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Nov 16, 2017 Cry freedom film,
artist essays Emil Orlik was born Prague on 21st July 1870 . Film? At that time Prague was the Most Dangerous Game, capital of a province of the Austro-Hungarian Empire and film thus he was an Austrian citizen, not Czechoslovakian as is frequently stated. His family, being Jewish, lived near the Prague ghetto. His father was a master tailor as was his brother Hugo. There was a large German speaking community in village life essay, Prague (called Bohemian Germans) including an artistic circle which included friends of cry freedom, Orlik's such as Franz Kafka, Franz Werfel, Max Brod and Rainer Maria Rilke. Throughout his school years Orlik had been passionate about drawing and on A Weekend NASCAR leaving school in 1889 he was allowed by cry freedom, his father to backmasking songs go to cry freedom Germany, hoping to be enrolled at the Academy of Fine Art there. Village Life Essay? He was not accepted however, so he enrolled at the private art school of Heinrich Knirr in cry freedom film, Munich, where a fellow pupil was Paul Klee. Pressure Ulcers In ICU Essay Example? Orlik's target remained the Munich Academy and he gained a place in cry freedom film, 1891 under Professor von Lindenschmit who soon recognised his talents and allocated him a small studio. Orlik worked hard, copying old masters at the Munich Pinakothek, constantly improving his techniques. In 1893 he won the Essay example, silver medal for cry freedom film two of his pastel drawings which were shown at the academy's annual exhibition, with the honour of hanging near works by Adolph von Menzel, one of the most prominent artists in Germany. The Academy had a department led by Professor Raab teaching copper engraving.
Orlik enrolled for these classes but was at of The Most Dangerous, loggerheads with the professor for film branching away from the curriculum, experimenting with all aspects of life essay, etching and lithography. He was soon doing work beyond Raab's understanding. Film? In 1893 Orlik impetuously left the academy as he felt constrained by Intervention Delinquency Evidence the Chicago Study, conservative academic training. He wanted to start working in cry freedom film, more modern styles and best man speech was drawn to the Munich Naturalistic movement and the circle around Wilhelm Leibl. After a year of military training he returned to Prague in 1894 and cry freedom film painted and Intervention Evidence from the Chicago Longitudinal Study made prints of film, his friends and surroundings there. Pressure Example? In 1896 Orlik returned to film Munich to work with his fellow pupil and life-long friend Bernhard Pankok on their first essays in the making of colour woodcut prints. They had seen examples of Japanese woodcut prints and were fascinated by them. Women Criminals? He began contributing illustrations to cry freedom film the journal Jugend . By 1897 Orlik was such an accomplished print-maker that four of his small etchings were chosen for publication in the prestigious art magazine PAN. The Chicago Study? Also illustrated in cry freedom, PAN was a reproduction of his first poster 'Die Weber', designed for essay the play of the film, same name produced by Gerhart Hauptmann. Hauptmann was so impressed by best man speech, the poster that he invited Orlik to Berlin to film visit his studio and this was the first stepping stone to Orlik's involvement in the theatre.
He went on to become a leading set and costume designer for many productions. Through his friend the writer Maria Rainer Rilke came the opportunity to become a book illustrator. By the spark notes king, end of 1897 Max Lehrs, assistant director of the Kupferstichkabinett (Graphics Collection) in Dresden began to film add prints by Orlik to this important museum print collection. Ulcers In ICU Essay? Lehrs can be considered to be the film, 'discoverer' of backmasking, Orlik and film he bought may of Orlik's prints for and Juvenile Delinquency from Longitudinal his own extensive collection. They were lifetime friends and film maintained a correspondence almost until the artist's death. Much of the details of best man speech friend, Orlik's travels and day-to-day life is known from this correspondence, which has amazingly been preserved. A book titled Malergr?sse (Artists Greetings) was published by cry freedom, Prestel in 1981 illustrating and lear transcribing the profusely illustrated letters and postcards. In 1898 Orlik made his first journey abroad, visiting England, Scotland, Belgium and film Holland as well as making the first of his many visits to Paris. There he came into king, contact with the film, woodcut artist Felix Vallotton and in London with William Nicholson who was making highly innovative woodcut posters and friend prints.
He recorded his travels in numerous etchings, lithographs and cry freedom woodcuts. A Weekend At A NASCAR Event? On returning to Prague he established himself in an atelier in film, an old tower with fine views over the picturesque city. He retained this studio until 1904. But by 1899 he was living in Vienna and showed works in the third exhibition of the Ulcers, Vienna Secession, of which, as a member, he also contributed to cry freedom the group's publications on modern art trends, including 'Japonisme'. On Literary Analysis Game By Richard Connell? The Society was gaining in cry freedom, importance and visitors came from spark lear, abroad, including K?the Kollwitz and Max Liebermann from Germany, and Auguste Renoir, Henri de Toulouse-Lautrec and cry freedom Camille Pissarro from Paris. There was much interchanging of best, ideas and discussion of Japonisme which was having such an cry freedom, impact throughout Europe, particularly on Art Nouveau and Jugendstil artists, and the Nabis school in Early Intervention Prevention: Evidence from the Chicago Longitudinal, Paris.
At the film, same time artists in Delinquency Prevention:, America were also coming under this influence (notably Mary Cassatt and Helen Hyde). In February 1900 Orlik had great success with his first one-man exhibition in Br?nn in Austria, showing works in many media. It was at film, this time that Max Lehr introduced Orlik to Marie von Gomperz and her family. Her father, Max von Gomperz was a wealthy industrialist and on Literary Analysis Game Connell patron of the arts. He bought from and commissioned many paintings and film other works by backmasking, Orlik. Marie Gomperz and Orlik developed a life-long friendship documented through their correspondence which continued until the time of Orlik's death. The extensive Gomperz collection of his work was exhibited at cry freedom, the Jewish Museum in Vienna in 1997. Life Essay? Orlik's oeuvre reflects this patronage and friendship through many portraits of members of the family and cry freedom of their country estate of Oslawan in women criminals, Slovakia and its surroundings. Meanwhile, in cry freedom, March of 1900 Orlik undertook his first voyage to the Far East, the momentous 'Reise nach Japan'.
He wanted to learn at spark king, first hand and at cry freedom, its source how to backmasking songs master the techniques which were of such fascination to him. He absorbed much knowledge from the artists, woodblock-carvers and printers with whom he worked. He wrote many letters with descriptions of his travels in Japan to friends in Europe and Reiner Maria Rilke contributed an article to the magazine 'Ver Sacrum' relating the descriptions written to cry freedom film him by best man speech for best friend, Orlik. Cry Freedom? He wrote to Max Lehr on notes lear 22nd February 1901 that he had spent a fortune on acquiring prints, netsuke and cry freedom film other Japanese artefacts. As soon as Orlik arrived home in November 1901 he had to on Literary Most Dangerous Game Connell prepare for cry freedom an important exhibition of his work to be held at Essay on Literary Most Connell, the prestigious Cassirer Gallery in Berlin in cry freedom, December. From Longitudinal Study? During the following year Orlik had a series of cry freedom film, one-man shows in many venues, including one at the Rudolphinum in Prague at man speech for best, which the entire exhibition was bought by the Prague Kupferstichabinett.. At the XIIIth exhibition of the Vienna Secession he showed 16 works, all of Japanese subjects, alongside works by Max Klinger. His name now appeared in film, the index of the Berlin Secession, together with those of Klimmt, Monet and essay Camille Pissarro. Many articles appeared in various publications about his Japanese travels, the artefacts he brought back and cry freedom his work.
He travelled again to England and Paris, where the A Weekend at a NASCAR Essay, work of film, C?zanne made a great impression on him. At the end of 1904 Orlik was appointed head of the department for graphic art and book illustration at the Academy of the life essay, Museum of Applied Arts in cry freedom film, Berlin, the backmasking, teaching post he retained until his retirement in 1930. Among his many pupils who gained fame in cry freedom, their own right was George Grosz who wrote admiringly of Ulcers in ICU Essay, Orlik's teaching in his autobiography. Cry Freedom Film? Orlik was now established in Berlin and man speech for best began working on film his costume and stage designs for Pressure in ICU Essay the Deutsches Theater, led by Max Reinhardt. Many more articles about cry freedom film him and his work appeared in various publications, including one in 'The Studio' in London. At this time Orlik met and best man speech for best became friendly with the Berlin Secession group led by Max Liebermann, who had just returned from Paris and film was to become the leading German Impressionist painter. Other important members of the group were Lovis Corinth, Erich B?ttner and Max Slevogt. Ulcers In ICU? The SPOG group was also founded (Slevogt, Pankok, Orlik and Grundberg. Film? Grunberg was a dentist but also a fine amateur artist). Orlik had met the women criminals, author Lafcadio Hearn in cry freedom, Japan.
Hearn had assumed Japanese citizenship under a Japanese name and spark king he lectured at a number of universities writing many books on the country and its culture which were widely read in cry freedom, England and life essay America and greatly furthered knowledge in Europe of Japanese life, philosophy and cry freedom art. Orlik both translated Hearn's books into German and illustrated them. Over the Essay Most Dangerous by Richard, next few years Orlik was indefatigable in holding exhibitions in many venues and in film, working in women criminals, theatre design. In 1912 he made his next important journey abroad, visiting North Africa, Ceylon, China, Korea and Japan, returning via Siberia. In Egypt he executed an outstanding series of cry freedom film, etchings later published in a portfolio Aus Aegypten . Returning to Germany he continued to notes king play a leading role in the Berlin Secession until 1913 when he and Liebermann both resigned. Film? Book design became an important part of Orlik's oeuvre, as well as ex libris labels for literally hundreds of friends and songs book collectors. Book collectors of the time vied with each other in commissioning well known artists to designing their label, many having numerous designs. In all, Orlik designed 136 ex libris and although about a dozen were made gratis for film close friends, the backmasking songs, work was lucrative. He was paid up to film 500 marks each, a considerable sum in pre-World War I days. At A NASCAR Event? Orlik was also called upon to cry freedom film design colour posters for in ICU Essay exhibitions, theatre productions and even commercial products.
He produced hundreds of cry freedom film, posters most of which are today highly sought after and scarce. In December 1917 Orlik was appointed official artist to the Best-Litovsk Peace Conference at which Russia and Germany ended their conflict. He produced 72 portrait studies at songs, the conference, including a number of Leo Trotsky. Many of these he later published as lithographs in a portfolio. Film? After the Pressure example, war he continued working at cry freedom film, a frantic pace, exhibiting at many venues throughout Europe. He also became interested in Intervention Prevention: the Chicago, photography, experimenting with the use of light. He was one of the pioneers in the use of photographs as studies for graphics and film paintings, particularly for his portraits of backmasking, leading celebrities.
He claimed that photography permitted him to obtain the film, essence of his endeavours towards the perfect portrait. His earliest essays in on Literary of The Most Connell, photography were made around 1917, but by the mid-twenties he produced brilliant photo portraits of Marlene Dietrich, Albert Einstein and many others. In December 1923 Orlik made his last voyage out of Europe. He received a commission to paint the portrait of a sitter in Cincinnati. His passage and a two month's stay in cry freedom, the U S A were provided. While in America he had an exhibition in New York. The City fascinated him and he wrote to Gerhart Hauptmann : After overcoming the first confusion it is Pressure Ulcers Essay, a completely different world. Cry Freedom? The city is friend, amazing. The dollar rules here!.
He said he found it easier to get used to China than to New York. After his return to Europe he continued to work intensely and his fame increased. Cry Freedom Film? He became one of the best known artists of the spark notes, day. Cry Freedom Film? He continued travelling in Europe - to village life Spain, Italy, England and France. Film? Portrait commissions and village essay graphic work kept him busy till the time of film, his death from a heart attack in women criminals, Berlin on 28th September 1932, nine days after his great friend Max Slevogt. His brother Hugo inherited his considerable estate, including many paintings, drawings and prints. Cry Freedom? During his many visits to Paris he had acquired a fine collection of works by best for best, his friend Henri Matisse and by many other prominent artists, including C?zanne. Hugo Orlik and his family perished during the war at the hands of the Nazis. The only survivor of the family was an aunt who, after the war, regained some of cry freedom, what was left of spark king, Emil's effects. In 1963 the cry freedom film, first post-war German exhibitions of Early Prevention: from the Chicago Longitudinal Study, Orlik's works were held in cry freedom, Berlin and Stuttgart and then in 1977 there was a major retrospective in Austria. At A NASCAR Event? Interest in cry freedom film, his work was rekindled and his stature and Pressure example importance once again recognised.
Many books about film Orlik and his works have been published and once again he has taken his place in art history as an women criminals, important painter and ground-breaking print-maker.
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How to Put Examples in Your Essay. Learn the best way to add examples to your essay to support your ideas. You need to use a range of cry freedom linking words in spark lear, your essay and also use them flexibly in different locations in the sentence. See below for a list of useful linking words with sample sentences: Linking Words for film Giving Examples. for example for instance to illustrate as an illustration to village life essay give a clear example take, for film example, such as namely. Video Tutorial: How to Add Examples in Essay on Literary of The Most Game Connell, an Essay.
Sample Sentences with Supporting Examples. Please note that the linking words do not need to be at the start of the sentence. You can use them more flexibly by changing their location. Global warming should be taken more serious as it can result in a number of film disastrous consequences. To give a clear example , the best melting polar ice caps have not only caused a loss of habitat for polar bears but are also threatening seas levels worldwide. More and more women are choosing to film start a family later in life. 20% of women giving birth to their first child, for instance , are over the age of 30 in the UK.
Crimes should not have the same punishment. A Weekend NASCAR Event. Minor crimes, such as pick pocketing and traffic offences, should not have the cry freedom film same penalty as major crimes, namely murder and manslaughter. Children often learn behaviour from the adults around them subconsciously. Songs. To illustrate , around 50% of children who are brought up by film, aggressive parents often use aggression to solve their own problems later in life, life. Parents should be responsible for teaching their children right and film wrong. On Literary Analysis Dangerous By Richard Connell. If, for cry freedom film example , they see their child using bad language, they should spend time explaining to their child the serious consequences that can result from this type of behaviour.
More and on Literary of The Most by Richard more people are leading sedentary life styles due to work conditions. Take, for example , office workers in the UK who spend at cry freedom least 8 hours a day, 5 days a week sitting in front of backmasking songs their computers. All Linking Words for film Essay Writing. You can find a list of all linking words that can be used in Analysis Dangerous by Richard, essay writing: Linking Words for Writing. Develop your IELTS skills with tips, model answers, lessons, free videos and more. Good day to cry freedom you madam, I would like to spark lear ask how many sentences are recommended to give an example in an essay. Cry Freedom Film. I would also like to know if it is okay to not mention the backmasking songs actual source of a statistic in film, an essay that writes about contemporary issues. Thank you.
1) You don’t need to use examples. Essay Most Dangerous. So, if you use them, it’s your choice how many. 2) you should NEVER state the film source of numbers in an IELTS essay. In fact, most examples are better given without numbers. This is an English language test, not a essay presenting data. I have a burning question in women criminals, mind about examples. Would it be alright to use ither languages in an essay. For example,in an essay about using English as the only language, I pointed out that language often go side by film, side with culture. My sentences: Japanese add “guzaimasu” after a phrase or “san” after a name to express politeness.
In the Philippines, we say “bayanihan” to describe the value we place on our neighbors and community. NASCAR. There are no direct English translations for these words. I do hope you see this question. I have been learning quite a lot from you. Cry Freedom Film. This is, in fact, a question I got from your site. Thank you very much! Your aim in your essay is to provide clear, relevant main points which are well developed, explained and linked. Your other aim is to provide accurate grammar and backmasking songs vocabulary in cry freedom, English. Those examples might be appropriate to use one example but certainly not more than that. Once you make your point, move on – don’t become repetitive.
Your Japanese example is confusing for people who don’t understand Japanese but your example from the Philippines is clearer. Remember this is women criminals, not about filling your essay will all your ideas – it is about being selective and cry freedom deciding what to include and what to songs exclude. Thank you very much! Will try my very best! Is it ok to cry freedom film create statistical data as example for academic writing task 2? Why? It won’t help your band score at all.
It’s better to explain your ideas using English language and focus on backmasking, accuracy of language. In IELTS it is said : “Ideas should be supported by evidence, and examples may be drawn from the test takers’ own experience.” In many mock essays answers, there are no examples. Can an essay reach band score 9 without any examples? Thank you very much. The instructions mean that you must expand and explain your ideas – it does not means you must give examples.
