre a dure plus de 20 minutes . Il sest agit de 22 minutes ou lon montait et descendait, il tournait autour, et il essayait de meviter pendant que je poursuivais et jessayais de tirer. Strategies? La premiere fois que jai tire, cetaient des balles de 30 millimetres une seule peut detruire un camion. The Woman In White Analysis? Et jen ai envoye 64, un deluge de feu, et rien ne se passait du tout, et cest ce qui etait si surprenant. La possibilite de ne pas toucher mon objectif etait pratiquement impossible . Corporate Level? Jai gagne des recompenses pour ladresse au tir, et cest pourquoi ils mont envoye la-bas pour chasser cette chose. Essay About The Pecking Of Capital? La possibilite de mon loupage, cetait zero.

Lobjet que Santa-Maria poursuivait etait denviron 30 pieds (9 m) de diametre avec un dome sur le dessus, pas de moteur visible, dailes ou de fenetres. Level Strategies? Il a dit au comite quil essayait de comprendre comment mieux attaquer lengin inconnu. Jai essaye differentes positions. Essay Assess Theory Of Capital Structure? Quand il est passe, il y avait une vitesse supersonique. Corporate? Quand jai debarque a cote de lOVNI a 1,3 Mach, il sarreta , et puis, en quelques secondes, il atteint Mach 1,2, sans moteurs ! Cest quelque chose que personne, aucun engin peut faire, juste aller de zero a 1,2 Mach, a la verticale, pour atteindre ma meme position il etait en mesure danticiper mes mouvements et puis de me suivre.

Une fois que jai atterri, jai rencontre des officiers du renseignement, et nous avons regarde tous les catalogues pour voir quel possible engin despionnage cela aurait pu etre, mais il ny avait rien de semblable a ce que javais observe, et nous netions pas au courant de tous les types de technologie qui existaient sur Terre. Mass Culture In The? La deuxieme table ronde est composee dexperts internationaux qui proposent des temoignages sur les ovnis. Strategies? Les personnes (assermentees dans limage ci-dessous) sont (de gauche a droite) Antonio Huneeus (Chili-Etats-Unis), Nick Pope (UK), Grant Cameron (Canada), Sun Shili (Republique populaire de Chine) et Roberto Pinotti (Italie). Le Scientifique chinois Sun Shili est un fonctionnaire retraite du ministere des Affaires etrangeres et president de la Federation mondiale chinoise OVNI. Notre federation sert de plate-forme de communication pour les Chinois globalement sur tous les aspects des ovnis, y compris ceux de la Chine continentale, Hong Kong, Taiwan et a letranger. Essay About The Pecking Order? Les Chinois se considerent comme les descendants des dragons, qui viennent de lespace dans la culture chinoise. Nous appelons notre terre comme la terre des divinites ou des dieux et nous cherchons lharmonie entre lhomme et le ciel. Corporate Level Strategies? [Toutes ces choses] sont tres pertinentes a laudience qui se deroule aujourdhui.

Shili a dit au comite CHD quil etait un diplomate du gouvernement et professeur duniversite, mais depuis les annees 1970, il a commence a chercher sur les ovnis et les mysteres de lunivers. Tout le monde sur cette planete est a la recherche de nos racines dans lunivers. Why Was Of Arc? Nous avons le droit de connaitre et de decouvrir. Corporate Strategies? Toute tentative de secret est inacceptable. The Woman In White? Egalement des statistiques des groupements ufologiques de Chine [dont il existe environ 50.000 membres] montrent que, sur 1,3 milliard de personnes, nous avons plusieurs dizaines de millions de gens qui sont passionnes dOVNI. Sur la cinquieme et derniere journee a Washington, DC, un groupe de pilotes prives, commerciaux et militaires et lancien fonctionnaire de la FAA John Callahan ont temoigne au sujet dun certain nombre de rencontres OVNI vecues par les pilotes, et comment, dans de nombreux cas, les informations sur ces incidents ont ete deliberement cachees au public. CHD organisateur Stephen Bassett a annonce quune video de 15 minutes etait sur le point detre montre dun homme de 77 ans, en tres mauvaise sante, qui voulait profiter de loccasion pour devoiler une histoire de ce qui sest passe pour lui, alors quil travaillait pour la CIA sous le president Dwight Eisenhower en 1958. Bassett : Dans un sens, cette video represente les nombreuses personnes la-bas qui nont pas pu venir devant un comite comme celui-ci, qui veulent parler, mais cest difficile. Corporate Level? La grande majorite des personnes qui ont interagi avec ce probleme tout en travaillant pour le gouvernement, qui remonte aux annees 40, ont garde linformation quils avaient jusqua leur tombe et ne parlaient pas si on the woman in white analysis, leur a dit de ne pas parler.

Ce monsieur a recu de nombreuses menaces de son gouvernement de ne pas parler, mais il voulait que ce temoignage soit presente et nous en avons convenu. Strategies? Il a seulement ete interroge par deux chercheurs qui sont ici aujourdhui, Linda Moulton Howe et Richard Dolan. Cest une evidence que la CIA ne reconnait pas systematiquement lidentite des personnes qui travaillent pour lagence, nous ne pouvons pas confirmer qui est cet homme nous ne pouvons que presenter des parties de son temoignage, comme il parlait avec lhistorien Richard Dolan (vu a gauche sur la photo ci-dessus). Mass Culture In The 1920s? X comme nous lappellerons ici a raconte comment il a travaille pour la CIA sur un projet special concernant le projet Blue Book de lArmee de lAir des ovnis (qui a dure pendant environ 20 ans avant de mettre fin en 1969). X: le Projet Blue Book etait partiellement une fraude. Corporate? Mais les cas que nous avons obtenus ne sont pas venus du Pentagone ou du siege de la CIA.

Mon patron ma mis au courant du projet Blue Book et ce quils ont trouve a ce jour, autant sur les gris et les aliens et lincident de Roswell. Dolan: Quavez-vous ressenti quand ca sest revele a vous? X: Eh bien, jetais juste un peu depasse par tout cela. Essay About Assess Order? Mon patron a dit que nous allions faire partie de la poussee dEisenhower pour en savoir plus sur ces aliens. Strategies? Nous sommes alles dans le bureau ovale. Why Was Joan Famous? Le president Eisenhower etait la, et Nixon. A ce stade, X continue a parler de comment Eisenhower a ete bouleverse quand il a appris quil y avait des activites en cours a une base dans le Nevada (qui sera plus tard rebaptise Zone 51) et que le gouvernement naurait eu aucune juridiction dessus. Corporate Level? Eisenhower a envoye X et son patron a la base pour savoir ce qui se passait la-bas.

X decrit ce quils ont vu quand ils sont arrives. X: Il y avait differentes ouvertures de portes de garage et a linterieur il y avait differentes sortes de soucoupe. Mass Culture? Le premier etait lengin de Roswell cetait une sorte de crash, mais apparemment tout alien etait mort, sauf un couple. Corporate? Plus tard, nous avons vu le film de lautopsie, puis le colonel dit: Ce que nous avons ici est que nous avons une entrevue avec un alien gris. Differences Between Taoism? Dolan : Quavez-vous ressenti a ce moment? X: Je pensais, garcon, nous navions aucune idee que nous allions voir la vraie chose. Corporate? Tout ce que nous avons vu etait un film. Relationship Essay? Mon patron a pu y aller et avoir un entretien partiel. Strategies? Celui-ci avait lair un peu Oriental. Relationship Essay? Il navait pas lair humain avec la texture de la peau. Corporate? Le cerveau etait un peu plus grand, un tres, tres petit nez et les oreilles etaient comme des trous et la bouche etait tres petite. X et son superieur sont retournes a Washington pour rencontrer Eisenhower et Nixon a nouveau.

X: En outre, Hoover etait la. In The? Nous leur avons parle de lalien et de la situation dans son ensemble et il etait juste totalement choque. Strategies? Il est apparu pour la premiere fois etre inquiet. About Critically Assess Structure? Eisenhower a dit: Nous devons garder cette chose totalement secrete . Le pannel de la technologie (avoir prete serment ci-dessous), compose de (de gauche a droite) le Dr Roger Leir , lingenieur physique Valone Thomas , le Dr Steven Greer et lingenieur aeronautique Robert Wood . Au cours de cette session, Leir , un podologue, a decrit les nombreuses interventions chirurgicales quil a realisee avec une equipe medicale dans lesquelles ils ont enleve des petits objets insolites de personnes qui affirmaient avoir experimente un enlevement. Au cours de mes 50 annees de pratique de la chirurgie podiatrique, jai enleve des centaines dobjets a partir du pied humain, y compris le papier, le verre, le metal et les pierres. Toutes les personnes impliquees dans mon bureau nont presente aucune porte dentree pour lun des objets qui ont ete supprimes. Corporate Level Strategies? Il ny a pas formation de cicatrices visibles et sans interruption de lintegrite de la peau, meme lorsque lexamen a ete effectue avec une loupe grossissante. Mass? Toutes les personnes participant a letude ont presente etre positif aux rayons X ou a la tomodensitometrie montrant des corps etrangers metalliques plus ou moins denses. Corporate Level? En outre, par lutilisation dun detecteur de frequence des ondes radio, nous avons pu detecter que certaines frequences radio dans la bande FM, ont ete emises par lobjet . In White Analysis? Toutes les chirurgies que nous avons effectuees ont ete documentees avec des temoins oculaires, la video et la photographie. Nous constatons que, dans tous les rapports pathologiques, il ny a pas de reaction inflammatoire, il ny a pas de reaction de rejet. Corporate Level Strategies? Il ny a rien que nous avons trouve dans la science des materiaux qui ne produirait absolument aucune reaction inflammatoire dans le corps humain Le porte-parole international pour le CHD dune semaine est lastronaute dApollo 14 Edgar Mitchell , qui croit que la Terre a ete et peut encore etre visitee par des extraterrestres.

Je ne peux pas dire dou ils viennent, mais les preuves de leur presence ici sont assez ecrasantes si vous tenez a les chercher. Why Was Of Arc Famous? Ma seule hypothese pour expliquer pourquoi il y a cet embargo est parce quil y a des gens lies a largent, faisant de leur mieux (difficile) afin de tout tenir tranquille a cause du potentiel de profit qui va avec en ayant une capacite et une technologie qui pourraient aller a lexterieur de notre systeme solaire, Mitchell a dit eu HuffPost. Mitchell , le sixieme homme a marcher sur la lune, espere que le CHD de cette semaine permettra de fermer la porte sur le pretendu embargo sur la verite qui entoure la question des OVNI-ET. [Nous devons] repandre un peu plus de verite sur la nature de lunivers dans lequel nous vivons et le fait que nous ne sommes pas seuls dans lunivers. Corporate? Nous avons beaucoup, beaucoup de mysteres sur nos mains, et des mysteres a resoudre. In White Analysis? Nous ne savons pas vraiment la portee de notre existence et notre image de lunivers est encore assez primitive. Corporate Level? Lancien senateur Mike Gravel (D-Alaska), dit que la Maison Blanche a contribue a dissimuler la verite sur linfluence extraterrestre qui enquete sur notre planete au public.

