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Figure 8 depicts the holistic approach to assessing intra- This figure was published in “Anesthesia for Thoracic Sur- operative blood loss cheap nootropil 800mg online. Peripheral venous access Peripheral venous access is the quickest buy generic nootropil 800mg on line, simplest and For example generic nootropil 800 mg amex, a 16 gauge cannula will allow greater safest method of obtaining vascular access discount nootropil 800mg visa. The lower will allow greater flow than an equivalent caliber cen- limb can be used if necessary, the most successful site tral line, which is, by necessity, significantly longer. Avoid veins that are tortuous as well as ones with ob- Pressure drop is achieved by using rapid infusers that vious valves. In these cases, threading the cannula apply a squeeze to the fluid, usually with an air-filled will be difficult. Your thumb and third finger continue to ing too tightly on the skin, lest you flatten the vein stabilize the needle in place (stationary). The inter- inorganic or organic salts and distribute to varying ex- nal jugular vein is the most common site used intra- tents throughout the body water. The subclavian site is associated with an stituent of crystalloid solutions, distributes throughout increased risk of pneumothorax, while the femoral site the entire extracellular space. Glucose distributes is associated with an increased risk of infection, embo- throughout the entire body water (extracellular and in- lism and thrombosis. These particles cannot diffuse across There are many potential complications of central ve- capillary membranes and so remain trapped within the nous cannulation. Examples of colloids are albumin orrhage, pneumothorax, thoracic duct injury, neural in- (5%, 25%), hydroxyethyl starches (Pentaspan ®, Volu- jury, air embolism, infection, thrombosis, hydrothorax, ven ® , red cell concentrates, platelets, and plasma. The partitioning throughout the body’s compartments The use of ultrasound guidance for central line inser- of some of the various types of fluids for administra- tion allows more accurate needle placement and avoid- tion is summarized in Table 4 and illustrated in the ani- ance of complications. Normal saline or Ringer’s lactate are the preferred crys- talloids for intra-operative fluid administration and re- suscitation, as they provide more intravascular volume 24 tus or hepatic disease), and should be based on known Interactive 1. Finally, the half-life of crystalloid agement redistribution is only 15-30 minutes, so it must be given at a rate that accounts for its extravasation from the in- travascular space. These patients should be transfused to relatively blood volume needs to be replaced or when the conse- higher Hb levels (80-100 g/L). General indi- Transfusion of plasma, platelets or cryoprecipitate is in- cations for the transfusion of blood products are out- dicated only for the correction of defective clotting and lined in Table 5. Impaired clot- A patient with Class 3 or 4 hemorrhagic shock (Table 3) ting may be observed or anticipated in a given clinical should be transfused immediately. Prolonged clot- Healthy patients can tolerate Hb levels that are ap- ting times or thrombocytopenia alone, without clinical proximately ½ of normal (60-70 g/L). Compensations evidence of bleeding, are insufficient indications for may be inadequate in patients with pulmonary, cardiac transfusion. Compensation may be Risks and benefits of transfusion should be explained harmful in patients with certain types of heart disease to patients undergoing procedures likely to result in sig- such as severe coronary artery disease or aortic steno- 26 nificant blood loss. Table 5 Indications for blood product administration Complications of transfusion are numerous and are gen- erally categorized by acuity: early and late. The most common cause of transfusion reaction is clerical error, underscoring the need for careful adherence to fresh frozen plasma clotting factor deficits safety procedures by all members of the healthcare team. A more complete discussion of the indications and complications of the various blood products is be- yond the scope of this manual. Many excellent reviews cryoprecipitate fibrinogen on the subject can be found in the current anesthesia lit- erature. As well, you will be introduced to the equipment required for the safe delivery of anesthesia: the anesthetic machine and monitors. Premedication • To review the medical and psychological status of The patient’s and their relative’s previous anes- the patient. Re- factors where possible, and to delay surgery if neces- cording baseline vital signs is important, as is de- sary. If the patient’s medical condition cannot tecting any unstable, potentially reversible condi- be altered, then one can take other measures to tions such as congestive heart failure or broncho- attempt to reduce risk: substitute a lower-risk spasm. Studies are rarely ordered to establish a “base- On history, the anesthesiologist attempts to elicit line” but rather to detect abnormalities that re- symptoms of cardiac or respiratory disease as quire correction prior to surgery.