There are many ways to film illustrate and explain ideas. Is it okay to make up facts to use as examples? You should not be thinking about best man speech, memorising facts for your essay. Cry Freedom. It will not help your score at all. Best Man Speech For Best. IELTS don’t expect you to do that. When are you asked to support your ideas, it means to explain them or give examples of situations – not figures, statistics or facts. can i use personal pronoun in essay ? All your videos are very useful, all those tips and tricks really boosted my confidence, thanks a lot for that:) I have a doubt regarding the writing task2, when I was doing a sample writing task, I came across this “include any relevant examples from your knowledge or experience”. So, does this mean we can give real life examples while writing our essay? Your writing task 2 essay deals with world issues.
You can give examples but I advise you to use examples relating to the world in cry freedom film, general: “For example, it is commonly known that ….” or “For example, the majority of people ….”. These are examples of best friend your view of the world. Film. If, however, you write “For example, my friend Dave …” your essay loses style and language content. Thanks a lot, Liz:) that was a great example. I am taking my exam on life essay, 22 of this month, with all your videos and tips hoping to get a great score. Can we you hypothetical statistics? For example, if I want to make my point strong, can i use any university name or any research journal?? I mean can i state in the essay that, “In a recent article published by ABC university, 70% of the people have found addicted to cry freedom smartphones” Whereas in fact, there is no such article ever published stating this fact of 70%.
Yes, you can lie about stats but why? It won’t help your score at all. NASCAR Event. This phrase ““In a recent article published by ..” won’t boost your score. It’s a learn expression which is cry freedom, generic (it can be applied to life any topic) and this means the examiner won’t count it towards examples of your natural language. Thanks Liz for your reply. I have gone through a number of your advises and found them very useful. But I saw in some of the articles that if you show some reference and support with research data, you will be able to reinforce your argument. Had I rephrased it but still lied about the fact, would it add value then to my task 2? The examiner does not give you a higher band score because you are presenting statistics.
Statistics are irrelevant to your mark. The supporting points being assessed are relating to language, not figures. You can add all the stats you want, it won’t increase your score at all. That’s really helpful. It relief some of the film pressure of knowing statistical data related to NASCAR Essay the topic. Thanks once again, Wow, were you really trying to cry freedom remember stats for your essay? You are not marked on your knowledge at all. Just think of some relevant main ideas and then explain them – nothing more is notes king, needed. It is essentially an English language test.
Take a look at film my band 9 model essays: http://ieltsliz.com/ielts-writing-task-2/ I have a question regarding grammar. I am not in what case can we put Verb+ing after the word “to” I always thought that we have to put the songs verb whit its original form, but I have noticed two examples and still didn’t understand the rule. Here are the two examples I saw in your blog: – resort to buying ( why not resort to buy?) – I am looking forward to hearing from you ( why not looking forward to hear from you soon?) appreciate your always help. You can use “to” as a preposition. If you haven’t seen this before, don’t use it. More mistakes will lower your score. Use the grammar you know well.
Hi .. can I add “example” form my own information or not ? sorry i mean from. You can write anything you want. However, writing about the world in general usually produces a better level of English. As long as it is in the allotted time, are we allowed to write our essays out in rough first, then transfer them onto the exam papers? You will not have time. You need to spend at cry freedom film least 5 mins planning your essay which includes main ideas as well as supporting points. Essay Analysis Dangerous Game Connell. This means you can write your essay directly. Film. Try timing yourself and backmasking you will see how difficult it is to cry freedom film do both task 1 and task 2 in one hour.
I can not buy your lesson which must be paid by paybal, because in Turkey there is not paybal. How I can bu these lessons? Please inform me. Thanks for the amazing tips! And I would like to ask whether I can make up facts as an example in my writing test? Sure, if you want. But it’s better to explain your ideas rather than just make up stats. Hello Liz! I have to ask that is A Weekend at a NASCAR Event, it possible to get 7 bands in writing?
As I have never heard above 7 bands of any student. Why so? Liz, Thanks a lot for your fantastic information. Cry Freedom Film. Your work is exceptional and highly recommendable for not only IELTS test takers but also first-year university students who use English as a second language. I had a question about the use of “resort”. Essay On Literary Analysis Of The Dangerous Game Connell. Is it “resort to cry freedom doing” or “resort to do”? In the last scene, I was two sentences: 1. This is exemplified by the 70% of Essay on Literary Most Dangerous by Richard Connell working people in the UK, who resort to BUYING ready made meals for convenience. 2. This can be seen by the growing number of working people in the UK who resort to cry freedom BUY ready made meals for convenience instead of cooking at home. Is it a typo in the second sentence? Many thanks for notes lear your tutoring videos.
They are extremely helpful! I wonder if it is possible to include false statistics in cry freedom, my writings? It isn’t necessary. A Weekend At A NASCAR. You don’t need to put in cry freedom, statistics at all. Backmasking Songs. It’s best to explain your opinion. I post the film explanation of the resort. “resort to sth to make use of sth, especially something bad, as a means of achieving sth, often because there is no other solution.” E.g.
They felt obliged to at a resort to violence. We may have to resort to using untrained staff. So, we should put doing after the resort to. And you are right. Cry Freedom Film. there is a typo mistake in the second sentence. I think liz post that in the video. I need 6 bands in each tasks for IELTS General module.Still I’m worried about women criminals, Speaking and cry freedom Listening exam because I don’t get grip on at a NASCAR Essay, this tasks compared to other tasks.Please suggest me a technique for practice to acquire a good score.I have next exam on 18th February. Hi Liz, I just started to follow your blogs recently. As I read the topics above, I wonder if we could present or invent statistics in our own just to support our answers in essay #128578; ? Hi liz ,hope u r doing fine..i would be very grateful if u cud give some advice about the ielts..recently i sat for the it,n i got an overall 6.5band, with 7 listening , 6.5 writing, 6.5 reading and 5.5 speaking.though its not enuf for my professional career,im wondering if i shud give it again and if yes ,will i be able to attain the requirement that is a total of 7.5 with a minimum of 7 in each section….honestly speaking i had only ten days for the exam and during the process i didnt practice at film all,just read some sample essay on net n some passage reading..and i came to conclusion that the only way to succeed is practise because your only opponent on the day of exam is time.for instance for my case,i finish my essay just in best man speech, time,cud not do proofreading and this apply for the reading as well…n it was my first experiece with ielts…is there a chance that i can reach the objective band nxt time?my essay was is should the private life of celebrity be respected by the media,to what extent u agree or disagree..thnk u,,waiting impatiently for ur reply…
You will need to improve your English and also get training for IELTS to get band 7 in each criterion. Task 2: Some people say that interview is a good way of cry freedom selecting competent candidates. What are the other ways for selecting a good candidate. What do you think is the best way to select a good candidate. How write intro this question and village life make paragraph. Hi Liz. Cry Freedom Film. Thank for this tip. it’s really helpful. But i have a question. How can i explain my idea in writing task 2? I always have a problem with this.
The supporting points are only explanations of your ideas. For Best Friend. Just more detail. It could be examples, consequences, exceptions, explanation, causes – anything you feel will explain what you mean. If you aim for three body paragraph, you will only need about two supporting sentences which is easier. what i am looking for cry freedom is some questions that i need to question myself whenever i have an idea needed to explained.
I found your video bout ideas. I have a lot of them now. but dont know how to expand it. Ask yourself “why”. If you state “Firstly one of the best ways to tackle traffic congestion is to Essay of The Dangerous Game Connell build wider roads.” Then you ask “why is this a good method? What does it do?”. Cry Freedom. You then add: “By doing this, traffic will be able to flow more easily and congestion will be reduced”. Then you choose your next sentence, either an example or an opposite: “If the Essay on Literary Most Game by Richard Connell roads are not widened, traffic will slowly grind to a halt as traffic is no longer able to flow along the streets because they are too narrow.”. I strongly advice you to read all model essays online and make a note of what kind of cry freedom film information is spark notes, given in the supporting points. Then you will have a range of ideas. Could I write “As an example/illustration of something, …”? If I’m not mistaken, it is “Cambridge IELTS 9” on the shelf on each video.
Do you recommend this book? Thank you in advance! Yes, you can use those two ways to give examples. I have both Cambridge 9 and 10. They are the two most recent books published by cry freedom film, IELTS. They contain 4 practice tests but not tips. Friend. They are good for practicing. No students should enter the test without doing a full practice test at least once.
Can we make up our own examples with fake dates and events. The examiner will not check factual information so you can use examples as you wish. But it is unnecessary to invest data – just describe it for a higher score. I will just use supporting examples, which will make sense by different Organization names.I have exam on cry freedom film, 8 October, 2015. I was wondering, it won t be considered ok to write 2 ideas in one paragraph? For instance 1 BP with 2 ideas explained or 2 causes etx. It would be more correct to have only one idea/solution/cause/advantage in each BP? The organisation of ideas depends on the type of essay you have. You would need full training to understand more deeply: http://subscriptions.viddler.com/IELTSLizStore. I appreciate it.
that is the example, and I guess you are right.And where do you recommend I can write my opinion? computers are becoming an spark king, essential part of education. Discuss the advantages and cry freedom the disadvantages and give your own opinion? I’ve never seen those instructions before. However, to follow them, you must do exactly what they say: give the essay advantages, give the cry freedom disadvantages and at a give your opinion. Cry Freedom Film. If your opinion agrees with one side, then include it in your body paragraph. If your opinion agrees with neither side, put it in village essay, a separate body paragraph.
There’s no fixed rule. Regarding the advantage and disadvantage and giving your opinion question. where is the cry freedom best place exactly to express my opinion?is it in the conclusion sentence or included in the introduction? There is no question in women criminals, IELTS that asks for the advantages, disadvantages and your opinion. Are you talking about the discussion essay? For writing task 2, sometimes I don’t have relevant examples ? I start properly with a topic sentence and I explain it in detail, but I, sometimes, find difficulty of giving a clear example? if there is any other way to cry freedom state it ? You do not need to give examples unless you want to. Supporting points are any points which explain your idea further. Thank you very much for the very useful article. On Literary Analysis Most Dangerous Game Connell. I have some concern about the use of ‘i.e.’ and film ‘e.g.’.
Do you think they are formal enough to be used in IELTS writing? Many thanks again, Never use shortened forms in A Weekend at a, IELTS writing. I would be so grateful if you could suggest me the perfect study plan in order to prepare for my second Ielts exam on 12 September. I need to improve each section with 0.5 or 1 score. Thank you in advance, Sorry, I don’t provide study plans. Watch my video on my home page about preparing for IELTS and cry freedom film just cover the points mentioned.
You know your weaknesses and you know the women criminals time you have available – you are the best one to make a study plan. I want to use “Example” at the end of cry freedom my essay. So, which one is correct. Examples are usually put in the body paragraphs to support your ideas, not at the end. See this page for songs correct linking words: http://ieltsliz.com/linking-words-for-writing/. Then review all tips on the main writing task 2 page: http://ieltsliz.com/ielts-writing-task-2/ I would be acknowledge by my heartfelt appreciation about film, your website and merits videos . I’m settling in backmasking songs, Tehran and wand passing ielts strictly.
In recent years , there has been hard rise in ielts examination . Let’s emphatically endorse to this fact that the band score 7 and upper goals are crucial for us to make the future by proper mentoring , extensive training and cry freedom practicing . Hence , it’s important to be realistic about apprentices who need the band 6.5 in general training modules . With all this taken into account , I believe that I have some problems in reading to Essay on Literary of The Dangerous Game by Richard pass this examination . Another thing I should mention is how can I improve myself in listening module because I couldn’t accurately pass this . Cry Freedom Film. It has fluctuated on 5 to 6.5 in 3 mock examinations . This is often cited as a reason for practicing more but I can not fix my grade in best, 6.5 . Cry Freedom Film. It will make me feel happy if I solve this problem . Eventually, if you have leisure convenient, please, test us with some sample questions ( talking points ) by writing in both issues and make us as well . Let’s commonly apprentice about this website . I’m looking forward to knowing more from spark you . With warmest wishes, I will be very direct with you. To get band score 7, you need to have a very strong level of English in which you have good use of English but with few errors. Film. Your message above shows quite a lot of women criminals errors when you use vocabulary that is not appropriate. You clearly know a lot of vocabulary but not how to cry freedom film use it and what it really means. For example, “apprentice” is not a synonym for essay student.
For this reason, you are not getting band 7 in your listening or reading etc. Of course, you will need to cry freedom film check your techniques and follow the right tips but at spark notes the end of the day, if your English is not band 7, it will be hard to get that score. Spend time developing your English. I don’t mean learning new words (you have a wide enough vocabulary) but learning more about the meaning of the words, collocations, paraphrasing correctly and how to use words appropriately. firstly i would like to you say thanku for your support. second of all, can you plz recommend me books of good authors for preparation of ielts? I am weak in speaking module due to lack of ideas.please help me. You could try the Collins IELTS speaking book. That has good ideas and vocabulary for various topics. Hi Liz , u r ways of study fanatastic,I need ur guidance i live near border problem regarding internet, I can buy ur task 2 any book I need 6 GN plz help me. Unfortunately, I don’t have a book for IELTS at film present. Possibly in the future.
I would like to buy your essay tips, please could you tell me as soon as possible ,I just booked my test for first of August . At present, I have just opened my video course with in-depth lessons and tips for writing: http://subscriptions.viddler.com/IELTSLizStore I will add more lessons to my course in songs, the coming months. Hello liz. The linking words you presented to are very helpful. Hope to hear more from your post. Thank you. I’m glad you find them useful. They are so important to cry freedom film use in your essay. Hi liz. .I want to seek help from you in doing my essay. Backmasking. I am really having a hard to put my ideas. Cry Freedom. I need a band score of notes 7 in all categories. Please help me.
Unfortunately, I don’t offer individual tuition to help you. Film. You should go through topics and research ideas for your essays. You can find some ideas on Essay Dangerous Game, my blog and others online. Then practice adapting the ideas to film suit the essay question and king lear the instructions. hi liz. Cry Freedom Film. .ok. .I will do as you said. Lear. .I will read your blog. .thank you for patiently replying my issues. Im confused with the” to cry freedom buy and to buying” from your examples. 1. for example about 70% of people working in the UK resort to buying ready-made meals for convenience rather than doing home cooking. 2. This can be seen by the growing number of working people who resort to buy ready-made meals for best man speech convenience instead of cooking at home. Could you please explain to cry freedom me when should I use to on Literary Analysis of The Most Game Connell buy and to buying ? Thank you very much. Thanks for pointing it out.
It’s a typo. I’ve put a comment in the video. I just found this website yesterday when I was looking for some stuff for cry freedom film ielts self preparation. Yes, I would like to take an exam and also like to ask you how long you recommend a prepation before the exam date? It really depends on a number of women criminals factors, one of which is your understanding of the test and requirements of the band scores. If your English is film, suitable for the band score you are aiming for, you will only best man speech for best, need to focus on exam skills to make sure you reach your potential. The skills will help you understand how to cry freedom approach questions and what the examiner is looking for in your writing and speaking.
Once you feel comfortable with all that, you will have a clear idea of how long you want to practice before your test. Life. Whatever you decide, make sure you are frequently getting the band score you want in practice tests. Thank u for film your reply. Best Man Speech For Best. I need least band 6. What do u think about cry freedom, level B2 communicator. Backmasking Songs. Is possible to cry freedom film get that band and of course with preparation bfr exam.
Thanks in advance. Thank you. Looks possibly. How should i start my preparation plz advice and accordlingly i will follow in life, Reading/Writing/Speaking/Listining. You start in any way you want. I advise you to cry freedom learn the content and at a NASCAR Event Essay question types of all skills and then start practicing. Cry Freedom Film. Then do practice tests to check your level.
After that, start planning your development. Thanks for Analysis Most Dangerous Connell the useful lesson . I got overall 7.5 band score and the credit goes to you as well. Thankyou so much for being my virtual tutor. It’s my pleasure to study with you online. Cry Freedom. Preparation material and guidelines by you helped me a lot in achieving my target in village life, first attempt. Goodluck to all the students who are preparing for IELTS ,”it’s not that much difficult” Thanks Liz for all your efforts, stay blessed always #128578; Well done! It is an inspiration to all students #128578; Too good again, I am going to give my GT on 1st Aug. Thanking you so much.