Cela va droit a la Maison Blanche, et bien sur, une fois que la Maison Blanche prend une position, Et bien il ne se passe rien cela va juste en bas de la chaine de commandement, tout le monde demeure muet , raconte Gravel a Top Line . Gravel est lun des six anciens representants du Congres qui ont ete payes 20.000 dollars par le groupe de defense Paradigm Research OVNI a participer a une audition au Congres sur la divulgation a Washington cette semaine, ou temoin apres temoin ont presente des temoignages de premiere main sur des observations dovnis et des visites extraterrestres. Gravel affirme que les rapports les plus forts de rencontres extraterrestres sont ceux danciens officiers de larmee, comme le retraite de lAir Force, capitaine Robert Salas , qui a declare que les ovnis ont temporairement desactive les armes nucleaires dapres ce quil a vu. La preuve irrefutable sur lensemble de la question, est ce quils ont vu un vaisseau spatial planant dans le Wyoming et le Dakota du Sud au-dessus des silos de missiles de lICBM et que les missiles ne pouvaient pas se lancer , dit Gravel . Gravel affirme que les medias ont aide a ce quil considere comme une dissimulation gouvernementale en ne prenant pas les rapports de rencontres ET au serieux. Ce a quoi nous sommes confrontes ici, cest, dans les domaines des medias, et du gouvernement aussi, un effort pour marginaliser et ridiculiser les gens qui ont des connaissances specifiques , dit-il. Interroge sur le fait quil a ete indemnise pour sa participation a laudience, Gravel affirme que cela na pas eu dinfluence sur lui pour accepter de temoigner. Cest une opportunite que jai pris de me concentrer sur cette question pendant toute une semaine et la preparation que jai fait pour arriver a cela ma convaincu que cest tres important , dit Gravel . Lancien ministre de la defense du Canada, Paul Hellyer , a cloture cette semaine daudiences et a repete son avis donne ici : Un documentaire de qualite cinematographique sera produit a propos de cet evenement prevu pour etre distribue en automne 2013. Spending? Le but de cet evenement/documentaire nest rien de moins que la fin sur lembargo a la verite en 2013. Si cette video ne fonctionne pas cliquez ici. source via

Mise a jour pour Investigations Ufo et Science le 7-5-2013 a 06 h 30.

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#8216;Alien#8217; guest essay: Looking back in horror to 1979. Ridley Scott just presented #8220;Prometheus#8221; to Hall H fans at Comic-Con, and that has Finland#8217;s Juhani Nurmi, a journalist and corporate level strategies, devoted fan of Essay about Critically assess the Pecking Order Structure, #8220;Alien,#8221; looking back in horror #8212; and appreciation. This painting, Necronom IV (1976), convinced director Ridley Scott to hire Swiss designer H.R.Giger to create the level titular monster in Alien. (H.R. Giger) #8220; In space, no one can hear you scream .#8221; Thats the best movie slogan I know, and in my book, nothing else comes even close. In White. Ditto for the poster (designed by legendary graphic artist Bill Gold), which is strategies sinister yet elegant in its minimalism. It depicts a luminescent egg floating in a dark void, above a grate. Obviously, were talking about Ridley Scotts #8220;Alien.#8221; This year marks the why was joan movies 32nd anniversary and corporate strategies, more than that, the movie is back in the pop culture conversation with new urgency as Ridley Scott toils in Iceland on #8220;Prometheus,#8221; the 2012 release that began life as a straight prequel but has now reportedly morphed into something else. I was 13 years old in Relationship Essay, 1979 when I first saw the trailer for #8220;Alien#8221; on corporate level, a television show about film. The pounding temp track, the ominous sound effects and the psychosexual imagery relating to consumption spending, that signature image #8212; the egg-like spore #8212; spooked me to the core, to say the least. If I thought the corporate level trailer was tough, the movie took it to consumption spending, a whole other wrenching level. From those classic opening titles onward, I and the rest of the audience were in for one hell of a ride #8212; if we even made it to the end of the movie.

Thinking back, there was only one other thriller in the 1970s which could compete, and that was William Friedkins #8220;The Exorcist#8221; (1972). Friedkins seminal thriller about demonic possession took a similarly relentless attitude to psychological suspense and visceral, venereal horror. Suffice to say, neither movie pulled any punches. The legendary Space Jockey by H.R. Corporate Strategies. Giger in of arc famous, Alien. (H.R. Giger) #8220;Alien#8221; certainly wasnt in corporate, the same tonal galaxies as #8220;Star Wars#8221; (1977), #8220;Close Encounters of the Third Kind#8221; (1977) or #8220;2001: A Space Odyssey#8221; (1968).

This was something altogether more terrifying and primordial. #8220;Alien#8221; was a haunted house experience camouflaged as a sci-fi movie and in white, no equal has been seen since. Despite its obvious B-movie roots, there was an level astounding level of film craft on display, from Ridley Scotts own mobile camera work to the late, great Jerry Goldsmiths eerily atonal score and the woman in white, the formidable, shape-shifting critter conceived by Swiss designer H.R. Level Strategies. Giger. Why Was Joan Famous. The original story by Dan OBannon and Ronald Shusett had been rewritten by producers David Giler and Walter Hill to amplify the corporate flow of the narrative, but alas, the shooting draft diminished details about the aliens culture. Essay Critically The Pecking Order Of Capital. All of us wanted to know more about the corporate level enigmatic Space Jockey, found in the alien derelict. However, Giler and Hill changed the scripts main hero to a heroine, Warrant Officer Ellen Ripley #8212; played very convincingly by a silver-screen novice named Sigourney Weaver. A female hero in a major Hollywood movie was a biggie in those days, and it only underlined further the importance of #8220;Alien#8221; as a masterpiece. Those first scenes, where a dormant spaceship, USS Nostromo, prepares to awaken its unsuspecting crew of consumption spending, seven astronauts from level strategies hyper-sleep, were both enigmatic and consumption spending, riveting. I truly believed that I was aboard Nostromo. Level Strategies. Not that I necessarily wanted to be.

Nostromo, with its shadowy, stylized corridors and cramped living quarters, was a very scary place to inhabit. It was obvious that Scott and concept designer Ron Cobb had watched Kubricks #8220;2001#8221; very closely. However, their agenda in designing Nostromos look and feel was revolutionary in late 1970s cinema #8212; they made that old tow ship gritty, rusty and Essay Critically assess Theory of Capital Structure, leaking! Nostromo was downright funky, and nothing proves this funkiness more vividly than an absolutely nerve-wracking scene in the movie, where Engineering Technician Brett (Harry Dean Stanton) goes to an immense storage room, trying to corporate level strategies, find the ships feline pet, Jones. Critically The Pecking. The creeping claustrophobia in #8220;Alien#8221; was evidenced by corporate level strategies, the scene in which a panicky, sweaty Capt. Dallas (Tom Skerritt) is crawling through Nostromos ventilation shafts in mass in the 1920s, search of the alien, equipped with a flamethrower. This scene is another masterful example of how Scott cranks up cinematic tension to an almost intolerable level.

Ultimately Dallas can no longer contain the fear and panic hes feeling. A captain must always show courage to his crew in the face of level, mortal danger, but defiance alone isnt enough to escape the claws of the alien. H.R. Giger#039;s airbrushed painting of the spending alien derelict. (H.R. Giger) I mentioned earlier that all audience members didnt make it to the end of the corporate level movie. In sneak previews, some audience members bolted for the lobby #8212; or the bathroom. Executive Officer Kane (John Hurt) #8212; who was attacked by an alien face-hugger on the planetoid LV-426 #8212; quickly became an unwilling host for the parasitic organism, whose voracious spawn ate through his chest in the climax of the woman, a seemingly mundane meal scene. In summer 1990, when the Internet didnt yet exist, I sent Gigers management a bunch of letters in the hope of meeting and interviewing the reclusive genius. I very nearly gave up. One day I received a letter in the mail. It invited me to come to Zurich, Switzerland, where Giger lives.

I didnt hesitate for a moment. The visit itself was at times an overwhelming experience. Corporate Level. I didnt know what to why was joan of arc, expect. I guess I somehow expected Giger to corporate level, be a slightly scary and differences taoism, introverted person. I couldnt have been more wrong. Level. Giger, who always prefers to be dressed in black, is the 1920s most cordial and generous man Ive ever met #8212; a perfect host. Gigers laugh is boyish and mischievous and he likes to laugh a lot. We talked for hours in that incomparable manse of his, situated near Zurichs international airport. Even today, Gigers house is filled with huge airbrushed paintings, real human skulls, skeletons and corporate level strategies, impressive sculptures.

Swiss designer and Academy Award winner, H.R. Giger.(Annie Bertram) Although Im allergic to cats, I couldnt resist Gigers beloved pet felines, as they purred in my lap while we talked in English and German. There have been many more interviews since then. In White. We keep in touch, and also meet every now and then. H.R. Giger has no illusions about the corporate true nature of the alien #8212; #8220;it exists to kill, and kills to exist#8221; #8212; and hes justifiably proud of analysis, his Oscar-winning creation. Giger feels that his biomechanical alien is level a very beautiful and elegant killing machine. Heres how the culture in the treacherous Science Officer Ash (Ian Holm) described the corporate level alien in the movie: #8220;Perfect organism. Its structural perfection is matched only by its hostility. A survivor #8230; unclouded by conscience, remorse or delusions of morality.#8221; Its also important to note that H.R. In White. Gigers space monster has been copied endlessly #8212; and shamelessly #8212; in countless movies.

His museum in Gruyeres, Switzerland, is a must visit. Giger is part of the #8220;Prometheus#8221; team, which for us hardcore #8220;Alien#8221; fans is dizzying news. Maybe well finally get more answers about the mysterious space race, too, represented by the Space Jockey and the Derelict. And, just maybe, some day very soon I will be watching a trailer and a film that will take me back to that dark stretch of corporate strategies, cold space where screams are silent but somehow echo for decades. Why Was Joan. 42 Responses to #8216;Alien#8217; guest essay: Looking back in horror to strategies, 1979. Great essay! That#8217;s awesome that you got to meet Giger and visit his house.

So glad that Giger is on the PROMETHEUS production team. Really looking forward to that film. ALIEN is 32 years old and it still RULES! Many thanks for the woman your kind words. Please thank also the corporate gracious Geoff Boucher and his staff at Hero Complex for giving us film journos the opportunity to contribute here! I have a feeling in my bones that PROMETHEUS will be a return to form of sorts for Sir Ridley.

I also wish to of arc, add that ALIEN looks absolutely smashing in level, Blu-ray, so if you#039;re hardcore fan of the movie as I am, make sure to joan of arc famous, check it out! Rick Deckard is not a replicant. Illogical. The slogan for the original Dawn of the Dead; #039;When hell is full the Dead will walk the corporate strategies earth#039; is just as good IMO. I was one of the ones who had to leave Alien briefly during one of the scarier scenes. Essay About Assess The Pecking Of Capital. Of course, it was even worse that I went in level, expecting something like Star Wars. I became a fan for life of Sigourney Weaver when she blasted that alien out of the airlock. I, too, fondly remember watching Alien, shivering in the theater because it was so air conditioned.

But as a student of film, I#039;m not so enamored with Alien#039;s so-called originality. In the 1930s, a genre of films began where a group of people in a haunted house would be killed, one by one. The thematic problem with these movies was a simple, Why didn#039;t those idiots just leave the house? Alien takes the same concept and differences between and confucianism, solves the level problem but putting the house where you cannot leave. Worse, Alien practically takes its entire plot from the 1958 low budget sci-fi film It! The Terror from Beyond Space. The earlier film even had a similar ending requiring the survivors to get in oxygen suits as they empty the ship of air. The Rocky Relationship Essay. Alien is a great film, but if it#039;s great, it#039;s only because it stands on the shoulders of giants. Corporate Level Strategies. My mother took me and my sister to see #039;Alien#039; when it first came out.

I was 14 and my sister was 11, as for my mom she was and still is the consummate horror movie fan meaning she does not like spending her money on of arc, crap. Anyway, we were riveted to the screen, afraid to watch, afraid to level strategies, look away for fear of missing something. About Assess Theory Structure. To this day, #039;Alien#039; and all of its subsequent sequels still rank up there among my favorites. It#039;s simply a masterful film! Can#039;t wait #039;til #039;Prometheus#039; comes out! When I was 10, I saw Hitchcock#039;s #039;Psycho#039;. Yeah, scary indeed#8230;but Psycho was nothing like Polanski#039;s #039;Repulsion#039; which I saw when I was 16#8230;now that was REALLY really freaky.

But #039;Alien#039; it didn#039;t just raise the bar, it redefined movie terror and nothing has come close since. I first saw this on corporate level strategies, a date at the movies when I was 19. Essay About Assess Theory Of Capital Structure. I don#039;t think it came close to being a movie I would#039;ve walked out on. I walked out of corporate strategies, a portion of Night of the Living Dead, but I was 11 and in 1970/71 nobody I was with had heard of the woman analysis, that movie. Dallas not being the hero was a surprise, Sigourney Weaver#039;s stripping down was a tease for the men in the audience, not an example of vulnerability like a film instructor told a friend of mine. A film critic called it an overrated B picture and I tend to agree. Watching that movie made an impression for life. Corporate Strategies. Even watching it 20 years later on Netflix, I chickened out and consumption spending, watched it with the corporate director#039;s commentary first.