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The various tissues of the body are classified in to four principal parts according to their function & structure 800mg nootropil fast delivery. They are subdivided in to: - Covering & lining epithelium - Glandular epithelium Covering and lining epithelium: it forms the outer covering of external body surface and outer covering of some internal organs discount nootropil 800mg line. It lines body cavity discount 800mg nootropil with visa, interior of respiratory & gastro intestinal tracts 800mg nootropil, blood vessels & ducts and make up along with the nervous tissue (the parts of sense organs for smell, 28 Human Anatomy and Physiology hearing, vision and touch). According to the arrangement of layers covering and lining epithelium is grouped in to: a) Simple epithelium: it is specialized for absorption, and filtration with minimal wear & tear. It is a single layered b) Stratified epithelium, it is many layered and found in an area with high degree of wear & tear. Based on the cell shape covering and lining epithelium is grouped in to: a) Squamous: - flattened & scale like b) Cuboidal: - cube shaped c) Columnar: - tall & cylindrical d) Transitional: - combination of cell shape found where there is a great degree of distention or expansion, these may be cuboidal to columnar, cuboidal to polyhydral and cuboidal to Squamous 29 Human Anatomy and Physiology Therefore considering the number of layers and cell shape we can classify covering and lining epithelium in to the following groups: Simple epithelium a) Simple – Squamous epithelium, contain single layer of flat, scale like resemble tiled floor. Stratified epithelium It is more durable, protects underlying tissues form external environment and from wear & tear. These are Non-Keratnized and Keratinized stratified squamous 30 Human Anatomy and Physiology epithelium. Non-Keratnized stratified squamous epithelium is found in wet surface that are subjected to considerable wear and tear. In Keratinized, stratified squamous epithelium the surface cell of this type forms a tough layer of material containing keratin. It is found in seat glands duct, conjunctiva of eye, and cavernous urethra of the male urogenital system, pharynx & epiglottis. Transitional epithelium The distinction is that cells of the outer layer in transitional epithelium tend to be large and rounded rather than flat. Exocrine: Those glands that empties their secretion in to ducts/tubes that empty at the surface of covering. Classification of exocrine glands They are classified by their structure and shape of the secretary portion. According to structural classification they are grouped into: 32 Human Anatomy and Physiology a) Unicellular gland: Single celled. By combining the shape of the secretary portion with the degree of branching of the duct of exocrine glands are classified in to - Unicellular - Multi-cellular Simple tubular Branched tubular Coiled tubular Acinar Branched Acinar 33 Human Anatomy and Physiology - Compound Tubular Acinar Tubulo-acinar 3. Embryonic connective tissue Embrayonic connective tissue contains mesenchyme & mucous connective tissue. Mucous (Wharton’s Jelly) connective tissue is found primarily in the fetus and located in the umbilical cord of the fetus where it supports the cord. Adult connective tissue composes connective tissue proper, cartilage, osseous (bone) & vascular (blood) tissue 34 Human Anatomy and Physiology a) Connective tissue proper, connective tissue proper has a more or less fluid intercellular martial and fibroblast. The various forms of connective tissue proper are: • Loose (areolar) connectives tissue, which are widely distributed and consists collagenic, elastic & reticular fibers and several cells embedded in semi fluid intercellular substances. It is common around the kidney, at the base and on the surface of the heart, in the marrow of long bone, as a padding around joints and behind the eye ball. It is poor conductor of heat, so it decrease heat loss from the body • Dense (Collagenous) connective tissue: Fibers are closely packed than in loose connective tissue. In areas where fibers are interwoven with out regular orientation the forces exerted are in many directions. In other areas dense connective tissue adapted tension in one direction and fibers have parallel arrangement. It helps to form a delicate supporting storma for many organs including liver, spleen and lymph nodes. It consists of a dense network of collagenous fibers and elastic fibers firmly embedded in chondriotin sulfate. The surface of a cartilage is surrounded by irregularly arranged dense connective tissue called perichondrium. Found at joints over long bones as articlar cartilage and forms costal cartilage (at ventral end of ribs). It forms embryonic skeleton, reinforce respiration, aids in free movement of joints and assists rib cage to move during breathing. Elastic cartilage: in elastic cartilage the chondrocyte are located in thread like network of elastic fibers.