I like those additional examples by using linking devices. I am from Pakistan and I want to tell you that you are indeed a very great teacher. I’m gonna appear in cry freedom, coming IELTS on 1st August. I’m feeling really confident now after going through your very informative lectures here. Thank you a lot for being so helpful! Need your prayers now #128578;
I got 5.5 band in first attempt. Please advice me how i need to follow.I need 6 band in each module immigration. Mirza Ehteshamulla Baig. The key is probably your level of English. Your results are quite even so you will probably need to develop your English language to get a higher score. Did you give third attempt? When writing essays, we usually don’t have statistical data at hand. Is it OK to make up such information to give examples? Sure, if you want. The examiner won’t know the difference. But you don’t need to give statistics.
Examples can just be an example of best for best friend a situation. I also have a question about statistics… Do we have to mention where we got the information from? You can give examples in any way you wish. Thank you so much for your very informative lesson here. It really helped me when I took the film exam on 11th of July and I got a total band score of 7.5. You are indeed a blessing.
God bless you more. Great news! Band 7.5 is a strong score. On Literary Game Connell. I hope you celebrated #128578; Current IELTS exam topics and questions: Share your IELTS test results.
Reading Skills for IELTS: Paraphrasing. Useful Links for cry freedom IELTS Line Graphs in WT1. WT1 Table 30th Sept: To be completed. IELTS Model Essays for notes king lear September 2017. IELTS Writing Questions September 2017. Hi, my name is cry freedom, Elizabeth (Liz). Songs. I'm an experienced IELTS teacher from the film UK and Essay of The Game Connell a graduate of the University of London.
I have been teaching for over 16 years and for the last 9 years I have specialised, exclusively, in IELTS. Cry Freedom Film. I have taught in a number of countries: England, Spain, New Zealand, South Korea, China and Vietnam, where I taught at the British Council.
Essay Writing Service - Cry Freedom - Wikipedia
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Food Service (Waitress Waiter) Resume Samples. Click the cry freedom, images to expand the resumes to a larger size. We have three resumes, and detailed explanations for how to write your own below. If you are an Essay Analysis Game by Richard entry-level candidate (or have never been a waiter before), click here. If you need a food service cover letter, click here. Attention line cooks, prep cooks, chefs, and other food service workers — Don’t see your job here? Please view our full list of cry freedom, food service resume samples here. Click here to spark lear download. This MS Word Food Service Resume. Food Service Resumes (Text Versions Quick Facts)
Restaurant Server (Chrono) Candidate uses a Reverse-Chronological resume format, and introduces the resume with a strong Career Objective Candidate emphasizes 7+ years of film, experience, and presents hard numerical evidence to prove she are a strong salesperson Candidate emphasizes depth of wine and entree knowledge to play up her competence. RESTAURANT SERVER (REVERSE-CHRONOLOGICAL) 8870 Haven Street, Bloomington, IN 44590(141)-212-5465. Food Service Worker with 7+ years of experience in food preparation and service, and songs, a certificate in Food Handling and Safety. Cry Freedom Film. Possesses a keen knowledge of wines, entrees, and the responsibilities of a successful restaurateur. Faithfully adhere to the highest standards of hygiene, quality and best for best, customer service.
Aiming to leverage my knowledge to effectively perform a management position at your restaurant. RIVERSIDE RESTAURANT Chicago, IL. Food Service Worker September 2011 – Present. Memorized restaurant’s wine stock and cry freedom film, the meals they should accompany, leading to daily wine sales averaging $150, fully 20% higher than company average Write patrons’ food orders on king lear, slips, memorize orders, or enter orders into computers for film, transmittal to kitchen staff in a 150+ seat restaurant Clean all work areas, equipment, utensils, dishes, and village life, silverware and ensure they are stored appropriately in cry freedom film, accordance to state law. Backmasking. Perform food preparation duties such as preparing salads, appetizers, and cold dishes, portioning salads, and brewing coffee in film, a fast-paced line kitchen. CARRABBA’S ITALIAN GRILL Chicago, IL. Trainee Food Service Worker August 2007 – July 2011. Present menus to patrons and best man speech friend, answer questions about menu items, making recommendations upon request in film, a 70+ seat restaurant Assisted host or hostess by backmasking songs answering phones to take reservations or to-go orders, and by greeting, seating, and thanking guests Stored food in designated containers and storage areas to prevent spoilage and increase shelf life Presented wine samples for cry freedom, guests to taste and opened the bottles for them upon their approval Served food and beverages to patrons, and songs, prepared or served specialty dishes at film tables as required. Certificate in life, Food Handling and Safety, June 2008. Bachelor of Arts Degree in Culinary Arts, June 2007. Team worker who is able to adapt in highly dynamic and changing situations.
Excellent problem solving and communication skills, with a focus on cry freedom film, customer service Familiarity with Point of backmasking songs, Sale terminals Bilingual (Spanish/English) Candidate uses a Combination resume format to emphasize achievements and skills, beginning with a Professional Profile introduction to present critical and relevant information Candidate bolds key waitressing skill keywords in film, the Professional Profile section, and Essay on Literary Analysis of The Most Dangerous Game Connell, lists her achievements after them Candidate emphasizes her ability to “upsell” customers on alcoholic beverages. Three Key Server Waitress Skills: 1. Salesmanship: Ability to convince customers to film make extra purchases by persuasively presenting entree wine pairings, selling desserts, and convincing patrons to return to the establishment. 2. Communication: Ability to host, entertain, small talk, and speak fluidly in front of strangers at length. Ability to songs work together with other food service workers as a team, often working in pairs for bigger tables.
Ability to keep a cool head when dealing with irate customers. 3. Management: Ability to teach new hosts and waiters how to present menu items, how to use Point of Sale (POS) Terminals, and test trainees for memorization of food ingredients. Project Execution: Implemented new menu introduction strategies, increasing customer purchases of cry freedom film, wine by women criminals 10% on film, average Management: Assisted in the training of 6 new waiters, ensuring attention to women criminals detail and comprehensive understanding of restaurant methodology and practices Awards and cry freedom film, Recognition: Frequently praised for excellent service on best man speech friend, restaurant online rating system Salesmanship: Deep and cry freedom, broad knowledge of wines and appropriate entree pairings Communication: Fluent in English and spark king, Spanish – Excellent verbal and written skills. Familiarity with Point of cry freedom, Sale (POS) and common restaurant machinery Able to memorize entire menu within a day, including ingredient combinations Proven ability to women criminals “upsell” alcohol, dessert, and appetizers to customers Bilingual Spanish and English. Waitress | Los Angeles, CA | 2012 – Present. Memorized restaurant’s wine stock and appropriate entree pairings, leading to daily wine sales averaging $180, fully 15% higher than company average Wrote patron’s food orders on slips, memorized orders, and managed food resources in a 120+ seat restaurant Operated POS terminals to input customer orders, swipe credit cards, and film, enter cash amounts received Received in-depth training for proper food handing techniques, including proper freezer placement, appropriate soup temperatures, and equipment cleaning processes. Hostess Waitress | Los Angeles, CA | 2010 – 2012. Awarded “Employee of the Month” two months consecutively Bussed tables, presented menus, seated customers, and assisted waiters with drink orders Trained 3 new hosts in providing excellent customer service and spark notes, conflict resolution techniques. Florida State University, Orlando, FL. Bachelor of Arts in English, May 2008. Three Transferable Skills for cry freedom, Food Service:
1. Customer Interactivity: If you have ever had any experience dealing with customers (whether you were scooping ice cream, greeting people at a front desk, operating a ticket booth, etc.), this type of experience is Analysis of The Most Game by Richard Connell transferable into cry freedom film any other customer service job. 2. Technical: Have you ever swiped a credit card, operated a Point of spark notes king lear, Sale (POS) Terminal, or re-stocked receipt paper? All of these skills are transferable into food service. 3. Cry Freedom. Communication: Bilingual ability, especially Spanish, will help your food service career chances significantly. If you’ve ever had a job where you’ve had to speak in front of other people, that kind of communication ability is considered transferable. 534 Shelby Avenue, Los Angeles, CA 24542 * (433) 623-6234 * [emailprotected] Superior salesmanship skills, consistently outperforming company peers Friendly, outgoing, and charismatic personality well suited for a fast paced, customer service oriented restaurant Experience with Point of spark notes lear, Sale (POS) Terminals, with excellent basic math skills Working knowledge of wines, cocktail mixes, and other bartending skills Conversational in Spanish.
Awarded “Employee of the Month” for film, consistently making achieving 15% above target sales Perfected menu presentation skills, providing customers a holistic understanding of the restaurant offerings, leading to more sales Trained 4 underperforming waiters in salesmanship methodology, increasing their sales to meet company average. Experience with 3 types of POS Terminals, receipt roll replacement, and coffee machine cleaning Familiarity with common restaurant bread cutting machines, dishwashers, and knowledge of equipment cleaning processes Excellent basic math skills, able to for best calculate and split bills in the event of POS Terminal downtime. Consistently scored over 90% satisfaction rating on customer feedback surveys Conversational in Spanish (able to cry freedom take orders from Spanish speaking customers.) Possess excellent conflict resolution skills in the event of customer dissatisfaction. University of South Carolina, Columbia, SC. Bachelor of A Weekend at a Essay, Science in film, Marketing, May 2005. 4 Steps to women criminals Writing the cry freedom film, Ultimate Server Resume. “Food service” encompasses many different roles within a restaurant, cafeteria, or other food service establishment, such as waiters and servers, line cooks, bartenders, hosts and hostesses, and busboys. A waiter takes orders from life a happy couple. These roles fall into what are called the “front end” (customer service) and the “back end” (food preparation) of the establishments. This resume is relevant to those of you with “front end” server experience.
We will teach you why this is an excellent resume, and cry freedom film, how you can write your own in a similar fashion. As a professional food service worker, you may currently be writing your resume in king, order to: Find a new working environment Earn more money Attain a managerial role. Read this resume writing guide to ensure you achieve your goals. By the film, way be sure to read our Resume Writing 10 Commandments to understand the backmasking, major rules that all resumes need to follow, including server resumes. If this seems difficult, you can always create a food service resume in minutes with our widely praised resume maker. 1. Film. Include These Key Server, Waitress, and Waiter Skills.
For some quick help, here are the key aspects you need to include on a server resume. Restaurant hiring managers will be looking for these specific traits to decide if you’re a worthwhile candidate. Be sure to include these key server skills on your resume. Keep in mind that if you have any food service certifications, such as a Certification in Food Handling and Safety, you should place it at the top of your resume. If you don’t have any, you can land more interviews and potentially increase your salary by earning one. The National Restaurant Association offers certifications here. 2. Write a Convincing Career Objective. The first major section of your resume is called the Career Objective.
This applicant’s Career Objective IMMEDIATELY puts her on the short list for village, an interview because she included relevant information throughout the objective. There are four reasons this example has a strong Career Objective. Film. Pay particular attention to the bolded parts: 1st: It immediately states years of experience: 7+ years of experience in food preparation and service… 2nd: It indicates earned titles or certificates: Certificate in Food Handling and Safety. 3rd: It emphasizes deep knowledge of the business: Keen knowledge of Essay Analysis Most Game by Richard Connell, wines, entrees , and the responsibilities of a successful restauranteur.
4th: It states the position she wants to fill: “Aiming to…effectively perform a management position at film your restaurant. “ In the eyes of a hiring manager, this applicant’s Career Objective IMMEDIATELY puts her on Essay Most Dangerous by Richard, the short list for an interview because she included great resume builders throughout the objective. It is also well written, and targeted at film the managerial role she wants to fill. Good news! Food service manager roles are projected to NASCAR increase by 11% through 2022.
It’s very important to remember that the Career Objective does not relate to what YOU want from the job, but rather what you can do for the company . In this way, the cry freedom film, applicant makes a convincing argument that she’d be an asset to the company in a managerial role. Our step by step Career Objective writing guide can give you concrete ideas about backmasking how to film write your own. 3. Best Man Speech. Describe your Server Experience with Numbers. Adding numbers to your job description bullet points will help the hiring manager grasp the size and scope of your responsibilities, and cry freedom film, give them a clearer mental picture of your experience. By quantifying your resume, it will immediately become better than the man speech, vast majority of your competition. The easiest way to cry freedom film do this is to NASCAR simply write how big your food establishment is, and how many seats it has. The applicant does this twice for film, the two establishments she worked in, as you can see from the bolded text below:
Write patrons’ food orders on slips, memorize orders, or enter orders into village life essay computers for transmittal to kitchen staff in a 150+ seat restaurant Present menus to patrons and answer questions about film menu items, making recommendations upon request in a 70+ seat restaurant. Even by making this simple addition, your resume will immediately be better than the backmasking, vast majority of your competition. If you really want to blow away the hiring manager, you’ll need to do more complex research, like this example: Memorized restaurant’s wine stock and the meals they should accompany, leading to daily wine sales averaging $150, fully 20% higher than company average. Do you know how much you make in sales daily or monthly? You can expect to film make an Essay on Literary Analysis of The Most Dangerous Game by Richard Connell average of $47,960 per film years as a Food Service Manager.
Most restaurants — especially big chains — will track their servers’ sales statistics for the purposes of budgeting (and, of course, to cajole low performers). You can ask your manager to see these statistics, and village life, include them on your resume. Even if you didn’t perform spectacularly (like the applicant), simply including this information in cry freedom film, your resume will indicate to the hiring manager that you are self-motivated and hard working. This is called writing an “achievement oriented” resume — and these tend to land the best for best friend, most interviews. Bonus: Action Verbs for Your Server Resume. 4. Film. Include Relevant Additional Skills. Your Additional Skills section should not list your hobbies and interests, unless they are relevant to the job.
Being bilingual in women criminals, Spanish and English is a valuable asset to have, especially for film, a managerial position. (For instance, a wine connoisseur would be a valuable asset to a restaurant that sells wine.) Since you are a professional food service worker, regardless if you are crafting a server resume or one seeking a more supervisory role, you should definitely include these bullet points in village life essay, your Additional Skills section to build a stronger resume: Familiarity with Point of Sale terminals Problem solving and cry freedom film, communication skills. If you also happen to be bilingual in Spanish and English, that also tends to be a valuable asset to have in a US based restaurant — especially for a managerial position. Candidate emphasizes having a Certification in Food Handling and Safety Candidate places Education Section first due to having recent school experience Candidate mentions her high customer satisfaction rating. Getting the Education Section Right. All entry-level candidate resume must begin with the education section. Essay On Literary Analysis Of The Most. Although this candidate has had prior work experience, it was as a trainee, or as a part-time worker. The most important reason the applicant is considered entry-level is film because she just recently graduated from community college . This applicant has educational experience related to food service (Certificate in Most Dangerous Game, Food Handling and Safety, BA in Food Science). Understandably, you may not — and that’s fine.
If you have no experience whatsoever, you’ll need to write a very convincing cover letter that the employer should take a chance on cry freedom, you. The education section on village, an entry-level resume can be more detailed and whimsical than a professional resume , because it’s likely that you don’t have prior work experience. The hiring manager will be interested to know if you are generally an cry freedom active person or not. Backmasking Songs. Therefore, you can include information about: Clubs you’ve joined Greek life you participate in Relevant coursework GPA (if above 3.5/4.0) Other Good Food Service Industry Samples.
Waiter – Newjobs.com (Note: One of the few decent resume samples in cry freedom film, this industry on the net. Essay. The Professional Experience section introductory paragraphs are a bit overdone, and cry freedom, could instead use more bullet points. Otherwise, this is a great sample.) Waiter- career-development-help.com (Note: A simple, but effective resume. Has a well done “Professional Profile”.) Cook – CC.edu (Note: Overall an excellent resume, although the Work Experience section is not formatted very well.) Share Food Service (Waitress #038; Waiter) Resume Samples
The answer may surprise you. Put your skills to the test, and learn how to make your resume 6 second worthy! 3 Reasons Why I Wouldn't Hire Tom Brady. Tom Brady’s resume is a couple yards short of a touchdown. There are tons of errors throughout. See why. How to Modify and Maximize your Resume Template. Need a resume template? Feel free to download one, but be sure to make small modifications to unlock your. Would You Rather Work for friend, a Man or a Woman? Do people still care whether they work for a man or woman, or do most people simply look for a nice job.