An almost unbearable masterpiece and one of the very few original movies ever made. Consumption Spending. Excellent essay. Good to know HRG is involved. Level Strategies. But there#039;s more than the art of HRG here. There#039;s more than the atmospherics.

There#039;s more than the tension building then horrific climax#039;s of action, sometimes seen, but more often not. There#039;s a philosophy of existence that is slowly revealed. One akin to the woman in white analysis, what Lovecraft, Poe, and the Cthulu circle of pulp writers tried to share; Your life is not what you think it is. I had anticipated the release of this movie for so long that, when it finally made it to the theater, I had to walk out during part of it because I was so nauseated. I guess I was just too excited. I do not honestly think that any sci fi movie has ever affected me the corporate level way that one did. The Woman Analysis. I#039;m 57 now. I was 25 when I first sat through it. I also have it and all of its sequels in my video library. I#039;ll add one small point that I#039;m a little ashamed of.

That final scene with Sigourney Weaver in level strategies, the escape pod was one of the top ten sexy things I have ever experienced on the tube. Mass In The 1920s. She was so incredibly hot. I just didn#039;t realize how much until I got considerably older. I first saw the movie when I was 15 after my mother told me this was the only movie she walked out on because of the level John Hurt sceen. She finally watched it years later in it#039;s entirity. There are so many scenes I love and remember- Mother, I#039;ve turned the consumption cooling unit back on#8230; Or Ash as the level strategies deceitful human whose company agenda comes is exposed. I will forever love this movie, and every Christmas we watch it again and again#8230;.. H.R. Giger nailed it when developing the Alien. Consumption. Its a timeless and instantly recognizable piece od art.

I really wanted to level strategies, see the between taoism and confucianism film having read about it pre-release in the LA Times but, after hearing of the terrific scenes, I chickened out in seeing it. Finally, a buddy of corporate strategies, mine who had seen it got tired of of arc famous, hearing me talk about it and literally dragged me to the theater. Corporate Level. I think I saw that darned film like 3 more times!! i#8217;m 51 and i still get freaked out when i watch the re-runs! Exorcist scared the Sh*t out of me, and Night of the Living Dead, too#8230;but nothing came close to Critically the Pecking Order, Alien..I had to hide my face in my companion#039;s chest a few times, while he laughed, nervously, with false macho bravado..we both couldn#039;t wait to get safely home, and we couldn#039;t stop talking about it for weeks, afterwards.. Sigourney Weaver just made it perfect- finally, a true heroine. Excited to read here that Gieger is involved with PROMETHEUS my fingers are crossed that Ridley stay true to corporate strategies, form and creates a film that is as suspensful as the original. Differences Between. Seeing the trailer for the first time at strategies, 12 was as memorable to seeing that first billboard for Star Wars. In White. I have never been so terrified by level strategies, movie and to this day it still reigns. Thanks for mass the great read. J. I was in strategies, the Navy when I saw the movie in Chicago.

I was with three shipmates and one of why was, them actually screamed and jumped up out of his chair during the chest bursting scene! Needless to corporate strategies, say it took awhile before he lived that one down. The film set the bar pretty high for science fiction movies even to spending, this day and I couldn#039;t take my eyes off the screen for a second the entire time. i think juhani nailed it, i made a huge mistake of corporate, seeing #039;The Exorcist#039; at age 11 but i credit it with making me a better church-goer in consumption spending, the 70s! and not until #039;Alien#039; my senior year did i see a film that made me cringe and have trouble going to sleep at level strategies, night for a week; which is my litmus test for horror (does it achieve sleepless nights?). i knew i was in trouble as soon as the opening title montage began. like other commenters here i became a lifelong Weaver fan (Skerritt too); marveled at Essay the Pecking Order, how Scott got Hurt to play the crucial, short-lived and mind-blowing Kane role (and don#039;t forget Yaphet Kotto as Parker who had not done much and taken a lot of serious crap for his role in the James Bond black-sploitation film #039;Live and Let Die#039;). an overrated B-horror flick? all you have to do is take a look at corporate level strategies, the cast and crew. this film was put together perfectly. i love #039;House on Haunted Hill#039; and spending, most all Price and Chaney horror films, but #039;Alien#039; really did tread new ground. i#039;ll admit older horror films showed the way, but i don#039;t agree that #039;Alien#039; stood on the shoulders of corporate level strategies, those films. it was, and remains unique in its genre. I saw Alien at the Egyptian Theater with some friends from the George Page Museum not too long after it opened. Unfortunately, we had reservations at taoism, Miceli#039;s afterwards. You ever go to an Italian restaurant and try to avoid anything red and pasta-like or white (the Chest-Buster-Comes-To-Dinner scene) liquidy (When Ash got his head knocked off and then hooked up again on the workbench)? We had to explain our lack of appetite to Toni (greatest waitress in the world). The only other movie to scare the living daylights out of me stay in level, my head was Hitchcock#039;s Psycho. (Note to moviemakers out there: It#039;s not what you show that really terrifies people.

It#039;s what you don#039;t show. Differences Between Taoism. The anticipation of corporate strategies, horror is 1920s worse than anything you can put on the screen.) Interesting#8230;I was 11in 1979 when Alien came out and remember very vividly when it opened at the Egyptian as well. Obviously didn#039;t go see it as adults I#039;ve talked to were seriously freaked out about it. Just seeing that display everytime we passed the theater was enough for me. Incidentally, around that same time, my folks took me to see The Exorcist at the Pix down the street from the Egyptian (now the corporate level strategies Music Box) and remember having sleepless nights for weeks. Essay. And speaking of Miceli#039;s, I suppose Spaghetti with Alfredo sauce was not in your appetite list that night either, huh?

Best monster design EVER! Not only totally disorienting, but so damn familiar, as in mosquitos and wasps. We KNOW this nasty animal, even if we seldom see it until too late. Oh, hooray! Alien was the first and last movie I ever screamed in and I bet everyone who saw it on the big screen knows exactly when I screamed. Heck, the ENTIRE theater screamed, almost in corporate level strategies, unison. The Rocky. Plus, frankly, to corporate level, have a heroine was such a revelation!

Amazing! Wonderful! It was a Billie Jean King-Bobby Riggs thing. And to hear about the prequel I#039;ll be in line on the first day. Well, when I read the other posts I see that other people screamed at a different moment, so I#039;ll just say I screamed when the alien clasped Dallas in its embrace. Even now I have to look away during that scene.

Yikes! Critics likely saw it on culture in the 1920s, TV, not in a big theatre. Corporate Level. A week after it opened we caught the 5pm showing [to beat the crowds]. Maybe 6 other people in that showing. Great sound and visuals. Dark. Almost lonely. Through the 2nd half she almost ripped my arm off hiding from each progressive shock.

Best SciFi/horror flick I had ever seen [at that time]. As we exited [all 8 of mass culture in the, us], me with my shirt hanging out and hair messed up, the long line for the next showing went silent probably because we all looked awful. Three Jack Daniels later I finally began to relax. #8220;Alien#8221; is definitely the level scariest monster ever. But even more disturbing was the #8220;alien#8221; in the remake of #8220;The Thing#8221;. The #8220;stomach explosion#8221; scene makes the stomach scene in #8220;Alien#8221; look tame. And worst of all, you never find out what #8220;The Thing#8221; looked like or even if it was the culture in the 1920s original driver of the alien space ship. The last scene#8230; somebody was about to pull out a blow torch, and he was the same guy who #8220;fried#8221; the computer in the beginning (foreshadowing). The smile and laugh said so much.

Awesome movie. This is one film that has withstood the passage of time, it has not been eroded by the dazzling CGI and ever expanding budgets of corporate level, major studio productions because it was character driven. If you clock the about Critically Theory of Capital Structure total screen time that the Alien is corporate level actually in the frame it#039;s remarkable how much tension the actors, sets, and soundtrack were able to squeeze out of Relationship, us as an audience. However RS is level mistaken if he thinks that audiences didn#039;t ask the RIGHT questions about the origin of Space Jockey and Essay assess the Pecking Order Theory of Capital, how it came to be stranded there. Those of us who have followed the various books, graphic novels, and sequels have never been given the ANSWERS.

Intertwining the Predator franchise and the Alien universe while entertaining did nothing but dilute and corporate level, put an action flick spin on an elegant and foreboding fog shrouded chamber that we never fully explored. So I am very much looking forward to having a few of these questions at least touched upon, more than just how did the 1920s Space Jockey get there. Who installed the protective field in the chamber with all the eggs? We#039;ll just have to wait and level, see if Prometheus holds a candle to the original work that has stood apart from anything made since 1979. This essay is garbage. I still remember literally jumping out of my seat at the dinner table scene, and screaming aloud. I was 19, and Essay about Critically assess the Pecking, had never known fright like that before, and at 55 now, have never known anything like that fright again in any movie since. Strategies. Famed Poster Designer Bill Gold is credited, here, for the seminal poster of Alien, but as always with proper accreditation, he was the last person in a long chain of and confucianism, egos to manipulate this beautiful graphic idea he did do the poster on orders from the level top, but the actual design originates with 2 lads in the UK who also did the gorgeous opening/title sequence for the woman analysis the film ( and whose name I cannot, of corporate, course, recall ) who presented the The Rocky Relationship Essay concept to Ridley Scott during the post production of the film Ridley described it as simple and effective The egg design was used to film trailers for the picture, then handed over to the advertising agency who hired Bill Gold to corporate level strategies, execute it, presumably on differences taoism, direct instruction from Sir Ridley, who is strategies himself a seasoned designer and who takes great interest in his posters especially back then#8230; Giger was involved in between, Prometheus, yes, only briefly, and symbolically, and in order to patch up a badly damaged reputation which the Studio (FOX) had developed over the years with respect to their treatment of him and his creation, which, as this article points out, was lifted from an corporate existing copyrighted book long before lawyers were seriously looking at the intricacies of licensing of movie character ahem#8230; but I digress) His presence was requested merely to add credibility to the marketing of the Prometheus project, and prevent further legal acrimony. The film was well underway when he showed up for a brief pen-wagging session in the woman analysis, front of the DVD video crew As always, it is best for enthusiastic fans to not learn too much about level strategies how sausage is made#8230;ditto with Hollywood films.

I saw it when it opened at the Egyptian in culture in the 1920s, Hollywood. They had some of the set pieces from the film in the courtyard. Alien was a masterpiece of the genre, and level strategies, nothing like it had ever been seen before. It ranks with the original Frankenstein and Dracula as a milestone. It scared the crap out of me, and there is very little in the way of suspense in cinema that can compare with that final scene of Sigourney wearing only her panties and why was of arc famous, a tank top facing down the most horrendous monster of all time. LOL. I was one who walked out the first time I watched in level, the theatre. I scared the assess the Pecking Order of Capital crap out of me. I was 15 in 1979.

Great article. This is the first I am hearing that a prequel of sorts is in development stages. I almost started to level, cry. When I was 7 years old, my dad rented it for me (1988) because I couldn#039;t stop asking him about the weird egg on the cover of the book he was reading. He would tell me a little synopsis here and there about the story, but true to the actual film, my dad would never tell what the Alien truly looked like, or where it came from#8230;.or what its purpose of existence truly was. The Rocky Relationship. Unlike any other horror movie I saw at that age, it grasped me by the brain and has never let go. Can#039;t wait for Prometheus. The Nostromo was a commercial vessel owned by level strategies, the company and not a military vessel. Take the USS off of it. Analysis. Other then that, an ok essay. A true Alien fan would want to know how the company knew about the creature beforehand, not so much what the space jockey was.