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13 Must-Have Words to Include In Your Resume. Steer clear of overused cliches . Misspelled words are immediate grounds for denial. Words like “rockstar” and “synergy” are so 2015. We’ve all read about what not to include in a resume. Film! After all, one of Glassdoor’s most popular articles “21 Words to backmasking songs, Never Include In Your Resume” is bookmarked even by our staffers who want to cry freedom film, gut-check before making resume faux pas. Village! However, it’s time to film, talk about what works should be included in your resume. Diction or word choice is important when it comes to drafting your resume, not just to ensure that your resume is reviewed positively by software, but also because you want to wow recruiters with your skills, competencies and women criminals relevant credentials. “ The words used show what level the candidates is at in their career,” says Susan Joyce, owner and film operator of Job-Hunt.org , the guide for a smarter, safer job search. Backmasking! “If I picked up a resume for a C-suite candidate who chose vague descriptives, they would immediately be discredited. Some might think a candidate#8217;s experience outweighs the actual text of cry freedom film, a resume, but this is often not the case.
If a hiring manager doesn#8217;t see key indicators a candidate is qualified by spark king appropriate word choice or diction at first glance, chances are, the resume will be eliminated before they are even considered.” To help land your resume at the top of the pile, we tapped an expert panel of career coaches, resume writers and cry freedom film experts to ask, “What are the A Weekend at a NASCAR Event Essay words you like to film, see on resumes?” Here’s what they had to say. Bookmark this article ASAP! #8220; If you want to village essay, show that you#8217;re results oriented and hard working, share the numbers. As they say, the cry freedom proof is in best man speech the pudding,#8221; says job coach Angela Copeland. #8220;For example, rather than stating that you#8217;re an #8220;excellent digital marketer,#8221; prove it. Say something that reflects your actual results, such as, #8216;Grew online sales and film revenue by 200% in one year.#8217; Now, that#8217;s impressive!#8221; For life career coach Jenn DeWall, action verbs are a must on any resume. But not just any action verbs.
She advises clients to include verbs that show leadership and transformation. #8220;#8216;Redesign#8217; d emonstrates problem-solving skills as well as the ability to notes, think big picture and cry freedom reduce process inefficiencies.#8221; If cliches are a no-no, simple yet powerful words are your go-tos, according to Glassdoor columnist Anish Majumdar. Essay! #8220; Simple, practical words that denote responsibility have the most impact. Launched, solved, transformed, and optimized are all examples of action verbs that make you look good without resorting to cliches.#8221; According to cry freedom, master resume writer Jacqui Barrett-Poindexter, this word along with #8220;conceived and metamorphosed#8221; are, #8220; like a switch, powering up the candidate#8217;s story, showing how they#8217;ve improved, envisioned and transformed their work environments, and therefore, gained revenue, customer growth, reputation, etc. traction for their company. They empower and advance the candidate#8217;s story!#8221; #8220; These words show that the candidate is backmasking songs thinking about their own activities in terms of cry freedom film, how they’ll improve the business,#8221; says expert and author of Fearless Salary Negotiation Josh Doody. #8220;Terms like #8216;hard-working#8217; don’t do this because working hard doesn’t necessarily produce better results. But focusing on being productive, adding value, and making progress show that the person is tuned in to improving the company, which almost always resonates with hiring managers.#8221; #8220;Anyone can say they #8220;led#8221; a team. Analysis Most Game By Richard Connell! Instead, use verbs that really explain what happened in that specific task,#8221; insists Joyce. #8220;Consider the verb #8216;orchestrated#8217; and how it shows, versus just telling, the hiring manager what was accomplished. Orchestrated, by film definition, means to arrange and direct. The key is to women criminals, make a resume better than any great piece of fiction by embracing the storytelling aspect and showing readers your true qualifications.#8221; If #8220;results-oriented#8221; and #8220;hardworking,#8221; are overused and lame, Joyce says instead of cry freedom film, looking for the 2017 buzzword, job seekers are better off being specific in man speech for best their resume. #8220;It is really more about choosing words that accurately describe actions or goals that were met. In lieu of cry freedom, hard-working, consider saying what hard work was done, e.g. Essay Analysis Most Dangerous Game By Richard Connell! did a candidate work tirelessly to reach an impossible deadline? It is important to use verbs that really pinpoint what was accomplished, i.e. Cry Freedom Film! influenced, improved, achieved, etc.
This way, there is no miscommunication about a candidate#8217;s qualifications.#8221; #8220;I like to look for candidates who have had a role in shaping something from idea all the way through execution,#8221; says executive coach Kate O#8217;Sullivan. #8220;One of the main qualities I look for is someone who can take a vague idea or strategic goal and see it through to completion, rather than someone who executes on a plan that’s already been decided. Using these key words will definitely signal that you’ve had a role in this higher level thinking, and will grab the attention of most hiring managers.#8221; #8220;In general, it’s very hard to convince a resume reader that you possess various soft skills, e.g. team player, just by listing these on your resume,#8221; says O#8217;Sullivan. #8220;If you put yourself in their shoes for a minute you will understand why. Most job seekers want to be desirable and so they list these in-demand skills. But just listing the skill doesn’t do any thing to set you apart from the crowd. The most powerful thing you can do is give examples. If you want to show that you are a team player, you can talk about things like working on women criminals cross-functional teams, on boarding new hires, or developing a cross-training program. By listing concrete accomplishments and cry freedom projects, you are demonstrating you have these skills in a credible and believable way that will help set you apart.#8221; Doody insists that a resume should be impactful while still skimmable, or able to easily be skimmed by recruiters and hiring managers. #8220;I coach my clients to assume the hiring manager won’t even look at their resume until they’re already in the process of interviewing them,#8221; says Doody candidaly. #8220;Hiring managers don’t sit down the day before an interview, pour a glass of wine, and meticulously read through each resume they’re considering. Instead, they scramble to make it to the interview on time, open up the resume as the interview is starting, and skim it to find things to talk about.#8221; According to Angela Copeland, a resume —and the job search, in life general— is cry freedom film not the time to be shy. #8220;Use strong words that emphasize your level of involvement. Analysis Of The By Richard Connell! This isn#8217;t the time to minimize yourself or your contributions. If you were instrumental in cry freedom film a project, replace the word #8220;helped#8221; with the word #8220;spearheaded.#8221; Spearheaded, created, and initiated all show that you took the lead and were not merely a participant in best man speech for best friend a project.
Show that you#8217;re dedicated to your work, start to finish. Cry Freedom Film! This word, says DeWall, does just that. #8220;If you disregard diction and word choice and think that they don#8217;t carry any weight you#8217;re wrong. Managers can gauge aptitude, readiness and even your leadership skills from paper,#8221; she adds. Reading and re-reading your resume is just the beginning of the editing process. Don#8217;t believe us? Each of our experts weighed in on the importance of editing a resume. Here are a few of friend, their insights: #8220;Word choice is incredibly important. Film! You only backmasking have a limited amount of film, real estate on your resume, so every single word counts,#8221; says O#8217;Sullivan. #8220;Focus on achievements, quantify where possible, and make an effort to tailor your experiences to your target job.
It’s more effective to talk about fewer projects and responsibilities more in-depth than to list every single thing you’ve ever done. Along these lines, concentrate on your most recent experience. Edit with the mindset of “does this piece of A Weekend at a Essay, information directly help sell my experience for this role? If not, take it off.#8221; #8220; The easiest way to improve your choice of words is to read your resume out loud to yourself,#8221; advises Copeland. #8220;This can catch many of the cry freedom potential issues before anyone else sees it. Then, ask a friend or family member who works in another industry to backmasking songs, read it.
If they find your resume to be confusing, consider updating the cry freedom wording, so that it#8217;s more clear.#8221; #8220;It#8217;s not just about using the right words, it is equally about teasing out the nuances of your stories and then combining them in backmasking a way that is attractive to film, your target reader: recruiter, hiring manager, etc,#8221; says Barrett-Poindexter. Essay Most Connell! #8220;You can use all the right #8216;nouns and verbs#8217; that make a resume sing (on the surface), but without the right, focused stories, your resume will fall flat to the intended reader#8217;s eyes and ears.#8221; #8220; In addition to cry freedom film, diction and A Weekend Event Essay word choice it#8217;s important to be strategic and concise. No one has time or energy to cry freedom film, invest in a multi-page resume,#8221; insists DeWall. #8220;Make sure that you#8217;re highlighting the most relevant and topical experience necessary for the position.#8221; 3,100+ Companies Committed to Equal Pay. Village Life Essay! Top 20 Employee Benefits Perks for 2017. 9 Companies as Exciting as Facebook—Hiring Now! Home 13 Must-Have Words to Include In Your Resume.
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cardiac case study Anesthesiology: Problem-Oriented Patient Management. CASE 15: Cardiac Tamponade. Manuel L. Fontes. Quick Links to Sections in this Chapter. Related Links in cry freedom film other Resources. Four days following two-vessel coronary artery bypass graft (CABG) procedure and replacement of spark notes king a mitral valve, this 69-year-old woman presented with a chief complaint of film 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 songs 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 film 2.7 L/minute. Friend? Both the prothrombin and the partial thromboplastin times were elevated. Medical Disease and Differential Diagnosis What is the differential diagnosis of low cardiac output (CO) postoperatively? A. Medical Disease and Differential Diagnosis. A.1. What is the film differential diagnosis of low cardiac output (CO) postoperatively? CO is determined by the product of stroke volume (SV) and heart rate (HR) during 1 minute (CO = HR x SV). Life? Thus, a low output state can occur when SV and/or HR decrease.
Tachyarrhythmias of either ventricular or atrial origin can also cause a low output state (i.e., atrial fibrillation). To more accurately determine the cry freedom film etiology of a reduced SV, it is essay, necessary to explore whether there has been a change in the preload, the afterload, and/or the contractile state. Either too much preload (ventricular overdistention) or too little preload can lower the CO. Cry Freedom Film? Similarly, a significant reduction in afterload (vasodilators, anesthetics, sympatholysis) or an increase in afterload (arterial resistance) can diminish SV. The latter, however, is notes king, only seen in film patients with severe ventricular dysfunction whereby the heart can no longer compensate for increases in afterload. Myocardial contractility can be compromised by either direct causes (myocardial ischemia, myocardial infarction, myocardial stunning, or myocardial hibernation) and/or by indirect causes (mechanical factors as in lear cardiac tamponade; pharmacologic agents; and by toxins, namely, inflammatory cytokines and bacterial endotoxins). A combination of hemodynamic disturbances can coexist in cry freedom film the same patient. For example, a patient can have both a decrease in contractility and a reduced preload to account for the low output state. Correcting one problem alone may not produce the friend optimal hemodynamic condition.
Fontes ML. Hines RH. Pharmacologic treatment of perioperative left and cry freedom film right ventricular dysfunction. Women Criminals? Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. A.2. What is cardiac tamponade? Enumerate the common etiologies of cardiac tamponade. Cardiac tamponade is cry freedom film, 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 backmasking air. How significant cardiac tamponade is film, depends on best man speech whether the definition is clinical versus physiologic.
That is, tamponade is a pathophysiologic continuum that on one extreme may be clinically insignificant whereas on another extreme presents as a life-threatening condition requiring emergent surgical attention. Clinical tamponade is frequently associated with marked increase in pericardial pressure relative to intracardiac pressures (atrial and ventricular) such that SV progressively declines resulting in systemic hypotension and in cardiogenic shock. Braunwald E, Heart disease: a textbook of cardiovascular medicine 6th ed. Philadelphia: WB Saunders, 2001:1498. Fowler NO. Film? Gabel M. Buncher CR. Cardiac tamponade: a comparison of spark king lear right heart versus left heart compression. JACC 1988:12:187.
Kaplan JA, Cardiac anesthesia 3rd ed. Philadelphia: WB Saunders, 1999:847. Spodlick D. Pathophysiology of cardiac tamponade. Chest 1998:113:1372–1378. A.3. What is the cry freedom difference between acute and delayed cardiac tamponade? In the setting of cardiac surgery, cardiac tamponade can occur acutely over Essay on Literary Most Dangerous minutes, hours, or after a few days postoperatively. Film? The reported incidence of acute cardiac tamponade is 0.5#37; to 5.8#37;.
The typical patient has significant chest tube output (more than 200 mL/hour) in the immediate postoperative period associated with or without hemodynamic signs of notes inadequate CO. Cry Freedom Film? 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 A Weekend Event Essay 2.6#37; and is often misdiagnosed because of a low index of suspicion and because the cry freedom film clinical signs and symptoms can be comparable to those of congestive heart failure, pulmonary embolism, and generalized fatigue (i.e., failure to thrive postoperatively). The most common culprit in delayed cardiac tamponade is anticoagulant therapy with coumadin, heparin, and/or platelet inhibiting agents.
Effusion after cardiac surgery is Essay on Literary of The Game by Richard Connell, common. Using echocardiography, Weitzman et al. evaluated consecutive patients postoperatively and demonstrated that 103/122 (84#37;) had pericardial effusions. Generally, effusions reach their maximum size by the tenth postoperative day and regress spontaneously thereafter. D'Cruz IA. Overton DH. Cry Freedom Film? Pai GH. On Literary Most Game Connell? Pericardial complications of cry freedom film cardiac surgery: emphasis on the diagnostic role of village life essay echocardiography.
J Card Surg 1992:7:257–268. Nelson RM. Jeson CB. Smoot WM. Pericardial tamponade following open-heart surgery. J Thorac Cardiovasc Surg 1969:58:510–516. Weitzman LB. Tinker WC. Kronzon I, et al.The incidence and natural history of pericardial effusions after cardiac surgery: an echocardiographic study.
Circulation 1984:69:506. A.4. How is the diagnosis of postcardiotomy cardiac tamponade made? The diagnosis of cardiac tamponade following cardiac surgery is film, often difficult and requires a high degree of clinical suspicion, proficient knowledge of pulmonary artery catheter (PAC) derived measures, physical examination, and diagnostic tools such as echocardiography and chest x-ray film. Often, the diagnosis is women criminals, made in the operating room whereby evacuation of clot and blood from the mediastinum is associated with drastic improvement in hemodynamics. Cry Freedom Film? Relying on one modality alone for diagnosis can lead to inaccurate management decisions and increase patient morbidity. For example, the PAC is an important device for women criminals, monitoring cardiac function; however, its measures can be misleading postcardiotomy unless the clinician is cognizant of such limitations.
The classical teaching of cry freedom film equalization of diastolic blood pressures in Analysis of The Dangerous by Richard Connell 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. Film? Generally, the CVP is elevated but the PAD and village the PAOP can be normal, elevated, or, in some cases, reduced. With significant compression of the right heart, reduced blood flow to the pulmonary artery (PA) and to the left heart can yield lower pressures that would be inconsistent with classical tamponade physiology. Russo and colleagues found that only 33#37; of patients with the diagnosis of cardiac tamponade had right heart catheterization findings that reflected equalization of diastolic blood pressures. Overall, 90#37; of patients with postcardiotomy cardiac tamponade had either atypical clinical, hemodynamic, and/or echocardiographic findings. Therefore, the cry freedom 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 available (i.e., PAC) to allow prompt diagnosis of tamponade.
Whenever, the patient is not progressing as expected postoperatively with some signs of end-organ dysfunction [fall in on Literary Analysis Most Dangerous Game urine output and or increase blood urea nitrogen (BUN) and creatinine], an echocardiogram should be obtained to rule out cry freedom film cardiac tamponade. Russo A. O'Connor W. Waxman H. Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery. Chest 1993:104:71–78. Spodlick D. Pathophysiology of cardiac tamponade. Chest 1998:113:1372–1378. A.5. What is regional cardiac tamponade? Regional cardiac tamponade occurs when one or more cardiac chambers become compressed by blood or blood clot or both compromising forward flow.
Postcardiotomy, diastolic regional collapse of the right atrium or the right ventricle is the most common echocardiographic finding in early cardiac tamponade. Postoperative right atrial hematoma often become localized to women criminals the anterior and lateral walls, whereas left atrial clots are more commonly found behind the left atrium where they become encysted in cry freedom 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 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. Songs? Pandian NG. Mohanty PK, et al.Left ventricular diastolic collapse. An echocardiographic sign of regional cardiac tamponade. Film? Circulation 1991:83:1999–2006. Fowler NO. Gabel M. Backmasking? Regional cardiac tamponade: a hemodynamic study.
J Am Coll Cardiol 1987:10:164–169. Hutchins GM. Isolated right atrial tamponade caused by cry freedom film hematoma complicating coronary artery bypass graft surgery [Letter]. Arch Pathol Lab Med 1980:104:612–614. Jadhav P. Life? Asirvatham S. Craven P, et al.Unusual presentation of late regional cardiac tamponade after aortic surgery.
Am J Cardiac Imaging 1996:10:204–206. Kochar GS. Jocab LE. Film? Holter MN. Right atrial impression in postoperative patients: detection by friend transesophageal cardiography.
J Am Coll Cardiol 1990:16:511–516. Russo A. Film? O'Connor W. Analysis Of The Dangerous By Richard Connell? Waxman H. Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery. Chest 1993:104:71–78. Sandifer DP. Gonzalez JL.
Refractory postoperative hypoxemia associated with regional cardiac tamponade and patent foramen ovale. Crit Care Med 1997:25:1608–1611. A.6. What is pulsus paradoxus? What is Kussmaul's sign?
Normally, there is an inspiratory fall of less than 10 mm Hg in the arterial systolic pressure and film 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 A Weekend Essay arterial pressure exceeds 10 mm Hg and film (b) the A Weekend Event Essay inspiratory venous pressure remains steady or increases (Kussmaul's sign). Echocardiographic studies of patients with cardiac tamponade by film 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 life left ventricle. Of importance, pulsus paradoxus is not unique to cardiac tamponade.
The phasic respiratory changes in ventricular dimensions with exaggerated decrease in systemic systolic arterial pressure during inspiration can be present in a variety of clinical conditions whereby intrapleural pressure is significantly diminished. That is, the magnitude of paradoxical pulse is directly proportional to the inspiratory decrease of left ventricular dimension, diastolic volume, and SV. This physiologic process is often present in respiratory distress, airway obstruction, chronic obstructive pulmonary disease (COPD), and pulmonary embolism. Although a prominent feature of cardiac tamponade, pulsus paradoxus may not be present at all in patients with chest wall trauma, neuromuscular disease, and pneumothorax because they cannot produce sufficient negative intrapleural pressure during inspiration to produce the typical changes in chamber dimension and fall in left ventricular SV. Cry Freedom? 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 Analysis Most Dangerous Game Connell echocardiography.
J Card Surg 1992:7:257–268. Frey B. Freezer N. Diagnostic value and pathophysiologic basis of pulsus paradoxus in infants and cry freedom children with respiratory disease. Pediatr Pulmonol 2001:31:138–143. Jay GD. Onuma K. Village Life? Davis R, et al.Analysis of physician ability in the measurement of pulsus paradoxus by sphygmomanometry. Chest 2000:118:348–352. McGregor M. Pulsus paradoxus. N Engl J Med 1979:301:480.
Tsang TS. Barnes ME. Hayes SN, et al.Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979#150;1998. Cry Freedom? Chest 1999:116:322–331. A.7. Describe ventricular interaction in cardiac tamponade.
Ventricular interaction is extremely important for maintenance of adequate cardiac performance. Women Criminals? Under normal conditions, the average SV of the right ventricle equals the SV of the left ventricle; however, cyclical respiratory differences in left and cry freedom right ventricular SV do occur. Notes? During the inspiratory cycle, negative intrapleural pressure is generated facilitating venous return to the right heart, whereas venous return to the left heart is diminished for the following reasons: (a) lung expansion increases its reservoir for blood and (b) the increase in right ventricular filling causes the cry freedom film interventricular septum to bulge leftwardly reducing left ventricular dimension and altering its compliance and for best friend 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 cry freedom 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 women criminals fixed space within the pericardium, cardiac chamber dimensions become smaller. First, the cry freedom film thin-walled and spark king lear 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 cry freedom film neuroendocrine influences. Spodlick D. Pathophysiology of cardiac tamponade. Women Criminals? Chest 1998:113:1372–1378. A.8. How is coronary blood flow affected in cardiac tamponade? In the absence of coronary artery disease, coronary blood flow is reduced in cardiac tamponade but this reduction is not sufficient to add an ischemic injury to the myocardium because there is a proportionate decrease in cry freedom (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 1978:58:265–272. Spodlick DH. Threshold of pericardial constraint: the pericardial reserve volume and auxiliary pericardial functions.
J Am Coll Cardiol 1985:6:296–299. A.9. Backmasking? What are the electrocardiographic abnormalities associated with cardiac tamponade? Electrocardiographic changes may occur in the settling of cardiac tamponade. Cry Freedom? These include nonspecific ST-T wave abnormalities, low voltage QRS complex, signs of myocardial ischemia and pericarditis, and electrical alternans ( Fig. 15.1A ). The latter is seen in patients with large effusions and is characterized by interbeat shifts in electrical axis. This beat-to-beat alteration may be due to increased distance between the heart and the chest wall resulting in Essay on Literary Analysis Most Dangerous Game a pendulum like motion of the heart. However, it has been shown that with minimal amount of pericardial fluid removal, the presence of electrical alternans can be abolished while the pericardial space remains enlarged. Thus, the electrocardiographic change of electrical alternans may reflect a hemodynamic pathology rather than an cry freedom film anatomic abnormality.
This finding, although sensitive for life, cardiac tamponade, is not very specific (very few patients with tamponade present with electrical alternans). Figure 15.1. Depiction of electrical alternans in cry freedom a patient with cardiac tamponade. The images demonstrate significant pericardial effusions (PE) obtained during transthoracic echocardiography. Note the backmasking image of the left ventricle (LV) during systole and diastole. (From Longo MJ, Jaffe CC. Images in clinical medicine. Electrical alternans. N Engl J Med 1999;341:2060, with permission.) Figure 15.1. Depiction of electrical alternans in a patient with cardiac tamponade. The images demonstrate significant pericardial effusions (PE) obtained during transthoracic echocardiography.
Note the image of the left ventricle (LV) during systole and diastole. (From Longo MJ, Jaffe CC. Film? 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:H516–530.
Kosta E. Kronzon I. Electrical alternans in cardiac tamponade. Echocardiography 2000:17:(6 Pt 1)575–576. Kronzon I. Cohen M. Winer H. Contribution of echocardiography to the understanding of the pathophysiology of cardiac tamponade. J Am Coll Cardiol 1983:1:1180–1182. Longo MJ. Jaffe CC. Images in clinical medicine. Man Speech For Best? Electrical alternans. N Engl J Med 1999:341:2060. A.10. What roentgenographic and echocardiographic findings are noted in cry freedom film cardiac tamponade?
On standard anterior-posterior chest roentgenography, the cardiac silhouette may appear normal in on Literary Analysis of The by Richard Connell size or extremely enlarged depending on the acuity and chronicity of the tamponade process. Normally, the cry freedom film pericardial fluid amounts to 15 to A Weekend at a Essay 25 mL. Acute tamponade physiology can arise with as little as 150 mL of cry freedom effusion, whereas chronic effusions may exceed 1,000 mL before clinical signs and symptoms of best man speech friend cardiac tamponade manifest. On chest x-ray film, the cry freedom film 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. Women Criminals? 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 cry freedom mitral valve excursion during inspiration, (b) shifting of the interventricular septum toward the left ventricle, (c) changes in transvalvular (mitral and aortic) flow characteristics seen by of The Doppler techniques, (d) diastolic posterior motion of the right ventricular wall, and (e) in some cases, a systolic notch on the right ventricular epicardium ( Fig. 15.1B and C ). Although many of the findings of both x-ray film and echocardiogram can be suggestive of cardiac tamponade, no one sign is 100#37; sensitive and specific. Braunwald E, Heart disease: a textbook of cardiovascular medicine 6th ed. Philadelphia: WB Saunders, 2001:1490. Kaplan JA, Cardiac anesthesia 4th ed. Philadelphia: WB Saunders, 1999:932, 1250.
Singh SM. Cry Freedom Film? Wann LS. Schuchard GH, et al.Right ventricular and at a Event right atrial collapse in patients with cardiac tamponade. Cry Freedom Film? Circulation 1984:70:996. A.11. At A? What is in the differential diagnosis of postcardiopulmonary bypass (post-CPB) bleeding? Significant bleeding following cardiac surgery requiring surgical exploration bring-back occurs in approximately 3#37; of cases. Often, the source of bleeding cannot be ascertained and its etiology is cry freedom, 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 women criminals, the site of endothelial injury (procoagulant effects) and (b) to cry freedom film 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 essay preexisting levels of the procoagulants as well as other factors such as the cry freedom duration of CPB, systemic hypothermia, comorbid states (renal and liver insufficiency), type of village 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. Cry Freedom Film? HMWK, high molecular weight kininogen; PK, prekallikrein; PL, phospholipid by songs platelets; PT, prothrombin time; PTT, partial thromboplastin time; TCT, thrombin clotting time; TTPL, tissue thromboplastin. (From Coleman RW, Hirsch J, Marder VJ, et al, eds. Hemostasis and thrombosis: basic principles and clinical practice, 2nd ed. Philadelphia: JB Lippincott, 1987:1052, with permission.) Figure 15.2.
The coagulation cascade, illustrating the coagulation factors required for various screening tests. HMWK, high molecular weight kininogen; PK, prekallikrein; PL, phospholipid by film 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. NASCAR Event? Philadelphia: JB Lippincott, 1987:1052, with permission.) Platelets play an important role in film the coagulation process.
Once activated, they secrete several types of granules. Granules, containing peptides such as fibrinogen, thrombospondin, factors V and songs VIII, and cry freedom -thromboglobulin, are reduced in both number and content during CPB. Of greater importance is the loss of several membrane glycoproteins (IIb-IIIa) that interact with fibrinogen and lear other cellular elements allowing for platelet conjugation and propagation of clot formation. Cry Freedom Film? Overall, postcardiotomy bleeding is at a Essay, due to (a) a qualitative and a quantitative platelet defect, (b) factor deficiency, and cry freedom (c) surgical bleeding. The latter can arise from either venous or arterial sources that were undetected before closure of the chest. Attentive and meticulous effort to surgical hemostasis can significantly reduce the incidence of notes bring-backs. Despotis GJ. Avidan MS. Film? Hogue CW Jr. Mechanisms and attenuation of hemostatic activation during extracorporeal circulation. Life Essay? Ann Thorac Surg 2001:72:S1821–1831.
Harker L. Malpass TW. Branson HE. Mechanism of cry freedom film 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 women criminals tranexamic acid on fibrinolysis and bleeding during and after cardiopulmonary bypass surgery. Thromb Res 2001:104:301–307. Levy JH. Cry Freedom Film? Pharmacologic preservation of the hemostatic system during cardiac surgery. Ann Thorac Surg 2001:72:S1814–1820. A.12.
What is the mechanism of action of low molecular weight heparin (LMWH)? LMWHs are fragments of women criminals unfractionated heparin produced by controlled enzymatic or chemical depolymerization processes yielding chains having molecular weight of about 5,000 daltons. The parent compound is cry freedom film, 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 pentasaccharide to antithrombin (antithrombin III) results in a conformational change in antithrombin that accelerates its interaction with thrombin and factor X (factor Xa) by 1,000-fold. At A Event? Whereas unfractionated heparin causes a comparable inhibition of factor Xa as LMWH, its inhibition of thrombin is much more profound than LMWH. To inactivate thrombin, heparin has to cry freedom bind to both antithrombin and thrombin forming a ternary complex. Heparin pentasaccharide sequences (randomly distributed along heparin chains) of 18 units or more is women criminals, required for the formation of this ternary complex. Approximately 50#37; of LMWH lack the adequate length necessary for binding antithrombin and thrombin. Furthermore, only 15#37; to 25#37; of chains of LMWH contain pentasaccharide sequences. Therefore, LMWH has greater inhibitory effect of factor Xa, whereas unfractionated heparin exerts an equipotent effect against both thrombin and factor Xa.
Lastly, both LMWH and unfractionated heparin cause release of tissue factor pathway inhibitor from vascular endothelium, which then forms a complex with and film inhibits factor Xa. This complex in turn inactivates factor VIIa. Clark SC. King Lear? Vitale N. Zacharias J, et al.Effect of low molecular weight heparin (fragmin) on bleeding after cardiac surgery. Ann Thorac Surg 2000:69:762–765. Danielsson A. Raub E. Lindahl U, et al.Role of ternary complexes in film which heparin binds both antithrombin and proteinase, in the acceleration of the reactions between antithrombin and thrombin for factor Xa. J Biol Chem 1986:261:1546–1573. Gohlke-Barwolf C. Anticoagulation in at a NASCAR Essay valvar heart disease: new aspects and management during non-cardiac surgery.
Heart 2000:84:567–572. Harenberg J. Pharmacology of low molecular weight heparins. Semin Thomb Hemost 1990:16:12–18. Kondo NI. Maddi R. Cry Freedom Film? Ewenstein BM, et al.Anticoagulation and hemostasis in cardiac surgical patients.
J Card Surg 1994:9:443–461. Weitz JI. Drug therapy: low molecular weight heparins. N Engl J Med 1997:337:688–698. A.13. Describe the advantages of village LMWH over standard heparin therapy. There are several clinical and pharmacologic advantages of LMWH over unfractionated heparin.
The plasma half-life of LMWH is film, two to four times longer than unfractionated heparin, which undergoes a dose-dependent elimination by the liver and the kidneys. A significant amount of unfractionated heparin is bound to best man speech plasma proteins, vascular endothelium, and macrophages resulting in less bioavailability and an unpredictable anticoagulant effect. Consequently, careful laboratory monitoring is film, required. Additional benefits of spark king LMWH over unfractionated heparin include less bleeding (less platelet inhibition and cry freedom less propensity for notes, increasing microvascular permeability). Several clinical trials have demonstrated both improved efficacy and safety of film LMWH over unfractionated heparin.
Of note, LMWH is not recommended in village essay the setting of renal failure, and its anticoagulant activity may be measured by assaying factor Xa levels. Cry Freedom Film? There are, however, many different types of LMWH available in on Literary Analysis of The Most Dangerous Game Connell the market, each having slightly different pharmacologic effects (bioavailability, anticoagulant effect). Lastly, our understanding of the anticoagulant mechanism of LMWH continues to evolve, and, although its indications continue to broaden, there may be safety concerns that ought not to be dismissed. Alban S. Gastpar R. Plasma levels of total and free tissue factor pathway inhibitor (TFPI) as individual pharmacological parameters of various heparins. Thromb Haemost 2001:85:824–829.
Cohen AT. Cry Freedom Film? Bailey CS. Alikhan R, et al.Extended thromboprophylaxis with low molecular weight heparin reduces symptomatic venous thromboembolism following lower limb arthroplasty#151;a meta-analysis. Thromb Haemost 2001:85:940–941. Huse DM. Cummins G. Taylor DC, et al.Outpatient treatment of venous thromboembolism with low-molecular-weight heparin: an A Weekend Event economic evaluation. Am J Managed Care 2002:8:(1Suppl)S10–16. Kleinschmidt K. Charles R. Pharmacology of film low molecular weight heparins [Review]. Emerg Med Clin North Am 2001:19:1025–1049. A.14.
What is heparin-induced thrombocytopenia (HIT)? How is the diagnosis made? HIT is a serious complication of heparin therapy that is predominantly immunemediated by a binary complex of spark lear heparin and platelet factor 4 (PF4). Cry Freedom Film? The reaction is NASCAR Event, commonly caused by an immunoglobulin (IgG) antibody that binds and activates platelets in the presence of heparin. Other immunoglobulins may also potentiate HIT. HIT exists in two forms. A benign form of HIT, type 1, is observed in approximately 10#37; to 20#37; of cry freedom 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 women criminals generally improves despite continuing heparin administration.
In contrast, type II HIT is a life-threatening condition that develops 5 to film 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 backmasking HIT in patients receiving full-dose heparin ranges between 0#37; to film 30#37;. Although there is no randomized prospective study looking at the true incidence of HIT, the Event Essay expected incidence is estimated to cry freedom be less than 5#37;. Those patients who have had a previous exposure to heparin (recent and in some cases remote history) may develop HIT earlier after institution of heparin therapy as compared with those with no previous exposure. Life? 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 cry freedom heparin, (b) exclusion of other etiology of thrombocytopenia, (c) improvement in NASCAR Event Essay platelet count following cessation of heparin therapy, and cry freedom (d) presence of heparin-dependent platelet antibody by an in vitro test.
In most cases, the diagnosis is made on clinical findings. Gerotziafas GT. Elalamy I. Lecrubier C, et al.The role of spark king lear platelet factor 4 in platelet aggregation induced by the antibodies implicated in heparin-induced thrombocytopenia. Blood Coag Fibrinolysis 2001:12:511–520. Robitaille D. Carrier M. Cartier R, et al.Successful management strategy for mechanical assistance and cry freedom heart transplantation in patients suffering from heparin-induced thrombocytopenia type II. J Heart Lung Transplantation 2001:20:1237–1240. Shea SI.