Dracula, The Exorcist, Alien/Aliens my favorite horror movies of corporate level strategies, all time. Where Dracula was a sympathetic character who couldn#039;t survive sunlight, his fangs and the act of sucking blood from a living being makes me shiver. The Exorcist battling Satan is mind boggling and head-spinning, but Alien puts you out where no one can hear you scream the void of space. It#039;s not just the terror of slimy double-mouthed creatures that gut humans for incubators of their offspring, but the addition of it happening out The Rocky Relationship, there. At least on earth humans are in our element, but in space, on another planet, the possibility of rescue is corporate out of reach and culture 1920s, the likelihood of a terrifying death is no joke. I was 5 months pregnant when I saw the promo and level, was so intrigued that I saw the movie days later. Had I been further along in my pregnancy I might have given birth right there in the theater. The scene that stays with me is spending when Ripley is in corporate level, the escape pod and Essay, the #039;Alien#039; unfolds on the control board.

Before then I thought the creature would burst out of the cat, but it was worse than that, and the anxiety of knowing something was going to happen made me grip the arm rests of my chair so tight that I believe my fingernail imprints are probably embedded in them. Corporate Level. This movie may have borrowed some elements of 1950s sci-fi B-movies, but there#039;s no doubt Alien stands soundly on consumption, its own merits. All these years later and I still get wound up watching it and its equally outstanding sequel Aliens. Hats off to and sincere appreciation of corporate strategies, Ridley Scott and H.R. Essay Critically Assess The Pecking Order Theory. Giger for an incredible movie. They can scare the daylights out of me any time! And thank you Juhani Nurmi for corporate level strategies an excellent essay.

You nailed all the points on why the movie is so great. Essay The Pecking Of Capital. I hope both Ridley and H.R. read it. Great article. I think this re-imagining is a better option than a simple prequel. I wonder what the tagline for Prometheus will be? Can you give us one just as good. John Carpenter#039;s HALLOWEEN also had a great tagline as well: The Night He Came Home. I commented after watching the movie when it first played in level, theaters that it was odd that a life form discovered in taoism and confucianism, space and perfectly adapted to live there was considered an alien. I have so much to corporate, say about the movie Alien that I could fill a short novel, but I#039;ll just stick to the unusual things that most people don#039;t seem to realize in the movie or know about the creature itself.

First, if you look carefully whenever you see the consumption spending Alien, it has METAL teeth. The teeth could possibly be some sort of organic polymer with a metallic sheen, but they look like polished steel. Isn#039;t that weird? Perhaps this could be a precursor to the new Prometheus film that would explain the existence of the Aliens as a scientifically-manufactured bioweapon species. Secondly, of course you remember the derelict spaceship that the corporate level crew found? The primary reason that the derelict ship is so fear-inducing on so many levels is because it is truly alien due to being asymmetrically designed and so unlike what a human would create. A final word: the movie Alien is a true game-changer; this masterful and timeless film perfectly depicts a creature that isn#039;t so far-fetched when you consider all of the possibilities within the vastness of space. Who would want to go exploring new planets in the far reaches of the cosmos if there is even a 1% chance of running across something even 10% as dangerous as the Alien?

This movie was a team effort and not the creation of a director or art designer. A lucky combination of talent came together at spending, a particularly fertile time to make this movie great. The director did a superb job in corporate strategies, that he had some visions and was able to the woman analysis, get them done. Without the other artists, writers and workers, it would never have happened. Its kind of like the country#039;s founders of corporate, 1776 were all great statesmen and all within reach of each other. I know its an example but it helps to consumption spending, get my point across. I did kind of level, feel jipped by Jones the cat screeching in that locker. Like a cheap scare. But how did it get in the woman in white analysis, the locker?

The creature put it there so it wouldn#039;t find him and blow its cover. It#039;s too small for him to catch yet he was able to put it in the locker! It also looked at Jones in his cage near the shuttle scene. I liked the cat hissing in strategies, the landing leg room when the forms come down in in the 1920s, the background of level, Brett. But the The Rocky cat looking at him getting carried up#8230; kind of wasted frames that maybe could have shown more of the alien. Back to the cat in the cage, what was the purpose of that interaction with the creature? I guess it was curious and maybe trying to get clues to what was going on. The evacuation of the ship, and its need to go along or be stuck on strategies, the doomed mother ship. Sure was a resourceful monster able to figure things out.

One thing, backing up in the movie, is how much time elapsed between the monster showing up as a baby and its first attack? I would like to consumption spending, think like 13 or 16 hours and some kind of corporate level, access to food stores. It had to take a while to clean up the mess and wrap Kane#039;s body. What I like about the movie is consumption spending little things. What about the escape of the shuttle viewed from the cockpit window? You notice the Nostromo gets smaller real fast as she escapes but the stars stay stationary. That#039;s how it would really go down in space! I like the foreshadowing both visual and verbal.

Ripley is composed in the frame with positive space to her right when talking to Ash in medical. Level. See is frame left and this is not normal for a two actor conversation. The point? It shows a vulnerable and unexpected area for the creature to come into either now or in the future. How about when RIpley tells the guys, Yeah you#039;ll both get whats#039;s coming to you.. Pretty much foreshadowing in a humorous way because we the audience already know its a horror movie.

I also find watching the DVD straight through lends a sort of mass culture 1920s, simulated reality to the events, as the level strategies pacing is well-done. I kind of would have liked a little better report from Ripley at why was, the end before she goes to corporate strategies, bed. The movie is art to consumption, me. RT @MNightShyamalan: Day 1: Seventeen years in corporate level strategies, the making. Why Was Famous. #Glass days ago RT @tracycbrown: Stop dissing Wonder Woman days ago RT @jenyamato: Also discovered diving into this Stephen King Moment: Filmmakers love IT, critics can#039;t forget MAXIMUM OVERDRIVE https://t.c1 week ago RT @jenyamato: Why are we so obsessed w/ @StephenKing rn? #GeraldsGame#039;s @FlanaganFilm, 1922#039;s Zak Hilditch, @leonardmaltin explain https:/ 1 week ago Fans are running AMUCK at the news of a Hocus Pocus remake. week ago Follow @latherocomplex. Terms of Service | Privacy Policy, Updated 10/19/11 | Los Angeles Times, 202 West 1st Street, Los Angeles, California, 90012 | Copyright 2017.

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cardiac case study Anesthesiology: Problem-Oriented Patient Management. CASE 15: Cardiac Tamponade. Manuel L. Fontes. Quick Links to corporate strategies, 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 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 differences taoism and confucianism differential diagnosis of level strategies, low cardiac output (CO) postoperatively? A. Medical Disease and Differential Diagnosis. A.1. Taoism And Confucianism! What is the differential diagnosis of low cardiac output (CO) postoperatively? CO is determined by the product of corporate, 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 in white analysis, either ventricular or atrial origin can also cause a low output state (i.e., atrial fibrillation). To more accurately determine the etiology of a reduced SV, it is necessary to explore whether there has been a change in the preload, the afterload, and/or the corporate contractile state. Either too much preload (ventricular overdistention) or too little preload can lower the CO. Similarly, a significant reduction in afterload (vasodilators, anesthetics, sympatholysis) or an increase in afterload (arterial resistance) can diminish SV. The latter, however, is Relationship, 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 level strategies either direct causes (myocardial ischemia, myocardial infarction, myocardial stunning, or myocardial hibernation) and/or by spending indirect causes (mechanical factors as in cardiac tamponade; pharmacologic agents; and by toxins, namely, inflammatory cytokines and bacterial endotoxins). A combination of hemodynamic disturbances can coexist in the same patient. For example, a patient can have both a decrease in contractility and corporate level strategies, a reduced preload to account for the low output state. Consumption! Correcting one problem alone may not produce the corporate strategies optimal hemodynamic condition.

Fontes ML. Hines RH. Spending! Pharmacologic treatment of perioperative left and corporate strategies, right ventricular dysfunction. 1920s! Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:11551191. A.2. What is cardiac tamponade? Enumerate the common etiologies of cardiac tamponade. Cardiac tamponade is defined as significant compression of the heart by accumulating pericardial contents. These include blood and clots (postcardiotomy, chamber perforation, dissecting aortic aneurysm, trauma, anticoagulant therapy), exudative effusions (malignant states, infective pericarditis, idiopathic pericarditis), nonexudative effusions (uremia, systemic lupus erythematous, rheumatoid arthritis, idiopathic, radiation), and air. How significant cardiac tamponade is depends on whether the definition is clinical versus physiologic.

That is, tamponade is a pathophysiologic continuum that on one extreme may be clinically insignificant whereas on strategies, another extreme presents as a life-threatening condition requiring emergent surgical attention. Clinical tamponade is about Critically assess Order of Capital, frequently associated with marked increase in pericardial pressure relative to intracardiac pressures (atrial and ventricular) such that SV progressively declines resulting in systemic hypotension and in cardiogenic shock. Braunwald E, Heart disease: a textbook of strategies, cardiovascular medicine 6th ed. Philadelphia: WB Saunders, 2001:1498. Fowler NO. Gabel M. Buncher CR. Cardiac tamponade: a comparison of The Rocky Relationship Essay, 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 strategies, cardiac tamponade. Chest 1998:113:13721378. A.3. What is the difference between acute and in white analysis, delayed cardiac tamponade? In the setting of cardiac surgery, cardiac tamponade can occur acutely over level, minutes, hours, or after a few days postoperatively. The reported incidence of Critically the Pecking Order, 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. Corporate! Alternatively, the 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 7 days after pericardiotomy. The incidence is 0.3#37; to 2.6#37; and of arc famous, is often misdiagnosed because of a low index of level, suspicion and 1920s, because the clinical signs and symptoms can be comparable to those of level strategies, congestive heart failure, pulmonary embolism, and generalized fatigue (i.e., failure to thrive postoperatively). In The! The most common culprit in level 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 culture 1920s the tenth postoperative day and corporate strategies, regress spontaneously thereafter. D'Cruz IA. Overton DH. Pai GH. Pericardial complications of joan famous, cardiac surgery: emphasis on the diagnostic role of corporate level strategies, echocardiography.

J Card Surg 1992:7:257268. Nelson RM. Jeson CB. Smoot WM. Differences Between Taoism And Confucianism! Pericardial tamponade following open-heart surgery. Strategies! J Thorac Cardiovasc Surg 1969:58:510516. Weitzman LB. Why Was! 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 corporate, cardiac tamponade following cardiac surgery is culture in the 1920s, often difficult and requires a high degree of clinical suspicion, proficient knowledge of pulmonary artery catheter (PAC) derived measures, physical examination, and diagnostic tools such as echocardiography and corporate level strategies, chest x-ray film. Often, the diagnosis is made in the operating room whereby evacuation of clot and blood from the mediastinum is associated with drastic improvement in mass culture in the 1920s hemodynamics. Corporate! Relying on one modality alone for diagnosis can lead to inaccurate management decisions and culture in the, increase patient morbidity. Corporate Strategies! For example, the PAC is an spending, important device for monitoring cardiac function; however, its measures can be misleading postcardiotomy unless the clinician is cognizant of such limitations.

The classical teaching of level strategies, equalization of diastolic blood pressures in cardiac tamponade [central venous pressure (CVP) = pulmonary artery diastolic pressure (PAD) = pulmonary artery occlusion pressure (PAOP)] is infrequently observed postoperatively because the pericardium is left open. As such, blood or clot or both do not distribute around the heart homogeneously to produce equalization of pericardial diastolic pressures. Taoism! Generally, the CVP is strategies, elevated but the PAD and the PAOP can be normal, elevated, or, in spending some cases, reduced. With significant compression of the right heart, reduced blood flow to the pulmonary artery (PA) and to the left heart can yield lower pressures that would be inconsistent with classical tamponade physiology. Strategies! Russo and colleagues found that only Critically assess Order of Capital Structure, 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 corporate strategies, 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 delayed tamponade the complaints tend to be vague and less hemodynamic data is differences between, available (i.e., PAC) to allow prompt diagnosis of level strategies, tamponade.

Whenever, the patient is not progressing as expected postoperatively with some signs of differences taoism, end-organ dysfunction [fall in urine output and or increase blood urea nitrogen (BUN) and creatinine], an echocardiogram should be obtained to rule out cardiac tamponade. Russo A. O'Connor W. Waxman H. Atypical presentations and echocardiographic findings in corporate strategies 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 the woman in white most common echocardiographic finding in early cardiac tamponade. Postoperative right atrial hematoma often become localized to the anterior and lateral walls, whereas left atrial clots are more commonly found behind the left atrium where they become encysted in strategies the posterior space in the oblique sinus. Selective hematoma compression of the right heart becomes less prominent in delayed tamponade as the right heart becomes adherent or tethered to the anterior chest wall. As discussed in the previous answer, the consumption spending diagnosis of tamponade is often misdiagnosed because classical features of tamponade are often absent because of uneven distribution of blood and blood clots around the heart. The clinical presentation may be mistaken for congestive heart failure, acute left or right ventricular infarction, septic shock, or pulmonary embolism. Chuttani K. Strategies! Pandian NG. Mohanty PK, et al.Left ventricular diastolic collapse. An echocardiographic sign of mass 1920s, regional cardiac tamponade. Corporate! 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. Asirvatham S. Craven P, et al.Unusual presentation of culture, 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. O'Connor W. Waxman H. Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and level strategies, 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. About The Pecking Order Theory Of Capital Structure! What is pulsus paradoxus? What is Kussmaul's sign?

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

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

J Card Surg 1992:7:257268. Frey B. Consumption Spending! Freezer N. Diagnostic value and corporate level strategies, pathophysiologic basis of pulsus paradoxus in infants and children with respiratory disease. Pediatr Pulmonol 2001:31:138143. Jay GD. Onuma K. Davis R, et al.Analysis of physician ability in the measurement of pulsus paradoxus by 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 why was joan of arc famous management: Mayo Clinic experience, 1979#150;1998. Strategies! Chest 1999:116:322331. A.7. Describe ventricular interaction in cardiac tamponade.

Ventricular interaction is extremely important for maintenance of adequate cardiac performance. Under normal conditions, the between average SV of the corporate 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 in white, the right heart, whereas venous return to corporate level strategies, the left heart is Essay assess Order Structure, diminished for corporate the following reasons: (a) lung expansion increases its reservoir for blood and (b) the increase in right ventricular filling causes the interventricular septum to bulge leftwardly reducing left ventricular dimension and altering its compliance and filling (ventricular interaction). During exhalation, the reverse process occurs. In the case of cardiac tamponade, ventricular interaction also involves the interventricular septum but it can involve other chamber and processes depending on the etiology of the tamponade (fluid vs. clot, regional vs. global tamponade). Fundamentally, as intrapericardial content increases, it will reach a point whereby the parietal pericardium cannot stretch commensurate with the rising pressure. Because of the fixed space within the pericardium, cardiac chamber dimensions become smaller. 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 ventricular interaction in clinical cardiac tamponade becomes complex as the pressure-volume relationship of mediastinal and chest structure alters with each heartbeat and from respiratory and neuroendocrine influences. Spodlick D. Consumption Spending! Pathophysiology of cardiac tamponade. Chest 1998:113:13721378. A.8. How is coronary blood flow affected in cardiac tamponade? In the level absence of coronary artery disease, coronary blood flow is reduced in Relationship Essay cardiac tamponade but this reduction is not sufficient to add an ischemic injury to the myocardium because there is a proportionate decrease in (a) ventricular preload (underfilled) and (b) ventricular afterload (underafterloaded). Consequently, both myocardial work and oxygen consumption are reduced. In contrast, patients with coronary artery disease may be at increased risk for myocardial ischemia or infarction or both. Reddy PS.

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

J Am Coll Cardiol 1985:6:296299. A.9. Strategies! What are the electrocardiographic abnormalities associated with cardiac tamponade? Electrocardiographic changes may occur in the settling of why was joan of arc, cardiac tamponade. These include nonspecific ST-T wave abnormalities, low voltage QRS complex, signs of myocardial ischemia and pericarditis, and corporate, electrical alternans ( Fig. 15.1A ). The latter is why was famous, seen in patients with large effusions and is characterized by interbeat shifts in corporate strategies electrical axis. This beat-to-beat alteration may be due to increased distance between the heart and the chest wall resulting in a pendulum like motion of the heart. However, it has been shown that with minimal amount of pericardial fluid removal, the presence of electrical alternans can be abolished while the pericardial space remains enlarged. Mass! Thus, the electrocardiographic change of electrical alternans may reflect a hemodynamic pathology rather than an anatomic abnormality.

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

Note the image of the left ventricle (LV) during systole and diastole. (From Longo MJ, Jaffe CC. Images in clinical medicine. Electrical alternans. N Engl J Med 1999;341:2060, with permission.) Fox JJ. McHarg JL. Gilmour RF Jr. Ionic mechanism of electrical alternans. Am J Physiol Heart Circ Physiol 2002:282:H516530.

Kosta E. Kronzon I. Electrical alternans in cardiac tamponade. The Pecking Of Capital! Echocardiography 2000:17:(6 Pt 1)575576. Kronzon I. Cohen M. Level! Winer H. Contribution of echocardiography to the understanding of the The Rocky Relationship Essay pathophysiology of corporate, cardiac tamponade. J Am Coll Cardiol 1983:1:11801182. Longo MJ. Jaffe CC. Images in clinical medicine. Electrical alternans. N Engl J Med 1999:341:2060. A.10. What roentgenographic and echocardiographic findings are noted in differences between and confucianism 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 level strategies, 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 The Rocky Essay, symptoms of cardiac tamponade manifest. On chest x-ray film, the cardiac silhouette will appear widened with or without features such as obscuring of the pulmonary vessels at the hilum and a globular or water bottle configuration of the heart. Transthoracic or transesophageal echocardiography can differentiate between cardiac dysfunction arising from direct myocardial injury versus cardiac dysfunction associated with mechanical processes.

Pericardial effusions can be readily seen and semiquantitated. Likewise, pericardial blood clots can be demonstrated to compress the 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 corporate strategies transvalvular (mitral and aortic) flow characteristics seen by 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 mass in the, C ). Although many of the findings of corporate level strategies, 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 culture the differential diagnosis of postcardiopulmonary bypass (post-CPB) bleeding? Significant bleeding following cardiac surgery requiring surgical exploration bring-back occurs in approximately 3#37; of corporate, cases. Often, the 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 fibrinogen. The potential for postoperative bleeding will depend on the degree of activation and mass culture, preexisting levels of the corporate level 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 various screening tests. HMWK, high molecular weight kininogen; PK, prekallikrein; PL, phospholipid by platelets; PT, prothrombin time; PTT, partial thromboplastin time; TCT, thrombin clotting time; TTPL, tissue thromboplastin. (From Coleman RW, Hirsch J, Marder VJ, et al, eds. Hemostasis and spending, thrombosis: basic principles and clinical practice, 2nd ed. Corporate Level! Philadelphia: JB Lippincott, 1987:1052, with permission.) Figure 15.2.

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

Once activated, they secrete several types of granules. Critically Of Capital! Granules, containing peptides such as fibrinogen, thrombospondin, factors V and corporate level strategies, VIII, and -thromboglobulin, are reduced in between and confucianism both number and strategies, content during CPB. Essay! Of greater importance is the strategies loss of several membrane glycoproteins (IIb-IIIa) that interact with fibrinogen and taoism, other cellular elements allowing for platelet conjugation and propagation of clot formation. Overall, postcardiotomy bleeding is due to corporate level, (a) a qualitative and a quantitative platelet defect, (b) factor deficiency, and (c) surgical bleeding. The latter can arise from either venous or arterial sources that were undetected before closure of the chest. In White! Attentive and meticulous effort to surgical hemostasis can significantly reduce the incidence of bring-backs. Despotis GJ. Avidan MS. Hogue CW Jr. Mechanisms and attenuation of hemostatic activation during extracorporeal circulation. Ann Thorac Surg 2001:72:S18211831.

Harker L. Malpass TW. Branson HE. Mechanism of abnormal bleeding in patients undergoing cardiopulmonary bypass: acquired transient platelet dysfunction associated with selective alpha-granule release. Blood 1980:56:824. Kojima T. Gando S. Morimoto Y, et al.Systematic elucidation of effects of tranexamic acid on fibrinolysis and bleeding during and after cardiopulmonary bypass surgery. Thromb Res 2001:104:301307. Levy JH. Level Strategies! Pharmacologic preservation of the hemostatic system during cardiac surgery. The Rocky Relationship Essay! 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 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 strategies pentasaccharide to antithrombin (antithrombin III) results in consumption 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 corporate level strategies, factor Xa as LMWH, its inhibition of thrombin is much more profound than LMWH. To inactivate thrombin, heparin has to bind to spending, both antithrombin and thrombin forming a ternary complex. Heparin pentasaccharide sequences (randomly distributed along heparin chains) of 18 units or more is required for level the formation of this ternary complex. Approximately 50#37; of LMWH lack the of arc famous adequate length necessary for binding antithrombin and level, thrombin. Furthermore, only 15#37; to 25#37; of Critically the Pecking Order of Capital, chains of LMWH contain pentasaccharide sequences. Therefore, LMWH has greater inhibitory effect of factor Xa, whereas unfractionated heparin exerts an equipotent effect against both thrombin and factor Xa.

Lastly, both LMWH and unfractionated heparin cause release of tissue factor pathway inhibitor from vascular endothelium, which then forms a complex with and inhibits factor Xa. This complex in turn inactivates factor VIIa. Clark SC. Vitale N. Corporate Strategies! Zacharias J, et al.Effect of low molecular weight heparin (fragmin) on bleeding after cardiac surgery. Ann Thorac Surg 2000:69:762765. Danielsson A. Raub E. Lindahl U, et al.Role of ternary complexes in which heparin binds both antithrombin and consumption spending, 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 valvar heart disease: new aspects and management during non-cardiac surgery.

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

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

The plasma half-life of LMWH is corporate level strategies, two to four times longer than unfractionated heparin, which undergoes a dose-dependent elimination by the liver and the kidneys. Why Was Famous! A significant amount of unfractionated heparin is bound to strategies, plasma proteins, vascular endothelium, and macrophages resulting in less bioavailability and an unpredictable anticoagulant effect. Consequently, careful laboratory monitoring is required. Additional benefits of mass culture 1920s, LMWH over level strategies, 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 assess the Pecking Order Theory of Capital Structure, evolve, and, although its indications continue to broaden, there may be safety concerns that ought not to be dismissed. Alban S. Gastpar R. Corporate! Plasma levels of total and joan of arc, free tissue factor pathway inhibitor (TFPI) as individual pharmacological parameters of corporate strategies, various heparins. Thromb Haemost 2001:85:824829.

Cohen AT. Bailey CS. Alikhan R, et al.Extended thromboprophylaxis with low molecular weight heparin reduces symptomatic venous thromboembolism following lower limb arthroplasty#151;a meta-analysis. Thromb Haemost 2001:85:940941. Huse DM. Consumption! Cummins G. Taylor DC, et al.Outpatient treatment of level strategies, 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 diagnosis made? HIT is a serious complication of heparin therapy that is why was, predominantly immunemediated by a binary complex of heparin and corporate level strategies, platelet factor 4 (PF4). The reaction is commonly caused by an immunoglobulin (IgG) antibody that binds and activates platelets in the presence of heparin. Other immunoglobulins may also potentiate HIT. HIT exists in Critically the Pecking Order Theory Structure two forms. A benign form of HIT, type 1, is observed in approximately 10#37; to corporate level, 20#37; of patients receiving unfractionated heparin. This mild form of thrombocytopenia (rarely less than 100 x 10 3 / L) occurs after 1 to 4 days of therapy and generally improves despite continuing heparin administration.

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

In most cases, the diagnosis is between and confucianism, made on clinical findings. Gerotziafas GT. Elalamy I. Lecrubier C, et al.The role of corporate level strategies, 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. Of Arc Famous! 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. Nudo SA, et al.Frequency of anti-heparin-platelet factor 4 antibodies in corporate hemodialysis patients and correlation with recurrent vascular access thrombosis. Am J Hematol 2002:69:7273. Warkentin TE. Dunn GL. Cybulsky IJ. Off-pump coronary artery bypass grafting for acute heparin-induced thrombocytopenia. Ann Thorac Surg 2001:72:17301732. A.15.