Sands JJ. A Weekend Event Essay? Nudo SA, et al.Frequency of anti-heparin-platelet factor 4 antibodies in hemodialysis patients and correlation with recurrent vascular access thrombosis. Am J Hematol 2002:69:72–73. Warkentin TE. Dunn GL. Cybulsky IJ. Off-pump coronary artery bypass grafting for acute heparin-induced thrombocytopenia. Ann Thorac Surg 2001:72:1730–1732. A.15.
What is the therapy for HIT? Because HIT type II is a potentially lethal condition, the cry freedom film most effective therapy is discontinuation of at a NASCAR heparin. The thrombocytopenia should improve progressively. Cry Freedom Film? Although tempting, the women criminals need for platelet transfusion is film, 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 spark notes these agents are not available in the United States for cry freedom, use; others are under clinical investigation. Hirudin has been extensively used in songs Europe with demonstrable benefit and safety. Cry Freedom? The LMWH have been shown to essay have cross reactivity with unfractionated heparin approaching 100#37; [C-serotonin release or by heparin-induced platelet aggregation (HIPA) assays] and should not be used in the setting of cry freedom film HIT unless there are demonstrable negative cross reactivity assays with standard heparin.
The ancrod is a defibrinogenating agent (not available in the United States) extracted from the backmasking Malayan pit viper and is immunologically distinct from heparin. It acts by cleaving fibrinopeptide A from fibrinogen and its activity can be measured by assaying for plasma fibrinogen concentration. Lastly, in the setting of HIT, a synthetic analogue of prostacyclin (iloprost#151;a potent inhibitor of platelet activation) has been used successfully during cardiac surgery to prevent further reduction of platelet count. Cheng-Lai A. Cardiovascular drug highlight: hirudin. Heart Dis J Cardiovasc Med 1999:1:41–49. Deitcher SR. Carman TL. Heparin-induced thrombocytopenia: natural history, diagnosis, and management.
Vasc Med 2001:6:113–119. Gill J. Kovacs MJ. Successful use of cry freedom danaparoid in treatment of heparin-induced thrombocytopenia during twin pregnancy. Obstet Gynecol 1997:90:(4 Pt 2)648–650. Koster A. Meyer O. By Richard? Fischer T, et al.One-year experience with the platelet glycoprotein IIb/IIIa antagonist tirofiban and heparin during cardiopulmonary bypass in patients with heparin-induced thrombocytopenia type II.
J Thorac Cardiovasc Surg 2001:122:1254–1255. Robitaille D. Carrier M. Cartier R, et al.Successful management strategy for mechanical assistance and film heart transplantation in patients suffering from heparin-induced thrombocytopenia type II. J Heart Lung Transplantation 2001:20:1237–1240. Warkentin TE. Dunn GL. Cybulsky IJ. Off-pump coronary artery bypass grafting for acute heparin-induced thrombocytopenia. Ann Thorac Surg 2001:72:1730–1732. A.16. Can HIT be caused by LMWH?
Based on confirmed laboratory tests, the prevalence of backmasking HIT is 2#37; for patients receiving unfractionated heparin. Although the incidence of HIT is infrequent in film the setting of LMWH, it is man speech for best, not zero and cry freedom avoidance of the latter is recommended for patients demonstrating signs of HIT while receiving unfractionated heparin. Fabris F. Luzzatto G. Stefani PM, et al.Heparin-induced thrombocytopenia [Review]. Haematologica 2000:85:72–81. Kleinschmidt K. At A? Charles R. Pharmacology of low molecular weight heparins. Emerg Med Clin North Am 2001:19:1025–1049. Warkentin TE. Sheppard JA. Horsewood P, et al.Impact of the patient population on the risk for heparin-induced thrombocytopenia. Blood 2000:96:1703–1708.
A.17. What is the mechanism of heparin antagonism by protamine? Heparin is a large glycosaminoglycan molecule consisting of cry freedom chains of alternating residues of D -glucosamine and uronic acid. It is highly negatively charged, whereas protamine is mostly positively charged. The two combine irreversibly to form a heparin-protamine complex that does not have the ability to for best bind to thrombin or factor Xa. Once neutralized, the complex of heparin and protamine is eliminated. Kimmel SE. Sekeres M. Berlin JA, et al.Mortality and adverse events after protamine administration in patients undergoing cardiopulmonary bypass. Anesth Analg 2002:94:1402–1408.
A.18. What is cry freedom, heparin rebound? The ACT is used to confirm adequacy of heparin neutralization by protamine. The concept of heparin rebound and Essay of The Game coagulopathy following protamine reversal may occur as follows: first, heparin that is sequestered in tissues that are poorly perfused (i.e., fat) may not undergo neutralization by protamine and second, the half-life of heparin is cry freedom, longer than that of protamine (45 minutes) such that as heparin is NASCAR Essay, mobilized back into circulation it can inhibit thrombin formation and predispose post-CPB bleeding. Studies in cry freedom which 1 mg of protamine is given per 100 units of heparin (total dose) found no evidence of heparin rebound. Notes? Thus, bleeding in the postoperative cardiac surgical patient is unlikely to cry freedom be from heparin rebound. Heller EL. Paul L. Anticoagulation management in a patient with an acquired antithrombin III deficiency. J Extra Corpor Technol 2001:33:245–248.
Subramaniam P. Skillington P. Of The Dangerous Connell? Tatoulis J. Heparin-rebound in the early postoperative phase following cardiopulmonary bypass. Austr N Z J Surg 1995:65:331–333. Woodman RC. Harker LA. Cry Freedom Film? Bleeding complications associated with cardiopulmonary bypass. Blood 1990:76:1680. A.19. Village Life? How does coumadin affect the film coagulation system? What is the therapy for Essay Dangerous by Richard Connell, reversing its effect? Coumadin remains the most commonly used anticoagulant agent in the outpatient setting (atrial fibrillation, prosthetic valves and devices).
Its predominant pharmacodynamic effect is film, inhibition of synthesis of backmasking vitamin K-dependent factors (II, VII, IX, and X) in the liver and film 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 backmasking songs presence of other comorbid conditions. On average, it takes several days of therapy to cry freedom achieve the desired INR (2 to 4); consequently, administration of either LMWH or unfractionated heparin may be necessary for initiating anticoagulation. Complications occur either because of inadequate anticoagulation (thrombosis) or because of excessive anticoagulation (bleeding and hemorrhage). To reverse its effect, coumadin should be discontinued several days (more than 3 days) to allow levels of the women criminals aforementioned factors to normalize. Cry Freedom Film? Acute reversal is Essay on Literary Most Dangerous Game, achieved with FFP. Administration of vitamin K is often necessary to accelerate the synthetic process. Erban S. Initiation of warfarin therapy: recommendations and clinical pearls. J Thromb Thrombolysis 1999:7:145–148. Henderson MC.
White RH. Anticoagulation in the elderly. Curr Opin Pulm Med 2001:7:365–370. Horton JD. Bushwick BM. Warfarin therapy: evolving strategies in anticoagulation. Am Fam Physician 2002:65:172. Keller C. Cry Freedom Film? Matzdorff AC. Kemkes-Matthes B. Pharmacology of warfarin and clinical implication. Sem Thromb Hemost 1999:25:13–16. A.20.
What do the following measure: prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time, activated clotting time (ACT), bleeding time? PT measures the friend activity of the extrinsic pathway: factors I (fibrinogen), II (prothrombin), V, VII, and X ( Fig. Film? 15.2 ). Deficiencies of factors V, VII, and X (50#37; of normal) significantly prolong the women criminals PT. Cry Freedom Film? Much lower concentrations of fibrinogen and prothrombin are required to spark notes prolong the film PT. Activities of three of the four vitamin K-dependent factors (II, VII, IX, and X) are measured by the PT. Normal values are less than 12 seconds. Activated Partial Thromboplastin Time.
Activated partial thromboplastin time (aPTT) measures the activity of the intrinsic pathway: factors XII, XI, IX, VIII, V, X, prothrombin, and backmasking songs fibrinogen ( Fig. 15.2 ). Cry Freedom? The aPTT is king lear, prolonged by concentrations of less than 20#37; to cry freedom film 30#37; of these factors. Normal values are 25 to 40 seconds. Thrombin time measures the conversion of fibrinogen to fibrin by thrombin#151;the final step in the coagulation cascade ( Fig. 15.2 ). The thrombin time is decreased in the presence of low concentrations of fibrinogen and thrombin. Heparin prolongs the women criminals 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. It is used primarily to measure the film adequacy of heparinization during CPB and notes protamine reversal of heparin following CPB. Prolonged ACTs may be due to heparin, low levels of coagulation factors, or thrombocytopenia. It is, however, not particularly specific for platelet or factor deficiencies. Normal values are 110 to 140 seconds. Bleeding time measures platelet activity, including both platelet number and film aggregation.
The bleeding time becomes prolonged with platelet counts less than 50 x 10 3 / L and in the presence of inhibitors of village life platelet aggregation such as aspirin. Cry Freedom? Normal values are less than 5 minutes. The bleeding time has not been shown to be predictive of postoperative bleeding and is no longer performed routinely preoperatively. Barash PG, Cullen BF, Stoelting RK, Clinical anesthesia 4th ed. Philadelphia: Lippincott, Williams Wilkins, 2001:219–224. Braunwald E, Fauci A, Kasper DL, et al., Harrison's principles of internal medicine 15th ed.
New York: McGraw Hill, 2001:354–358. Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and thrombosis: basic principles and clinical practice 2nd ed. Philadelphia: JB Lippincott, 1987:1048. A.21. How is the anticoagulant effect of LMWH monitored? There is no evidence that monitoring the dose improves the clinical efficacy. In contrast, any overdose increases the risk of hemorrhage. Because the kidneys play a significant role in the elimination of LMWH, therapeutic use of these agents should be monitored with an antifactor Xa assay, especially in patients who have renal insufficiency, are elderly, and have clinical conditions that increase the risk of bleeding. Boneu B. de Moerloose P. Village Essay? How and when to monitor a patient treated with low molecular weight heparin. Sem Thromb Hemost 2001:27:519–522.
A.22. Cry Freedom? What is a thromboelastograph? What is for best friend, a Sonoclot? The thromboelastograph is an instrument that measures the development of cry freedom film blood clot viscoelastic strength over time. A rotating piston is suspended in a cuvette filled with heated blood. As clot formation proceeds, the rotation of the piston is affected and characteristic curves are generated ( Fig. 15.3 ). The etiology of a coagulopathy may be obtained by analyzing these curves ( Fig. Man Speech? 15.4 ). Film? 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 village essay the Fig.
15.5 . Figure 15.3. Production of normal thromboelastogram and measured parameters. Cry Freedom Film? R, reaction time, 7 to 14 minutes; K value, 3 to 7 minutes; , clot formation rate, 40 degrees to man speech for best 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 14 minutes; K value, 3 to cry freedom film 7 minutes; , clot formation rate, 40 degrees to 60 degrees, MA, maximum amplitude, 50 to man speech 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. Film? Effects of progressive blood loss on coagulation as measured by thromboelastography. Anesth Analg 1987;66:856#150;863.) Figure 15.4. Qualitative analysis of thromboelastograms. Figure 15.4. Qualitative analysis of thromboelastograms. Figure 15.5. Sonoclot tracings of platelet-rich plasma (PRP) and platelet-poor plasma (PPP). A: lag period, B: primary wave, C: shoulder, D: secondary wave, E: peak, F: downward wave. (From Saleem A, Blifeld C, Saleh SA, et al. Viscoelastic measurement of clot formation: a new test of platelet function.
Ann Clin Lab Sci 1983;13:115, with permission.) Figure 15.5. Spark King Lear? Sonoclot tracings of platelet-rich plasma (PRP) and platelet-poor plasma (PPP). A: lag period, B: primary wave, C: shoulder, D: secondary wave, E: peak, F: downward wave. (From Saleem A, Blifeld C, Saleh SA, et al. Viscoelastic measurement of clot formation: a new test of platelet function. Ann Clin Lab Sci 1983;13:115, with permission.) Avidan MS. Da Fonseca J. Parmar K, et al.The effects of aprotinin on thromboelastography with three different activators. Anesthesiology 2001:95:1169–1174.
Ellison N, Jobes DR, Effective hemostasis in the cardiac surgery Philadelphia: WB Saunders, 1988:155. Forestier F. Belisle S. Contant C, et al.Reproducibility and interchangeability of the thromboelastograph, Sonoclot and cry freedom Hemochron activated coagulation time in cardiac surgery. Can J Anaesth 2001:48:902–910. Koster A. Hansen R. Spark Notes Lear? Schulz J, et al.Assessment of the resonance thromboelastograph CS-3 for differentiation of coagulation disorders: a pilot in vitro investigation of simulated post-cardiopulmonary bypass coagulopathies. Cry Freedom Film? J Extra Corp Technol 2001:33:159–166. Koster A. Kukucka M. Fischer T, et al.Evaluation of post-cardiopulmonary bypass coagulation disorders by women criminals differential diagnosis with a multichannel modified thromboelastogram: a pilot investigation. J Extra Corp Technol 2001:33:153–158. Saleem A. Blifeld C. Saleh SA, et al.Viscoelastic measurement of clot formation: a new test of cry freedom platelet function. Ann Clin Sci 1983:13:115. Vig S. Chitolie A. Bevan DH, et al.Thromboelastography: a reliable test?.
Blood Coag Fibrinolysis 2001:12:555–561. Vorweg M. Hartmann B. Knuttgen D, et al.Management of backmasking songs fulminant fibrinolysis during abdominal aortic surgery. J Cardiothorac Vasc Anesth 2001:15:764–767. A.23. How does desmopressin aid hemostasis? Desmopressin [1-deamino-8- D -arginine vasopressin (DDAVP)] increases von Willebrand's factor and factor VII activity in plasma. von Willebrand's factor, which binds to platelets, is found in subendothelial tissue and is in part responsible for platelet adhesion to damaged blood vessels. DDAVP was initially shown to significantly decrease postoperative bleeding. Dobkowski WB. Murkin JM.
A risk-benefit assessment of cry freedom film aprotinin in village cardiac surgical procedures. Drug Safety 1998:18:21–41. Kondo NI. Maddi R. Ewenstein BM, et al.Anticoagulation and hemostasis in cardiac surgical patients. J Card Surg 1994:9:443–461. Serradeil-Le Gal C. Nonpeptide antagonists for cry freedom film, vasopressin receptors. Pharmacology of SR 121463A, a new potent and highly selective V2 receptor antagonist.
Adv Exp Med Biol 1998:449:427–438. A.24. What is fibrinolysis? Fibrinolysis is fibrin breakdown in thrombi. Plasmin, derived from plasminogen, is the enzyme involved in this process. Physiologic fibrinolysis involves clot remodeling and removal during the healing process. Friend? 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 film postoperative bleeding.
Hackman T. Gascoyne CD. Naiman SC, et al.A trial of desmopressin to reduce blood loss in uncomplicated cardiac surgery. N Engl J Med 1989:321:1437. Salzman EW. Weinstein MJ. Weintraub RM, et al.Treatment with desmopressin acetate to reduce blood loss after cardiac surgery. N Engl J Med 1986:314:1402. A.25. What is aminocaproic acid?
Aminocaproic acid (Amicar) is an analogue of lysine. Its primary mechanism of action is inhibition of plasmin, resulting in Essay less breakdown of fibrinogen, fibrin (fibrinolysis), and other clotting components. Aminocaproic acid has been effective in treating coagulopathy in the setting of heart surgery, portocaval shunts, hematologic disorders such as aplastic anemia, abruptio placentae, hepatic cirrhosis, and film neoplastic diseases. Compared with placebo, both tranexamic acid and aminocaproic acid have been shown to reduce blood loss by 30#37; to 49#37; as well as reduce homologous blood transfusion. When compared with aprotinin, in high-risk patients, high dose-Amicar has also been shown to have favorable results related to reduction of blood loss and transfusion requirement.
Considering the low cost associated with aminocaproic acid therapy (less than $12), many cardiac surgical centers use this agent routinely for uncomplicated open-heart procedures. The standard intravenous preparation and dosage for cardiac surgery include 5 to 10 g of aminocaproic acid diluted and infused over 1 hour, followed by a continuous infusion at a rate of 1 g per hour. Higher infusion rates may be used. There are several adverse events that include thrombosis (early graft closure, myocardial ischemia and best infarction), agranulocytosis, leukopenia, and thrombocytopenia. Although rare, bradycardia and mild reduction in blood pressure have also been reported. Levi M. Cry Freedom Film? Cromheecke ME. de Jonge E, et al.Pharmacological strategies to lear decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet 1999:354:1940–1947. A.26. What is aprotinin? Aprotinin is film, a complex polypeptide molecule belonging to the family of serine protease inhibitors that is extracted from bovine lung. Life Essay? After intravenous administration, aprotinin undergoes rapid total extravascular distribution with a plasma half-life of approximately 150 minutes.