What is the therapy for HIT? Because HIT type II is a potentially lethal condition, the most effective therapy is mass 1920s, discontinuation of heparin. The thrombocytopenia should improve progressively. Although tempting, the need for platelet transfusion is strategies, discouraged because bleeding occurs infrequently and vascular thrombosis may be potentiated. Several agents have been recommended for use in HIT. These include direct thrombin inhibitors (hirudin, argatroban), LMWH, LMW heparinoid, ancrod, and antiplatelet agents. Most of these agents are not available in the United States for use; others are under clinical investigation. Hirudin has been extensively used in Europe with demonstrable benefit and safety. The LMWH have been shown to have cross reactivity with unfractionated heparin approaching 100#37; [C-serotonin release or by heparin-induced platelet aggregation (HIPA) assays] and the woman analysis, 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 level the United States) extracted from the Malayan pit viper and the woman analysis, is immunologically distinct from heparin. It acts by cleaving fibrinopeptide A from fibrinogen and its activity can be measured by assaying for corporate level plasma fibrinogen concentration. Lastly, in the setting of HIT, a synthetic analogue of prostacyclin (iloprost#151;a potent inhibitor of platelet activation) has been used successfully during cardiac surgery to prevent further reduction of analysis, platelet count. Cheng-Lai A. Cardiovascular drug highlight: hirudin. Heart Dis J Cardiovasc Med 1999:1:4149. Deitcher SR. Carman TL. Heparin-induced thrombocytopenia: natural history, diagnosis, and management.

Vasc Med 2001:6:113119. Gill J. Kovacs MJ. Successful use of danaparoid in corporate strategies 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. 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. The Woman! Cybulsky IJ. Off-pump coronary artery bypass grafting for acute heparin-induced thrombocytopenia. Level Strategies! Ann Thorac Surg 2001:72:17301732. A.16. Can HIT be caused by famous LMWH?

Based on level strategies, confirmed laboratory tests, the prevalence of HIT is 2#37; for The Rocky Relationship patients receiving unfractionated heparin. Although the incidence of HIT is infrequent in corporate strategies the setting of LMWH, it is not zero and avoidance of the latter is consumption, recommended for patients demonstrating signs of HIT while receiving unfractionated heparin. Fabris F. Luzzatto G. Stefani PM, et al.Heparin-induced thrombocytopenia [Review]. Haematologica 2000:85:7281. Kleinschmidt K. Level Strategies! 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 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 Critically assess Order of Capital ability to bind to thrombin or factor Xa. Once neutralized, the corporate strategies complex of heparin and protamine is Essay assess, eliminated. Kimmel SE. Sekeres M. Berlin JA, et al.Mortality and adverse events after protamine administration in patients undergoing cardiopulmonary bypass. Anesth Analg 2002:94:14021408.

A.18. What is heparin rebound? The ACT is used to corporate level, confirm adequacy of heparin neutralization by protamine. The concept of heparin rebound and the woman analysis, coagulopathy following protamine reversal may occur as follows: first, heparin that is corporate strategies, sequestered in mass 1920s 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. Studies in which 1 mg of protamine is given per 100 units of corporate, heparin (total dose) found no evidence of heparin rebound. The Woman! Thus, bleeding in corporate level strategies the postoperative cardiac surgical patient is unlikely to of arc, be from heparin rebound. Heller EL. Paul L. Anticoagulation management in a patient with an acquired antithrombin III deficiency. J Extra Corpor Technol 2001:33:245248.

Subramaniam P. Skillington P. Tatoulis J. Heparin-rebound in 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 corporate level strategies coagulation system? What is the in white analysis therapy for reversing its effect? Coumadin remains the most commonly used anticoagulant agent in level the outpatient setting (atrial fibrillation, prosthetic valves and devices).

Its predominant pharmacodynamic effect is inhibition of synthesis of vitamin K-dependent factors (II, VII, IX, and X) in mass culture in the 1920s the liver and its clinical efficacy is monitored by measuring the PT or more specifically the international normalized ratio (INR). The safe or efficacy levels of either INR or PT is variable due to multiple factors, including hepatic, nutritional, drug interaction, age, and presence of other comorbid conditions. On average, it takes several days of therapy to achieve the desired INR (2 to 4); consequently, administration of either LMWH or unfractionated heparin may be necessary for initiating anticoagulation. Complications occur either because of strategies, inadequate anticoagulation (thrombosis) or because of excessive anticoagulation (bleeding and hemorrhage). To reverse its effect, coumadin should be discontinued several days (more than 3 days) to assess of Capital, allow levels of the aforementioned factors to normalize. Acute reversal is achieved with FFP. Administration of vitamin K is often necessary to accelerate the corporate level strategies synthetic process. Erban S. Relationship Essay! Initiation of corporate level strategies, 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. Why Was Famous! Warfarin therapy: evolving strategies in corporate level anticoagulation. 1920s! Am Fam Physician 2002:65:172. Keller C. Matzdorff AC. Kemkes-Matthes B. Pharmacology of corporate level, 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 the woman, X ( Fig. Level Strategies! 15.2 ). Between And Confucianism! Deficiencies of corporate level, factors V, VII, and X (50#37; of normal) significantly prolong the PT. Much lower concentrations of fibrinogen and prothrombin are required to why was joan famous, prolong the PT. Level! Activities of three of the four vitamin K-dependent factors (II, VII, IX, and X) are measured by the PT. Normal values are less than 12 seconds. Activated Partial Thromboplastin Time.

Activated partial thromboplastin time (aPTT) measures the activity of the intrinsic pathway: factors XII, XI, IX, VIII, V, X, prothrombin, and consumption spending, fibrinogen ( Fig. 15.2 ). The aPTT is prolonged by concentrations of less than 20#37; to 30#37; of these factors. Normal values are 25 to 40 seconds. Thrombin time measures the conversion of fibrinogen to level strategies, fibrin by of arc famous thrombin#151;the final step in the coagulation cascade ( Fig. 15.2 ). The thrombin time is decreased in the presence of low concentrations of fibrinogen and thrombin. Heparin prolongs the thrombin time, whereas coumadin has little effect. Normal values are less than 10 seconds. Activated Clotting Time.

ACT measures the general function of the coagulation system. Strategies! 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 spending, 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 level strategies, inhibitors of platelet aggregation such as aspirin. Analysis! Normal values are less than 5 minutes. The bleeding time has not been shown to corporate, be predictive of why was of arc famous, postoperative bleeding and strategies, is no longer performed routinely preoperatively. Barash PG, Cullen BF, Stoelting RK, Clinical anesthesia 4th ed. Philadelphia: Lippincott, Williams Wilkins, 2001:219224. Braunwald E, Fauci A, Kasper DL, et al., Harrison's principles of internal medicine 15th ed.

New York: McGraw Hill, 2001:354358. Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and thrombosis: basic principles and clinical practice 2nd ed. Philadelphia: JB Lippincott, 1987:1048. A.21. How is the anticoagulant effect of LMWH monitored? There is no evidence that monitoring the dose improves the clinical efficacy. Culture In The! In contrast, any overdose increases the risk of hemorrhage. Because the kidneys play a significant role in level strategies the elimination of LMWH, therapeutic use of why was of arc famous, these agents should be monitored with an antifactor Xa assay, especially in corporate level strategies patients who have renal insufficiency, are elderly, and have clinical conditions that increase the risk of The Rocky Relationship, bleeding. Boneu B. de Moerloose P. Corporate Level Strategies! 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 analysis, time. A rotating piston is level, suspended in joan a cuvette filled with heated blood. As clot formation proceeds, the rotation of the piston is affected and characteristic curves are generated ( Fig. 15.3 ). The etiology of 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 measures the impedance to vibration at the tip of the probe. Sonoclot tracings obtained from platelet-rich plasma and platelet-poor plasma are shown in the Fig.

15.5 . Figure 15.3. Corporate Strategies! Production of normal thromboelastogram and measured parameters. R, reaction time, 7 to 14 minutes; K value, 3 to in white, 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 15.3. Production of normal thromboelastogram and measured parameters.

R, reaction time, 7 to corporate level strategies, 14 minutes; K value, 3 to differences between and confucianism, 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 strategies thromboelastography. Anesth Analg 1987;66:856#150;863.) Figure 15.4. Qualitative analysis of culture in the 1920s, thromboelastograms. Figure 15.4. Qualitative analysis of level, thromboelastograms. Figure 15.5. Sonoclot tracings of platelet-rich plasma (PRP) and platelet-poor plasma (PPP). Consumption Spending! A: lag period, B: primary wave, C: shoulder, D: secondary wave, E: peak, F: downward wave. (From Saleem A, Blifeld C, Saleh SA, et al. Viscoelastic measurement of clot formation: a new test of platelet function.

Ann Clin Lab Sci 1983;13:115, with permission.) Figure 15.5. Sonoclot tracings of platelet-rich plasma (PRP) and corporate level, platelet-poor plasma (PPP). A: lag period, B: primary wave, C: shoulder, D: secondary wave, E: peak, F: downward wave. (From Saleem A, Blifeld C, Saleh SA, et al. Viscoelastic measurement of clot formation: a new test of platelet function. Mass Culture In The! Ann Clin Lab Sci 1983;13:115, with permission.) Avidan MS. Da Fonseca J. Parmar K, et al.The effects of aprotinin on thromboelastography with three different activators. Anesthesiology 2001:95:11691174.

Ellison N, Jobes DR, Effective hemostasis in the cardiac surgery Philadelphia: WB Saunders, 1988:155. Forestier F. Belisle S. Contant C, et al.Reproducibility and level, interchangeability of the thromboelastograph, Sonoclot and Hemochron activated coagulation time in cardiac surgery. Can J Anaesth 2001:48:902910. Koster A. Consumption! Hansen R. Schulz J, et al.Assessment of the resonance thromboelastograph CS-3 for differentiation of coagulation disorders: a pilot in strategies vitro investigation of simulated post-cardiopulmonary bypass coagulopathies. J Extra Corp Technol 2001:33:159166. Koster A. Kukucka M. Fischer T, et al.Evaluation of post-cardiopulmonary bypass coagulation disorders by differential diagnosis with a multichannel modified thromboelastogram: a pilot investigation. J Extra Corp Technol 2001:33:153158. Saleem A. The Rocky Relationship! Blifeld C. Saleh SA, et al.Viscoelastic measurement of corporate level strategies, clot formation: a new test of platelet function. Ann Clin Sci 1983:13:115. Vig S. Consumption! Chitolie A. Bevan DH, et al.Thromboelastography: a reliable test?.

Blood Coag Fibrinolysis 2001:12:555561. Vorweg M. Level Strategies! Hartmann B. Knuttgen D, et al.Management of fulminant fibrinolysis during abdominal aortic surgery. J Cardiothorac Vasc Anesth 2001:15:764767. A.23. Why Was Famous! 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 corporate, damaged blood vessels. DDAVP was initially shown to significantly decrease postoperative bleeding. Dobkowski WB. In The 1920s! Murkin JM.

A risk-benefit assessment of aprotinin in cardiac surgical procedures. Drug Safety 1998:18:2141. Kondo NI. Maddi R. Level! Ewenstein BM, et al.Anticoagulation and hemostasis in cardiac surgical patients. J Card Surg 1994:9:443461. Serradeil-Le Gal C. Consumption! Nonpeptide antagonists for vasopressin receptors. Pharmacology of level strategies, 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. In White Analysis! Plasmin, derived from corporate, plasminogen, is the enzyme involved in this process. Physiologic fibrinolysis involves clot remodeling and removal during the healing process. Pathologic fibrinolysis occurs when fibrin in a thrombus is broken down before healing. Although elevated concentrations of plasminogen activators are found during CPB, their half-lives are very short after bypass. In cardiac surgery, fibrinolysis is 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. Between And Confucianism! Weinstein MJ. Level! Weintraub RM, et al.Treatment with desmopressin acetate to reduce blood loss after cardiac surgery. N Engl J Med 1986:314:1402. A.25. Culture In The! What is corporate, aminocaproic acid?

Aminocaproic acid (Amicar) is an analogue of lysine. Its primary mechanism of action is inhibition of differences between and confucianism, plasmin, resulting in level less breakdown of fibrinogen, fibrin (fibrinolysis), and other clotting components. Differences Between Taoism And Confucianism! Aminocaproic acid has been effective in treating coagulopathy in the setting of heart surgery, portocaval shunts, hematologic disorders such as aplastic anemia, abruptio placentae, hepatic cirrhosis, and neoplastic diseases. Compared with placebo, both tranexamic acid and aminocaproic acid have been shown to reduce blood loss by 30#37; to 49#37; as well as reduce homologous blood transfusion. When compared with aprotinin, in high-risk patients, high dose-Amicar has also been shown to corporate level, have favorable results related to about Critically assess of Capital, 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 corporate level, aminocaproic acid diluted and infused over 1 hour, followed by a continuous infusion at a rate of the woman in white analysis, 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 level strategies, thrombocytopenia. Although rare, bradycardia and mild reduction in blood pressure have also been reported. Levi M. Cromheecke ME. de Jonge E, et al.Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of The Rocky, clinically relevant endpoints. Lancet 1999:354:19401947. A.26. What is aprotinin? Aprotinin is a complex polypeptide molecule belonging to strategies, the family of serine protease inhibitors that is extracted from bovine lung. Famous! 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. Corporate Strategies! The basis for its efficacy is not fully understood but consists of a complex activation-interaction of the following systems: kallikrein resulting in differences between kinin generation, complement and inflammatory pathways, coagulation (intrinsic and extrinsic), fibrinolytic, angiotensin, and others not yet determined ( Fig. Corporate Level Strategies! 15.6 ). Initial contact between blood elements and the nonendothelialized surface of the CPB circuit promote contact activation of both humoral and cellular inflammatory processes. The coagulation system may be the consumption first to be activated by contact generating factor XIIa from factor XII, which then interacts with prekallikrein and high molecular weight kininogen (HMWK) to form kallikrein as well as promote the activation of the other coagulation factors. Once activated, kallikrein functions to stimulate and accelerate the generation of bradykinin from HMWK, factor XIIa, angiotensin, and complement activation. Factor XIIa, in turn, also interacts with fibrinogen to produce plasmin ( Fig. 15.7 ). Figure 15.6. Contact activation and strategies, 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. Spending! (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. 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 various components of coagulation including the coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and the fibrinolytic system. Level Strategies! C1, complement; HMW, high molecular weight. (From slide set no. 3, tryaslol slide library [online]. Spending! Bayer, 2000. Available at: with permission.)

Figure 15.7. Level! Involvement of the various components of the woman in white analysis, coagulation including the level coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and why was joan famous, the fibrinolytic system. Strategies! C1, complement; HMW, high molecular weight. Consumption! (From slide set no. 3, tryaslol slide library [online]. Level Strategies! 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 platelet surface glycoproteins (IIb/IIIa), which is Theory Structure, necessary for level strategies platelet-fibrinogen interaction and clot formation. The inflammatory properties of aprotinin (both cellular and humoral) have been shown in the woman in white analysis animal and in some human studies; however, clinical outcome trials addressing this effect have not been conducted. In contrast, clinical trials comparing Aprotinin to placebo and/or to corporate, Amicar have consistently shown greater efficacy related to reduction in blood loss and transfusions of blood elements. Concerns regarding prothrombotic potentials, including myocardial infarction and renal dysfunction, have since been dismissed. The infarction rate and the incidence of mass 1920s, renal dysfunction are comparable to those of placebo ( Table 15.1 ). Aprotinin does compete with creatinine for excretion and, in some patients, there may be a mild increase in serum creatinine. Rarely, if aprotinin is level strategies, 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 spending, reagent used to monitor adequacy of heparinization (ACT). Kaolin is the corporate level strategies recommended agent to be used to assess ACT when aprotinin is used (greater than 480 seconds). If Celite is used, the ACT value should be more than 750 seconds before initiation of CPB. Aprotinin is not an antithrombotic agent, and, therefore, adequate amount of heparin must be given.

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

The following dosing regimen is suggested: 1 mL [10,000 kallikrein inactivator units (KIU)] test dose is administered intravenously at least 10 minutes before the loading dose, followed by close observation for signs of an allergic reaction. A loading dose of 2 million KIU should then be given over 20 to level strategies, 30 minutes. An additional 2 million KIU dose is added to the priming solution. Relationship! The maintenance dose is a constant infusion of 500,000 KIU/hour for the duration of surgery. It may be beneficial and corporate level strategies, cost effective to continue the infusion of the remaining amount of the drug while the patient is transferred and recovering in the ICU. A half-dose regimen has been proposed and entails reducing the previously mentioned recommendation in half. Cosgrove DM III. Heric B. Lytle BW, et al.Aprotinin therapy for reoperative myocardial revascularization: a placebo-controlled study. Ann Thorac Surg 1992:54:10311038. Dobkowski WB.

Murkin JM. A risk-benefit assessment of The Rocky Essay, aprotinin in cardiac surgical procedures. Drug Safety 1998:18:2141. Fujii S, Kinins V, Part B. Advances in experimental medicine and level, biology vol 247B: New York: Plenum Press, 1989:3542. Hoffmann H. Siebeck M. Thetter O, et al.Aprotinin concentrations effective for the inhibition of tissue kallikrein and plasma kallikrein in vitro and in vivo. Abe K, Moriya H, Landis RC, et al., The antithrombotic and differences taoism and confucianism, antiinflammatory mechanisms of action of aprotinin. Ann Thorac Surg 2001:72:21692175. Murkin JM. Attenuation of corporate strategies, 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. Mass Culture 1920s! 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. Koksch M, et al.Aprotinin has no effect on platelet activation and adhesion during cardiopulmonary bypass. Thromb Haemost 1996:75:844848. B. Strategies! Preoperative Evaluation and Preparation. B.1. Interpret the hemodynamic findings of this patient. The patient has an mass 1920s, adequate blood pressure; however, this appears to be maintained via compensatory mechanism including increase in both arterial resistance [systemic vascular resistance (SVR)] and corporate level strategies, HR. The PA systolic pressure is consistent with pulmonary hypertension arising most likely from chronic mitral valvular disease (either stenosis or insufficiency). Both the differences between and confucianism PAD and the PAOP suggest that the left ventricular end diastolic pressure#151;a correlate of strategies, left ventricular preload#151;is within the analysis 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. Corporate Strategies! A CVP of 23 torr is suggestive of right ventricular or biventricular dysfunction, tricuspid stenosis or insufficiency, or obstruction and compression of the right atrium. The CO is inadequate. The derived SV of 22 mL (CO/HR), combined with the other derangements (elevated CVP and PAOP of 14 mm Hg), strongly reflect right heart dysfunction. Taking into consideration the patient's overall presentation (physical examination and laboratory findings), the differential diagnosis includes right ventricular ischemia and or infarction, pulmonary embolism, atrial or ventricular septal defect (most likely left-to-right), and cardiac tamponade. An echocardiogram should be performed to assist in the diagnostic process and clinical management. Fontes ML. Bellows W. Ngo L et al. and McSPI Research Group.

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

While waiting for the echocardiogram to be performed, a fluid bolus can be attempted. If there is a positive response (i.e., the blood pressure and or the CO increase), additional fluid bolus can be administered until the limit of the preload reserve has been reached (operating on 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 corporate level, important to note that fluid challenge alone will not improve cardiac performance without addressing the contractility and joan of arc famous, the afterload that, in this patient, appear to be deranged. Because there is corporate, no knowledge of the exact etiology of the low output state, it would be rational to differences taoism, institute inotropic support (initially, the corporate choice of the inotrope is not that important despite the tachycardia). With regard to the afterload, both systemic and pulmonary afterloads are elevated. Between! On the right side, PA hypertension can be improved with the nitrossovasodilators (nitroglycerin or nitroprusside) but the associated systemic hypotension would prohibit their use. In fact, most vasodilators with the exception of nitric oxide would compromise the systemic pressures. Alternatively, an inotrope that has vasodilatory properties (phosphodiesterase inhibitors#151;milrinone or amrinone#151;or dobutamine) would be better choices. The SVR is a derived number (mean arterial pressure minus CVP divided by the CO and strategies, multiplied by a factor of famous, 80). It is important to corporate level, identify and treat the cause of the Theory of Capital altered CO (i.e., change in HR or SV) and not to react to level, changes in SVR.

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

Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:11551191. B.3. Strategies! 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 analysis hematocrit and level, the platelet function are adequate, attention should be directed to the elevated PT and the aPTT. The most obvious etiology for consumption 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. Strategies! The most common agent to famous, be used 4 days after surgery is warfarin (coumadin). This agent affects the vitamin-K dependent factors (II, VII, IX, and X) whose synthesis occurs in the liver. Measuring the PT and or the INR assesses the status of its anticoagulant effect. Why is the aPTT also elevated? This coagulation measure reflects the function of the following factors: V, VIII, IX, X, XI, XII, prothrombin, and level, fibrinogen. It can also be surmised that the elevated aPTT is due to anticoagulant therapy (e.g., excessive coumadin therapy, use of unfractionated heparin, or a combination of the woman analysis, treatment with heparin and corporate level, coumadin). The latter approach is standard practice in cardiac surgery for patients requiring prolonged anticoagulation (i.e., valvular replacement) and can account for elevations of both the PT and the aPTT.

Other etiologies to consider include liver disorder, sepsis, and other hematologic dysfunction. Boneu B. Differences Between Taoism! 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. 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 corporate strategies labile factors V and VIII as well as the stable coagulation factors (II, VII, IX, X, XI). In addition, FFP contains other plasma proteins and mass in the, 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 antithrombin III on corporate, the activated coagulation time in why was joan of arc patients on heparin therapy. Anesth Analg 2000:90:10761079. Nuttall GA. Oliver WC.

Santrach PJ, et al.Efficacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology 2001:94:773781. Strategies! , discussion 5A#150;6A. B.5. Of Arc Famous! What are the indications for transfusing FFP, platelet concentrate, and cryoprecipitate? Blood usually coagulates appropriately when coagulation factor concentrations are at least 20#37; to 30#37; of normal and when fibrinogen levels are greater than 75 mg/dL. Although laboratory values such as PT and partial thromboplastin time (PTT) may be abnormal, The American Society of Anesthesiologist Task Force on corporate, Blood Component Therapy discourages conventional use of FFP for perioperative treatment of why was joan, bleeding because there are few clinical circumstances whereby coagulopathy arises from level, factor deficiency. Mass In The 1920s! Whereas massive blood replacement can produce prolongation of PT and/or PTT, the task force states that a true dilutional coagulopathy does not ordinarily occur until more than 100#37; of the patient's blood volume has been replaced.

It supports the use of FFP in corporate level strategies 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 consumption spending, one platelet concentrate will increase the platelet count by approximately 5 to 10 x 10 3 / L in the average adult. The usual therapeutic dose is 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 consultation with the strategies 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 Essay about assess the Pecking, 100 mg/dL. One unit of cryoprecipitate per 10-kg body weight raises plasma fibrinogen concentration approximately 50 mg/dL in the absence of continued consumption or massive bleeding. Bleeding following cardiac surgery without demonstrable abnormalities of coagulation is not considered to corporate level strategies, be an indication for transfusion of FFP, platelets, or cryoprecipitate. American Society of Anesthesiologists. Guidelines for blood component therapy.

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

Silberstein LEL. Guidelines for joan 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 strategies acute blood loss: dilutional coagulopathy as a course of surgical bleeding. Consumption! Anesth Analg 1995:80:336342. Shore-Lesserson L. Manspeizer HE. 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. Parks R, et al.Variability in corporate level 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 routine application of of arc famous, blood products: is 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 level strategies, blood elements include transmission of infectious agents (e.g., hepatitis, HIV infection), hemolytic and between taoism, nonhemolytic transfusion reactions, immunosuppression, anaphylactic or anaphylactoid reactions, and alloimmunization to level strategies, platelet-specific antigens and the Rh antigen (resulting from erythrocyte contamination because they are stored at room temperature). Platelets in differences between and confucianism particular may contain proliferating bacteria.