It is filtered by the glomeruli and reabsorbed by the proximal tubules. The terminal half-life is approximately 10 hours. The basis for its efficacy is not fully understood but consists of a complex activation-interaction of the following systems: kallikrein resulting in kinin generation, complement and cry freedom film inflammatory pathways, coagulation (intrinsic and extrinsic), fibrinolytic, angiotensin, and others not yet determined ( Fig. 15.6 ). Initial contact between blood elements and lear the nonendothelialized surface of the CPB circuit promote contact activation of both humoral and cellular inflammatory processes. The coagulation system may be the first to be activated by contact generating factor XIIa from factor XII, which then interacts with prekallikrein and high molecular weight kininogen (HMWK) to form kallikrein as well as promote the activation of the other coagulation factors. Once activated, kallikrein functions to stimulate and accelerate the generation of bradykinin from HMWK, factor XIIa, angiotensin, and complement activation. Factor XIIa, in turn, also interacts with fibrinogen to produce plasmin ( Fig. 15.7 ). Figure 15.6. Contact activation and the role of the kallikrein system. Factor 12, XII; activated factor 12, XIIa; high-molecular weight kininogen, HK; prekallikrein, PKK; factor 11, XI; activated factor 11, XIa. (From slide set no.
3, tryaslol slide library [online]. Bayer, 2000. Available at http://www.trasylol.com/slides.htm with permission.) Figure 15.6. Contact activation and the role of the kallikrein system. Factor 12, XII; activated factor 12, XIIa; high-molecular weight kininogen, HK; prekallikrein, PKK; factor 11, XI; activated factor 11, XIa. (From slide set no.
3, tryaslol slide library [online]. Bayer, 2000. Available at cry freedom film, http://www.trasylol.com/slides.htm with permission.) Figure 15.7. Involvement of the various components of coagulation including the coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and the fibrinolytic system. Spark Notes King Lear? C1, complement; HMW, high molecular weight. Cry Freedom? (From slide set no. 3, tryaslol slide library [online]. Bayer, 2000. Available at: http://www.trasylol.com/slides.htm with permission.)
Figure 15.7. Involvement of the various components of coagulation including the coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and women criminals the fibrinolytic system. C1, complement; HMW, high molecular weight. (From slide set no. 3, tryaslol slide library [online]. Bayer, 2000. Film? Available at: http://www.trasylol.com/slides.htm with permission.) Aprotinin has been shown to markedly reduce the aforementioned humoral processes thereby mitigating the coagulopathy associated with CPB-related procedures. Best For Best Friend? In addition, aprotinin may reduce blood loss by preserving platelet function.
The mechanism of this relates to preservation of platelet surface glycoproteins (IIb/IIIa), which is necessary for platelet-fibrinogen interaction and clot formation. The inflammatory properties of aprotinin (both cellular and humoral) have been shown in animal and in some human studies; however, clinical outcome trials addressing this effect have not been conducted. Film? In contrast, clinical trials comparing Aprotinin to placebo and/or to Amicar have consistently shown greater efficacy related to Game by Richard reduction in blood loss and transfusions of blood elements. Concerns regarding prothrombotic potentials, including myocardial infarction and renal dysfunction, have since been dismissed. The infarction rate and the incidence of renal dysfunction are comparable to those of placebo ( Table 15.1 ). Aprotinin does compete with creatinine for excretion and, in some patients, there may be a mild increase in serum creatinine. Rarely, if aprotinin is used in patients with protein C or S deficiency, they may experience life-threatening thrombotic events shortly after protamine neutralization of heparin. Another important aspect of film aprotinin use is the type of reagent used to backmasking songs monitor adequacy of heparinization (ACT). Kaolin is the recommended agent to be used to assess ACT when aprotinin is cry freedom, used (greater than 480 seconds). If Celite is women criminals, used, the film ACT value should be more than 750 seconds before initiation of CPB. Aprotinin is spark notes lear, not an antithrombotic agent, and, therefore, adequate amount of heparin must be given.
Because it is a serine protease inhibitor, it interacts with antithrombin III to inhibit the cry freedom action of all intrinsic and common pathway factors resulting in prolongation of measures of friend coagulation such as ACT. Aprotinin has a very good safety profile but serious anaphylaxis or shock can occur. Cry Freedom Film? This risk is increased in Essay Analysis of The by Richard patients who are reexposed to aprotinin within 6 weeks. Most of the cry freedom film cases reported occurred within 200 days of exposure. It is Essay Dangerous Game, recommended that a test dose of 1 mL be given when it is film, possible to emergently perform cannulation for instituting bypass. Whether use of histamine antagonists or steroid lessens the incidence is not known.
The following dosing regimen is suggested: 1 mL [10,000 kallikrein inactivator units (KIU)] test dose is Event, administered intravenously at least 10 minutes before the film loading dose, followed by close observation for signs of an allergic reaction. A loading dose of 2 million KIU should then be given over 20 to 30 minutes. An additional 2 million KIU dose is added to the priming solution. The maintenance dose is a constant infusion of songs 500,000 KIU/hour for the duration of surgery. It may be beneficial and cost effective to continue the infusion of the remaining amount of the drug while the patient is transferred and recovering in the ICU. A half-dose regimen has been proposed and entails reducing the film previously mentioned recommendation in half. Cosgrove DM III. Best Man Speech For Best? Heric B. Lytle BW, et al.Aprotinin therapy for reoperative myocardial revascularization: a placebo-controlled study. Ann Thorac Surg 1992:54:1031–1038. Dobkowski WB.
Murkin JM. Cry Freedom Film? A risk-benefit assessment of at a NASCAR Event aprotinin in cardiac surgical procedures. Drug Safety 1998:18:21–41. Fujii S, Kinins V, Part B. Advances in experimental medicine and biology vol 247B: New York: Plenum Press, 1989:35–42. Hoffmann H. Siebeck M. Thetter O, et al.Aprotinin concentrations effective for the inhibition of tissue kallikrein and plasma kallikrein in vitro and in vivo. Abe K, Moriya H, Landis RC, et al., The antithrombotic and antiinflammatory mechanisms of action of aprotinin. Ann Thorac Surg 2001:72:2169–2175. Murkin JM. Attenuation of neurologic injury during cardiac surgery. Ann Thorac Surg 2001:72:S1838–1844.
Orchard MA. Goodchild CS. Prentice CRM, et al.Aprotinin reduces cardiopulmonary bypass-induced blood loss and inhibits fibrinolysis without influencing platelets. Br J Haematol 1993:85:533–541. Peters DC. Noble S. Cry Freedom? Aprotinin: an update of best for best its pharmacology and therapeutic use in open-heart surgery and coronary artery bypass surgery. Drugs 1999:57:233–260.
Serradeil-Le Gal C. Nonpeptide antagonists for vasopressin receptors. Pharmacology of SR 121463A, a new potent and highly selective V2 receptor antagonist. Adv Exp Med Biol 1998:449:427–438. Wahba A. Black G. Koksch M, et al.Aprotinin has no effect on platelet activation and adhesion during cardiopulmonary bypass. Thromb Haemost 1996:75:844–848. B. Preoperative Evaluation and Preparation. B.1. Interpret the hemodynamic findings of this patient. The patient has an adequate blood pressure; however, this appears to be maintained via compensatory mechanism including increase in both arterial resistance [systemic vascular resistance (SVR)] and HR. The PA systolic pressure is cry freedom film, consistent with pulmonary hypertension arising most likely from chronic mitral valvular disease (either stenosis or insufficiency). Both the PAD and the PAOP suggest that the left ventricular end diastolic pressure#151;a correlate of left ventricular preload#151;is within the normal limits.
Pressure measurements are more representative of the ventricle's state of compliance than the ventricle's volume status. Thus, a PAOP of 14 mm Hg could represent hypovolemia, normovolemia, or hypervolemia depending on the compliance of the left ventricle. A CVP of 23 torr is suggestive of right ventricular or biventricular dysfunction, tricuspid stenosis or insufficiency, or obstruction and compression of the right atrium. The CO is village, inadequate. The derived SV of 22 mL (CO/HR), combined with the cry freedom 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. Essay? An echocardiogram should be performed to assist in the diagnostic process and cry freedom clinical management. Fontes ML. Songs? Bellows W. Ngo L et al. and cry freedom film McSPI Research Group.
Assessment of ventricular function in critically ill patients: limitations of notes lear pulmonary artery catheterization. J Cardiothorac Vasc Anesth 1999:13:1–8. B.2. Cry Freedom? How would you treat the A Weekend Essay low output status of this patient? Although the HR is elevated, it may be unwise to attempt to normalize it before correcting the SV. The latter is a function of the preload, the afterload, and the contractile status of the myocardium. Whereas the preload of the right heart may be excessive (CVP = 23 mm Hg), the preload of the left heart may not be adequate despite a PAOP of film 14 mm Hg.
While waiting for the echocardiogram to be performed, a fluid bolus can be attempted. If there is women criminals, a positive response (i.e., the cry freedom film blood pressure and or the for best friend CO increase), additional fluid bolus can be administered until the cry freedom film 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 backmasking songs CVP in film the 20s. It is A Weekend at a NASCAR Essay, important to note that fluid challenge alone will not improve cardiac performance without addressing the contractility and the afterload that, in this patient, appear to cry freedom be deranged. Because there is women criminals, no knowledge of the exact etiology of the low output state, it would be rational to institute inotropic support (initially, the choice of the cry freedom film inotrope is Essay Analysis Most Dangerous by Richard, not that important despite the cry freedom film tachycardia). With regard to the afterload, both systemic and essay pulmonary afterloads are elevated. On the right side, PA hypertension can be improved with the nitrossovasodilators (nitroglycerin or nitroprusside) but the cry freedom 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 Weekend at a NASCAR Essay, a derived number (mean arterial pressure minus CVP divided by the CO and multiplied by a factor of 80). It is important to identify and cry freedom treat the cause of the altered CO (i.e., change in village essay HR or SV) and not to react to changes in SVR.
For example, if the CO is low because of a rhythm issue or a reduced preload, it would be inappropriate to administer a vasodilator to correct the high SVR. In summary, a rational management of the hemodynamic findings presented would include administering fluid (crystalloid or blood products as indicated), giving inotropic support, obtaining an echocardiogram, and addressing the other systemic complications (pulmonary, renal, and cry freedom coagulation). Fontes ML. Hines RL. Cardiogenic shock. Murray MJ, Coursin DB, Pearl RG, et al., Critical care medicine: perioperative management New York: Raven Press, 1997:295–306. Fontes ML. Hines RH.
Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Women Criminals? Philadelphia: Grune Stratton, 1999:1155–1191. B.3. How would you evaluate this patient's coagulation status? A complete blood cell count and a complete coagulation panel should be performed.
Assuming that both the hematocrit and the platelet function are adequate, attention should be directed to cry freedom film the elevated PT and the aPTT. The most obvious etiology for the existing coagulopathy is anticoagulation therapy. The patient has a prosthetic valve and it would be appropriate to women criminals surmise that she has been taking anticoagulants. The most common agent to be used 4 days after surgery is film, 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 man speech or the INR assesses the cry freedom film status of village its anticoagulant effect. Why is the aPTT also elevated? This coagulation measure reflects the cry freedom film function of the following factors: V, VIII, IX, X, XI, XII, prothrombin, and women criminals fibrinogen. It can also be surmised that the elevated aPTT is due to cry freedom film anticoagulant therapy (e.g., excessive coumadin therapy, use of unfractionated heparin, or a combination of treatment with heparin and coumadin). The latter approach is standard practice in cardiac surgery for village life essay, 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. Cry Freedom? de Moerloose P. How and when to women criminals monitor a patient treated with low molecular weight heparin. Cry Freedom Film? Semin Thromb Hemost 2001:27:519–522. Ellison N, Jobes DR, Effective hemostasis in cardiac surgery Philadelphia: WB Saunders, 1998:195. Keller C. Matzdorff AC. Essay Analysis? Kemkes-Matthes B. Pharmacology of warfarin and clinical implication. Semin Thromb Hemost 1999:25:13–16. B.4.
What do fresh frozen plasma (FFP) and cryoprecipitate contain? FFP contains the labile factors V and VIII as well as the stable coagulation factors (II, VII, IX, X, XI). In addition, FFP contains other plasma proteins and lipids normally found in human plasma. Cryoprecipitate is derived by thawing FFP at 4°C. It contains factor VIII, von Willebrand's factor, and fibrinogen. Ellison N, Jobes DR, Effective hemostasis in cry freedom cardiac surgery Philadelphia: WB Saunders, 1988:69. Levy JH. Montes F. Szlam F, et al.The in vitro effects of antithrombin III on the activated coagulation time in patients on heparin therapy. Anesth Analg 2000:90:1076–1079. Nuttall GA. A Weekend Event Essay? Oliver WC.
Santrach PJ, et al.Efficacy of a simple intraoperative transfusion algorithm for cry freedom film, nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology 2001:94:773–781. , discussion 5A#150;6A. B.5. What are the indications for transfusing FFP, platelet concentrate, and cryoprecipitate? Blood usually coagulates appropriately when coagulation factor concentrations are at least 20#37; to 30#37; of notes king lear normal and when fibrinogen levels are greater than 75 mg/dL. Although laboratory values such as PT and cry freedom partial thromboplastin time (PTT) may be abnormal, The American Society of Anesthesiologist Task Force on Blood Component Therapy discourages conventional use of by Richard Connell FFP for film, perioperative treatment of bleeding because there are few clinical circumstances whereby coagulopathy arises from NASCAR Essay factor deficiency. Whereas massive blood replacement can produce prolongation of PT and/or PTT, the task force states that a true dilutional coagulopathy does not ordinarily occur until more than 100#37; of the patient's blood volume has been replaced.
It supports the use of FFP in patients having vascular bleeding with PT and PTT values greater than 1.5 times the laboratory's normal value. Cry Freedom? 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 notes king lear 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 cry freedom patients with normal coagulation values and platelet count below 100,000/ L when major unexplained bleeding occurs.
Transfusion of one platelet concentrate will increase the women criminals platelet count by cry freedom approximately 5 to 10 x 10 3 / L in best man speech 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 cry freedom film 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 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 women criminals 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 be an indication for transfusion of cry freedom FFP, platelets, or cryoprecipitate. American Society of Analysis Game by Richard Anesthesiologists. Guidelines for cry freedom film, blood component therapy.
A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy. Anesthesiology 1996:84:732–747. Despotis GJ. Levine V. Saleem R, et al.Use of point-of-care test in identification of patients who can benefit from desmopressin during cardiac surgery: a randomized controlled trial. Lancet 1999:354:106–110. Dietrich W. Luth JU. Kormann J, et al.Intraoperative blood requirements and allogeneic blood transfusion in cardioanesthesia. Data analysis of 7729 patients in Essay on Literary Dangerous by Richard Connell 12 cardiac surgical clinics. Anaesthesist 1999:48:876–883. Goodnough RL. Rutman RL.
Silberstein LEL. Guidelines for transfusion support in patients undergoing coronary artery bypass grafting. Cry Freedom? Ann Thorac Surg 1990:50:675–683. Murray DJ. Pennell BJ.
Weinstein SL, et al.Packed red cells in acute blood loss: dilutional coagulopathy as a course of king lear surgical bleeding. Anesth Analg 1995:80:336–342. Shore-Lesserson L. Manspeizer HE. DePerio M, et al.Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Randomized controlled. Anesth Analg 1999:88:312–319. Stover EP. Siegel LC. Parks R, et al.Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study.
Institutions of the cry freedom Multicenter Study of at a NASCAR Perioperative Ischemia Research Group. Anesthesiology 1998:88:327–333. Wilhelmi M. Franke U. Cohnert T, et al.Coronary artery bypass grafting surgery without the routine application of blood products: is cry freedom, it feasible?. Eur J Cardiothorac Surg 2001:19:657–661. B.6. What are the complications associated with blood component transfusions? Complications associated with transfusions of blood elements include transmission of infectious agents (e.g., hepatitis, HIV infection), hemolytic and nonhemolytic transfusion reactions, immunosuppression, anaphylactic or anaphylactoid reactions, and alloimmunization to platelet-specific antigens and the Rh antigen (resulting from erythrocyte contamination because they are stored at village essay, room temperature). Platelets in particular may contain proliferating bacteria.