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

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

NIH Consensus Development Conference Statement 1986:6:(7)1. Sazama K. Reports of Essay Critically assess the Pecking Order Theory, 355 transfusion-associated deaths: 1976 through 1985. Transfusion 1990:30:583590. B.7. What is the risk of acquiring HIV from blood exposure? The risk of HIV infection in corporate the United States is 1/200,000 to 1/2,000,000 per unit transfused. However, with the implementation of donor screening tests for differences between HIV-1 antigen, there is an expectation of preventing up to 25#37; of the window period cases (the period between viral infection and its detection by tests for the presence of antibodies). Perhaps the immunoviral agent most transmitted by blood transfusion is cytomegalovirus.

Bartlett JG. Report from IDSA: symposium on healthcare worker issues. The. Hopkins HIV Report: A Bimonthly Newsletter for Healthcare Providers 2000:12:(1)3, 8. Goodnough LT. Corporate Strategies! 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 transmission of the human immunodeficiency virus by screened blood in differences taoism the United States. N Engl J Med 1995:333:17211725. Lowe KC. Corporate! Farrell K. Ferguson EM, et al.Current perceived risks of transfusion in Essay Critically assess Order Theory the UK and relevance to the future acceptance of blood substitutes. Artif Cells Blood Substit Immobil Biotechnol 2001:29:179189.

B.8. In what situation might aminocaproic acid improve hemostasis? Epsilon-aminocaproic acid (EACA) inhibits plasminogen activation by corporate level 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 culture in the, subarachnoid hemorrhage from an corporate level strategies, intracranial aneurysm. Why Was Joan Of Arc Famous! Primary fibrinolysis is rarely a cause of bleeding in the postcardiac surgery patient. Butterworth J. James RL. Lin YA, et al.Gender does not influence epsilon-aminocaproic acid concentrations in adults undergoing cardiopulmonary bypass. Anesth Analg 2001:92:13841390. Chauhan S. Kumar BA. 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 corporate strategies, thrombosis: basic principles and clinical practice 2nd ed. Philadelphia: JB Lippincott, 1987:1026. Ray MJ. O'Brien MF. Spending! Comparison of level, 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 about Critically Order Theory following steps should be taken: first, a complete review of the patient's history, physical examination, and laboratory findings are mandated; second, key areas of concern should be identified and appropriate steps taken to address them; third, an anesthetic plan that is tailored to strategies, cardiac tamponade is devised; last, communication with the respective medical (surgeons, nurses, perfusionist, blood bank) and paramedical staff to of arc famous, ensure readiness and strategies, teamwork. The patient's presentation suggests that she is in Relationship some degree of respiratory distress. Strategies! Initially, management should consist of supplemental oxygen, review of chest x-ray film, and assessment of arterial blood gasses. Shortness of breath and the inability to lie supine are frequent symptoms in patients having cardiac tamponade physiology and every effort should be made to provide comfort and lessen the associated emotional stress. Positive pressure ventilation should be avoided at all cost unless the clinical picture indicates that the consumption spending patient will have a cardiac arrest. The persistent oliguria most likely reflects prerenal or renal (acute tubular necrosis) process secondary to reduced CO and the associated vasoconstrictive state. As described in the previous answer, optimization of hemodynamics should also improve the renal function. Whereas some may administer diuretics in level this setting, such management is strongly discouraged. The most effective management is surgical evacuation of the pericardial effusion or clot.

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

Pericardial tamponade following open-heart surgery. J Thorac Cardiovascular Surg 1969:58:510516. B.10. What premedication would you prescribe? Although it is important to reduce the emotional stress preoperatively, in the setting of cardiac tamponade it would be unwise to administer any type of anxiolytic. The most effective approach is communication with the patient. Often, the physical appearance and the hemodynamics can be misguiding and Essay of Capital, catastrophic consequences can arise from premedicating patients in tamponade. A state of marked sympathoadrenal activation exists to support perfusion to corporate strategies, vital organs. By partially blocking this compensatory effect with an mass culture in the 1920s, anxiolytic, cardiovascular collapse may ensue and most efforts to resuscitate the corporate level strategies 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 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 The Rocky Relationship F IO 2 as needed. All necessary equipment for intubation should be present (laryngoscope and several blades, bag-mask units, and adult-size endotracheal tube) DC cardioversion unit: in case of tachyarrhythmias. Phenylephrine: dose: bolus, 0.1 to 0.5 mg; infusion, 25 to corporate level strategies, 125 g/minute. Epinephrine: dose 0.01 to differences, 0.1 g/kg/minute. Calcium chloride: dose 2 to corporate level strategies, 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 differences between taoism, action. Level Strategies! After the initial dose, patients may remain unconscious for 10 to 15 minutes, but the analgesic effect (somatic greater than visceral) persists for an additional 30 minutes or longer. Essay! 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 level inhibition of norepinephrine uptake into postganglionic sympathetic nerve endings. Ketamine has also been shown to mass, 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 level, moderate negative inotropic effect as well as vasodilatory property. The Rocky Relationship Essay! The hemodynamic response relates to the dose, coexisting diseases (hypertension, ventricular dysfunction), age, intravascular volume, and intactness of autonomic sympathetic responses. Generally, doses of corporate level strategies, 1 to 2 mg/kg do not cause significant hemodynamic disturbance; however, in patients with cardiac tamponade, thiopental should not be used for induction. These patients are, literally, on the edge of cardiovascular collapse. Fentanyl does not possess any depressant effects on myocardial contractility but because of its vagotonic effect (decreases in HR) and mild sympatholytic effect (central sympathetic outflow), a reduction in blood pressure may be noted. Differences! This response may be more profound in strategies shock or preshock states and when fentanyl is used concomitantly with other induction agents (benzodiazepines, thiopental, propofol).

Propofol produces very similar effects as thiopental. It can cause significant reductions in systemic pressures (greater than 30#37;) and there have been several reports of cardiovascular arrest in both adults and why was joan famous, children following inductions with propofol. Propofol also has some antiarrhythmic effect on the atrioventricular (AV) node as well as on corporate level, other conduction pathways. It should be used with caution when other agents that similarly slow down AV nodal conduction are present (calcium channel blockers, -blockers, digoxin). As with thiopental, the use of propofol for induction in cardiac tamponade is strongly disfavored. Etomidate has a very favorable hemodynamic profile and Relationship Essay, 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 corporate mean arterial pressure but such changes are not attributable to myocardial depression as is typical of propofol and the woman analysis, sodium thiopental. Pain at the injection site and level, involuntary muscle movements are the most common adverse events noted with etomidate. It also appears to reduce seizure threshold and differences between taoism and confucianism, enhance its duration when used during electroconvulsion therapy.

Midazolam may cause mild to moderate systemic vasodilation, particularly when used in strategies combination with narcotics. Overall, of the agents discussed, etomidate would be the preferred agent for induction followed by ketamine, and/or fentanyl; whereas, thiopental and propofol would be the least desired. Kaplan JA, Cardiac anesthesia 4th ed. Philadelphia: WB Saunders, 1999:611626. Tweed WA. Minuck M. Mymin D. Circulatory responses to ketamine anesthesia. Anesthesiology 1972:37:612. C.3. Describe the consumption spending 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 strategies, systemic arterial pressures and for obtaining blood gases.

This patient has a PAC in place; however, its use in this setting remains debatable. The actual induction should proceed ONLY in the presence of a surgical team that is ready and Essay, gowned and after the 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 corporate induction technique, the anesthesiologist should expect and culture, be prepared to manage ensuing circulatory collapse. Fontes ML. Hines RH.

Pharmacologic treatment of perioperative left and right ventricular dysfunction. Corporate Level Strategies! Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:11551191. C.4. Following induction and about assess the Pecking Order of Capital Structure, 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 corporate level, caused by significant pericardial pressure from accumulating pericardial contents (fluid, blood, and blood clots) that impede chamber filing resulting in a low CO state. Why Was Joan Famous! 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 strategies, inotropy of the heart; third, the physiologic consequences of switching from negative pressure ventilation to about Critically Structure, positive pressure ventilation will further reduce cardiac filling by level strategies increasing intrathoracic pressure and afterload; and lastly, placing the patient in a supine position will also compromise atrial and ventricular preload (i.e., hydrostatic effects, loss of diaphragm, and weight of mediastinal structures on the heart). The management of hypotension will require use of vasoactive drugs, cardioactive drugs, and/or fluid challenge. Reducing inspiratory positive pressure (i.e., lowering tidal volume or switching from ventilator-delivered breaths to hand ventilation) may also improve the hemodynamic status.

These would be merely temporizing measures; surgical relief of tamponade would be the definitive treatment of this problem. Fontes ML. Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction. Famous! 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 tamponade and its hemodynamic effects. Unless the myocardium has suffered injury or is level strategies, stunned, the expected hemodynamic change includes drastic improvement in blood pressure and SV. Joan Of Arc! Most of the vasoactive and cardioactive agents being administered can be quickly weaned. Level Strategies! In addition, oxygenation, acid-base status, and renal function (urine output) tend to The Rocky, 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 corporate, infarction). It has also been noted that myocardial function can be coupled or uncoupled with tissue perfusion. For example, following a period of oxygen deprivation and restoration of flow, the differences taoism and confucianism 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 level, 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. Critically Assess The Pecking Theory Of Capital! Myocardial hibernation, on strategies, 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 taoism, lower their metabolic activity and oxygen consumption to survive during states of oxygen deprivation. The definitive diagnosis of stunning and hibernation may be difficult to make because regional myocardial blood flow is difficult to assess or quantify clinically. Therefore, most cases of stunning and corporate level, hibernation require a retrospective analysis. Culture In The 1920s! First, segmental myocardial dysfunction must be established; second, myocardial blood flow should be restored by revascularization (surgical, pharmacologic, or angioplasty/stenting); and level strategies, third, improvement of regional function should follow revascularization. D'Ancona G. Donias HW. Bergsland J, et al.Myocardial stunning after off-pump coronary artery bypass grafting: safeguards and pitfalls. Critically The Pecking Theory Of Capital! Ann Thorac Surg 2001:72:21822183. Fontes ML. Hines RH. Corporate Level Strategies! 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 Essay about Critically the Pecking Order Theory the presence of corporate level strategies, left ventricular dysfunction and mass in the 1920s, hibernating myocardium. Eur J Cardio Thorac Surg 2001:20:937948. Shah BR. Velazquez E. Shaw LK, et al.Revascularization improves survival in ischemic cardiomyopathy regardless of electrocardiographic criteria for level strategies 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. In White! J Cardiovasc Magn Reson 2001:3:195208. D. Postoperative Management. D.1. How would you manage hypertension in the intensive care unit (ICU)? The management of hypertension depends on its etiology.

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

Labetalol antagonizes both - and why was of arc, -adrenergic receptors and is an effective antihypertensive agent. Alternatively, metoprolol, atenolol, esmolol, or propranolol can be used particularly if the hypertension is associated with tachycardia. Corporate Strategies! 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 mass culture 1920s, moderate and severe ventricular dysfunction. In addition, the cardioprotective effects of level strategies, -blockers have been shown in several perioperative trials whereby the incidence of Essay about assess the Pecking of Capital, myocardial injury and mortality (up to 2 years postoperatively) are significantly reduced in patients treated perioperatively with -blockers. Kotlyar E. Macdonald PS. Keogh AM, et al.Optimization of left ventricular function with carvedilol before high-risk cardiac surgery. J Heart Lung Transplantation 2001:20:11291131. Leslie J. Brister N. Levy JH, et al.Treatment of postoperative hypertension after coronary artery bypass surgery.

Double-blind comparison of intravenous isradipine and strategies, sodium nitroprusside. Circulation 1994:90:(5 Pt 2)II256261. Lucas WJ. Boysen PG. Consumption! 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 level, extubation depends on the following: Clinical stability (stable hemodynamics without need for significant inotropic or vasoactive support) Intact neurologic function (alertness and ability to comprehend and execute simple verbal commands) Adequate pulmonary function (acceptable arterial blood gases and acid-base status and adequate weaning parameters#151;tidal volume, respiratory rate, vital capacity, and inspiratory effort) Normal body temperature and neuromuscular function (reverse paralysis if necessary)

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