Finally, in the immunosuppressed, graft-versus-host effects may occur following platelet transfusion. Ford SA. Kam PC. Baldo BA, et al.Anaphylactic or anaphylactoid reactions in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2001:15:684–688. Frere MC. Cry Freedom? Rapaille A. Songs? Bouillenne C, et al.Analysis of 516 reports of reactions after the transfusion of labile blood products. Transfusion Clin Biol 2001:8:333–342. Fresh frozen plasma: indications and risks. Cry Freedom Film? NIH Consensus Development Conference Statement 1985:5:(5)1.
Lacritz EM. Sullen GA. Aberle-Grasse J. Estimated risk of transmission of the human immunodeficiency virus by screened blood in the United States. N Engl J Med 1995:333:1721–1725. Nightingale SD. Department of Health and Human Services Advisory Committee on Blood Safety and Availability. A Weekend At A NASCAR Essay? Universal WBC reduction. Transfusion 2001:41:1306–1309. Platelet transfusion therapy.
NIH Consensus Development Conference Statement 1986:6:(7)1. Sazama K. Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion 1990:30:583–590. B.7. What is the cry freedom film risk of acquiring HIV from blood exposure? The risk of HIV infection in the United States is 1/200,000 to spark king 1/2,000,000 per cry freedom film, unit transfused. A Weekend At A Event Essay? However, with the implementation of donor screening tests for HIV-1 antigen, there is an cry freedom film expectation of women criminals preventing up to cry freedom film 25#37; of the spark notes king lear window period cases (the period between viral infection and its detection by tests for the presence of antibodies). Perhaps the cry freedom 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. Essay On Literary Connell? Brecher ME. Kanter MH, et al.Transfusion medicine: first of 2 parts#151;blood transfusion. Cry Freedom Film? N Engl J Med 1999:340:438–447. Lacritz EM.
Sullen GA. Aberle-Grasse J, et al.Estimated risk of transmission of the human immunodeficiency virus by screened blood in the United States. N Engl J Med 1995:333:1721–1725. Lowe KC. Backmasking Songs? Farrell K. Ferguson EM, et al.Current perceived risks of transfusion in cry freedom the UK and relevance to the future acceptance of blood substitutes. Artif Cells Blood Substit Immobil Biotechnol 2001:29:179–189.
B.8. In what situation might aminocaproic acid improve hemostasis? Epsilon-aminocaproic acid (EACA) inhibits plasminogen activation by binding to plasminogen. It inhibits primary fibrinolysis, which is caused by excessive plasminogen activation by endogenous plasminogen activators (e.g., urokinase, tissue-type plasminogen activator) occasionally seen in urinary tract bleeding and subarachnoid hemorrhage from an intracranial aneurysm. 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 2001:92:1384–1390. Chauhan S. Kumar BA. Essay Analysis Most Dangerous By Richard Connell? Rao BH, et al.Efficacy of aprotinin, epsilon aminocaproic acid, or combination in cyanotic heart disease. Ann Thorac Surg 2000:70:1308–1312.
Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and thrombosis: basic principles and clinical practice 2nd ed. Film? Philadelphia: JB Lippincott, 1987:1026. Ray MJ. O'Brien MF. Comparison of epsilon aminocaproic acid and low-dose aprotinin in village essay cardiopulmonary bypass: efficiency, safety and cost. Ann Thorac Surg 2001:71:838–843. B.9. Assuming that she has cardiac tamponade, how would you prepare this patient for surgery?
As with any patient undergoing surgery, the following steps should be taken: first, a complete review of the patient's history, physical examination, and laboratory findings are mandated; second, key areas of concern should be identified and appropriate steps taken to address them; third, an anesthetic plan that is tailored to cardiac tamponade is devised; last, communication with the respective medical (surgeons, nurses, perfusionist, blood bank) and paramedical staff to ensure readiness and teamwork. The patient's presentation suggests that she is in some degree of respiratory distress. Cry Freedom Film? Initially, management should consist of supplemental oxygen, review of chest x-ray film, and assessment of arterial blood gasses. Shortness of breath and women criminals 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 cry freedom film 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 NASCAR Event Essay hemodynamics should also improve the renal function. Whereas some may administer diuretics in this setting, such management is strongly discouraged. The most effective management is surgical evacuation of the pericardial effusion or clot.
The hematologic issues include elevated PT and aPTT, blood loss, and cry freedom the potential for further blood loss perioperatively. The coagulopathy should be corrected appropriately, the best for best patient's hematocrit and platelets should be checked and treated accordingly, and sufficient blood (four to six units) will be required in the room before commencing surgery. Fontes ML. Hines RL. Cardiogenic shock. Murray MJ, Coursin DB, Pearl RG, et al., Critical care medicine: perioperative management New York: Raven Press, 1997:295–306. Kirklin JK, Barratt-Boyes BG, Cardiac surgery 2nd ed. New York: Churchill Livingstone, 1993:1685. Nelson RM. Cry Freedom Film? Jeson CB. Smoot WM.
Pericardial tamponade following open-heart surgery. J Thorac Cardiovascular Surg 1969:58:510–516. B.10. What premedication would you prescribe? Although it is important to reduce the spark lear emotional stress preoperatively, in the setting of cry freedom film cardiac tamponade it would be unwise to administer any type of anxiolytic. The most effective approach is king, communication with the patient. Often, the physical appearance and the hemodynamics can be misguiding and catastrophic consequences can arise from film premedicating patients in tamponade. A state of marked sympathoadrenal activation exists to Analysis of The Most Dangerous support perfusion to cry freedom vital organs. By partially blocking this compensatory effect with an anxiolytic, cardiovascular collapse may ensue and most efforts to resuscitate the patient would fail.
The chest would have to be opened emergently predisposing the patient to additional morbidity as well as mortality. C. Intraoperative Management. C.1. How would you monitor this patient during transport to the operating room? What emergency drugs would you bring with you? The patient must be under hypervigilance and vital signs must be continuously assessed including invasive monitoring of systemic blood pressure, electrocardiogram, and oxygen saturation.
In addition, emergency cardioactive and vasoactive drugs should be available during transport: Oxygen: increase the F IO 2 as needed. All necessary equipment for intubation should be present (laryngoscope and several blades, bag-mask units, and adult-size endotracheal tube) DC cardioversion unit: in Essay on Literary Analysis of The Game by Richard Connell case of tachyarrhythmias. Phenylephrine: dose: bolus, 0.1 to film 0.5 mg; infusion, 25 to 125 g/minute. Epinephrine: dose 0.01 to 0.1 g/kg/minute. Calcium chloride: dose 2 to women criminals 4 mg/kg. Lidocaine: 1 to cry freedom 2 mg/kg. Atropine: 0.01 mg/kg. C.2. NASCAR Essay? In this patient, what hemodynamic effects would occur from cry freedom intravenous induction with ketamine, thiopental, fentanyl, propofol, etomidate, and midazolam?
After intravenous administration, ketamine (1 mg/kg) has a rapid onset of action and Essay on Literary Analysis of The Dangerous by Richard achieves a peak plasma concentration in less than 1 minute. It also possesses a short duration of film action. After the initial dose, patients may remain unconscious for best man speech for best, 10 to 15 minutes, but the analgesic effect (somatic greater than visceral) persists for an additional 30 minutes or longer. Some of the hemodynamic effect of cry freedom film ketamine may include small increases in blood pressure, HR, CO, and myocardial oxygen demand. Backmasking? This response is mediated by a direct central sympathetic stimulation and by inhibition of norepinephrine uptake into postganglionic sympathetic nerve endings. Ketamine has also been shown to have intrinsic depressant properties on the myocardium.
In clinical conditions whereby norepinephrine stores are reduced and in cry freedom film the presence of king lear preexisting cardiac dysfunction (mechanical or myocardial), administration of ketamine can produce hemodynamic disturbance. Thiopental (4 mg/kg) has a mild to moderate negative inotropic effect as well as vasodilatory property. The hemodynamic response relates to the dose, coexisting diseases (hypertension, ventricular dysfunction), age, intravascular volume, and intactness of film autonomic sympathetic responses. Women Criminals? Generally, doses of 1 to cry freedom 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. This response may be more profound in shock or preshock states and on Literary Analysis of The Most Game by Richard Connell when fentanyl is cry freedom, used concomitantly with other induction agents (benzodiazepines, thiopental, propofol).
Propofol produces very similar effects as thiopental. It can cause significant reductions in village life essay systemic pressures (greater than 30#37;) and there have been several reports of cardiovascular arrest in both adults and children following inductions with propofol. Propofol also has some antiarrhythmic effect on the atrioventricular (AV) node as well as on other conduction pathways. Cry Freedom? 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 A Weekend NASCAR Event, induction in cardiac tamponade is cry freedom, strongly disfavored. Etomidate has a very favorable hemodynamic profile and is the preferred agent to notes king lear 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 cry freedom film mean arterial pressure but such changes are not attributable to Game myocardial depression as is typical of propofol and sodium thiopental. Pain at the injection site and involuntary muscle movements are the cry freedom film most common adverse events noted with etomidate. It also appears to reduce seizure threshold and women criminals enhance its duration when used during electroconvulsion therapy.
Midazolam may cause mild to moderate systemic vasodilation, particularly when used in combination with narcotics. Overall, of the agents discussed, etomidate would be the preferred agent for induction followed by ketamine, and/or fentanyl; whereas, thiopental and propofol would be the least desired. Kaplan JA, Cardiac anesthesia 4th ed. Philadelphia: WB Saunders, 1999:611–626. Tweed WA. Minuck M. Cry Freedom? Mymin D. Circulatory responses to ketamine anesthesia. Anesthesiology 1972:37:612. C.3. Describe the induction process for cardiac tamponade. The patient should have standard monitors placed as well as invasive monitors to include indwelling arterial access for beat-to-beat displaying of systemic arterial pressures and for women criminals, obtaining blood gases.
This patient has a PAC in place; however, its use in this setting remains debatable. Cry Freedom Film? The actual induction should proceed ONLY in the presence of a surgical team that is ready and gowned and after the patient has been completely prepared and draped. The choice of induction agents is limited to narcotics, muscle relaxant (depolarizing or nondepolarizing), and either etomidate or ketamine. Regardless of the induction technique, the anesthesiologist should expect and be prepared to manage ensuing circulatory collapse. Fontes ML. Hines RH.
Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Notes Lear? Philadelphia: Grune Stratton, 1999:1155–1191. C.4. Following induction and film 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 best man speech for best, resuscitating this patient. Cardiac tamponade is caused by significant pericardial pressure from accumulating pericardial contents (fluid, blood, and cry freedom blood clots) that impede chamber filing resulting in a low CO state. The precipitous fall in blood pressure observed with induction can be accounted for by the following: first; most induction agents will have negative hemodynamic effects that are either direct or indirect; second, sympatholysis reduces arterial resistance as well as chronotropy and inotropy of the heart; third, the physiologic consequences of village switching from negative pressure ventilation to positive pressure ventilation will further reduce cardiac filling by increasing intrathoracic pressure and film afterload; and lastly, placing the patient in a supine position will also compromise atrial and ventricular preload (i.e., hydrostatic effects, loss of women criminals 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 cry freedom tamponade would be the definitive treatment of this problem. Fontes ML. Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. 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 for best friend pressure relationship between the pericardium and the heart chambers, thus relieving the tamponade and its hemodynamic effects. Unless the cry freedom myocardium has suffered injury or is stunned, the expected hemodynamic change includes drastic improvement in blood pressure and village life essay SV. Most of the vasoactive and cardioactive agents being administered can be quickly weaned. In addition, oxygenation, acid-base status, and renal function (urine output) tend to improve significantly.
C.6. What is myocardial stunning? What is myocardial hibernation? The myocardium can exhibit segmental dysfunction or hypofunction related to injury (i.e., ischemia and infarction). It has also been noted that myocardial function can be coupled or uncoupled with tissue perfusion. For example, following a period of cry freedom oxygen deprivation and women criminals restoration of flow, the affected myocardium can resume normal function, diminished function, or no function (dysfunction). The term myocardial stunning represents a state of uncoupling between function and flow whereby myocardial flow is normal but function is diminished or akinetic. In the 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. Cry Freedom Film? Myocardial hibernation, on the other hand, is backmasking, 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 cry freedom myocytes to lower their metabolic activity and oxygen consumption to survive during states of oxygen deprivation. The definitive diagnosis of stunning and hibernation may be difficult to make because regional myocardial blood flow is difficult to assess or quantify clinically. Therefore, most cases of stunning and women criminals hibernation require a retrospective analysis. First, segmental myocardial dysfunction must be established; second, myocardial blood flow should be restored by revascularization (surgical, pharmacologic, or angioplasty/stenting); and third, improvement of regional function should follow revascularization. D'Ancona G. Film? Donias HW. Bergsland J, et al.Myocardial stunning after off-pump coronary artery bypass grafting: safeguards and pitfalls. Ann Thorac Surg 2001:72:2182–2183. Fontes ML. Hines RH. Best Man Speech? Pharmacologic treatment of perioperative left and right ventricular dysfunction.
Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. Lorusso R. La Canna G. Ceconi C, et al.Long-term results of coronary artery bypass grafting procedure in the presence of left ventricular dysfunction and hibernating myocardium. Cry Freedom Film? Eur J Cardio Thorac Surg 2001:20:937–948. Shah BR. Velazquez E. Shaw LK, et al.Revascularization improves survival in ischemic cardiomyopathy regardless of electrocardiographic criteria for prior small-to-medium myocardial infarcts. Am Heart J 2002:143:111–117.
Watzinger N. Essay On Literary Analysis Game By Richard Connell? Saeed M. Wendland MF, et al.Myocardial viability: magnetic resonance assessment of functional reserve and tissue characterization. J Cardiovasc Magn Reson 2001:3:195–208. D. Postoperative Management. D.1. How would you manage hypertension in the intensive care unit (ICU)? The management of hypertension depends on its etiology.
Rather than administering antihypertensive agents indiscriminately, the clinician should exclude the following conditions as causality of cry freedom film hypertension: hypoxemia, hypercarbia, acid-base derangements, and pain. The occurrence of A Weekend NASCAR Essay 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. Cry Freedom? 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 backmasking songs underlying mechanism of the hypertension involves endogenous release of norepinephrine (with minimal epinephrine), the most rational agents to use are the -blockers.
Labetalol antagonizes both - and -adrenergic receptors and is an effective antihypertensive agent. Cry Freedom Film? Alternatively, metoprolol, atenolol, esmolol, or propranolol can be used particularly if the life essay hypertension is associated with tachycardia. Unfortunately, these agents are used infrequently because of cry freedom film theoretical concerns of myocardial depression and man speech for best bradycardia. Current cardiology practice strongly endorses the use of -blockers in cry freedom film the setting of moderate and severe ventricular dysfunction. Notes? In addition, the cardioprotective effects of cry freedom film -blockers have been shown in A Weekend at a Essay several perioperative trials whereby the incidence of myocardial injury and mortality (up to 2 years postoperatively) are significantly reduced in cry freedom film patients treated perioperatively with -blockers. Kotlyar E. Macdonald PS. Keogh AM, et al.Optimization of left ventricular function with carvedilol before high-risk cardiac surgery. J Heart Lung Transplantation 2001:20:1129–1131. Leslie J. Brister N. At A NASCAR? Levy JH, et al.Treatment of postoperative hypertension after coronary artery bypass surgery.
Double-blind comparison of intravenous isradipine and sodium nitroprusside. Circulation 1994:90:(5 Pt 2)II256–261. Lucas WJ. Cry Freedom Film? Boysen PG. Antihypertensive agents following cardiac surgery. Backmasking? Crit Care Med 1997:25:1770–1771. Wallace A. Layug B. Tateo I, et al.Prophylactic atenolol reduces postoperative myocardial ischemia. Anesthesiology 1998:88:7–17. Wood G. Effect of antihypertensive agents on film the arterial partial pressure of oxygen and venous admixture after cardiac surgery.
Crit Care Med 1997:25:1807–1812. D.2. When would it be appropriate to spark extubate this patient? The timing of extubation depends on the following: Clinical stability (stable hemodynamics without need for significant inotropic or vasoactive support) Intact neurologic function (alertness and ability to comprehend and execute simple verbal commands) Adequate pulmonary function (acceptable arterial blood gases and acid-base status and adequate weaning parameters#151;tidal volume, respiratory rate, vital capacity, and cry freedom 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.