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It is made of simple squamous epithelium called endothelium nootropil 800 mg with mastercard, which is continuous with the endothelial lining of the blood vessels (see Figure 19 order nootropil 800 mg with mastercard. Once regarded as a simple lining layer buy nootropil 800 mg visa, recent evidence indicates that the endothelium of the endocardium and the coronary 832 Chapter 19 | The Cardiovascular System: The Heart capillaries may play active roles in regulating the contraction of the muscle within the myocardium nootropil 800mg low price. The endothelium may also regulate the growth patterns of the cardiac muscle cells throughout life, and the endothelins it secretes create an environment in the surrounding tissue fluids that regulates ionic concentrations and states of contractility. Endothelins are potent vasoconstrictors and, in a normal individual, establish a homeostatic balance with other vasoconstrictors and vasodilators. Internal Structure of the Heart Recall that the heart’s contraction cycle follows a dual pattern of circulation—the pulmonary and systemic circuits—because of the pairs of chambers that pump blood into the circulation. In order to develop a more precise understanding of cardiac function, it is first necessary to explore the internal anatomical structures in more detail. Septa of the Heart The word septum is derived from the Latin for “something that encloses;” in this case, a septum (plural = septa) refers to a wall or partition that divides the heart into chambers. Normally in an adult heart, the interatrial septum bears an oval-shaped depression known as the fossa ovalis, a remnant of an opening in the fetal heart known as the foramen ovale. The foramen ovale allowed blood in the fetal heart to pass directly from the right atrium to the left atrium, allowing some blood to bypass the pulmonary circuit. Within seconds after birth, a flap of tissue known as the septum primum that previously acted as a valve closes the foramen ovale and establishes the typical cardiac circulation pattern. Unlike the interatrial septum, the interventricular septum is normally intact after its formation during fetal development. It is substantially thicker than the interatrial septum, since the ventricles generate far greater pressure when they contract. It is marked by the presence of four openings that allow blood to move from the atria into the ventricles and from the ventricles into the pulmonary trunk and aorta. Located in each of these openings between the atria and ventricles is a valve, a specialized structure that ensures one-way flow of blood. The valves at the openings that lead to the pulmonary trunk and aorta are known generically as semilunar valves. In this figure, the atrioventricular septum has been removed to better show the bicupid and tricuspid valves; the interatrial septum is not visible, since its location is covered by the aorta and pulmonary trunk. Since these openings and valves structurally weaken the atrioventricular septum, the remaining tissue is heavily reinforced with dense connective tissue called the cardiac skeleton, or skeleton of the heart. It includes four rings that surround the openings between the atria and ventricles, and the openings to the pulmonary trunk and aorta, and serve as the point of attachment for the heart valves. The presence of the pulmonary trunk and aorta covers the interatrial septum, and the atrioventricular septum is cut away to show the atrioventricular valves. As much as 20–25 percent of the general population may have a patent foramen ovale, but fortunately, most have the benign, asymptomatic version. Patent foramen ovale is normally detected by auscultation of a heart murmur (an abnormal heart sound) and confirmed by imaging with an echocardiogram. Despite its prevalence in the general population, the causes of patent ovale are unknown, and there are no known risk factors. In nonlife-threatening cases, it is better to monitor the condition than to risk heart surgery to repair and seal the opening. Coarctation of the aorta is a congenital abnormal narrowing of the aorta that is normally located at the insertion of the ligamentum arteriosum, the remnant of the fetal shunt called the ductus arteriosus. If severe, this condition drastically restricts blood flow through the primary systemic artery, which is life threatening. Detectable symptoms in an infant include difficulty breathing, poor appetite, trouble feeding, or failure to thrive. In older individuals, symptoms include dizziness, fainting, shortness of breath, chest pain, fatigue, headache, and nosebleeds. Treatment involves surgery to resect (remove) the affected region or angioplasty to open the abnormally narrow passageway. Failure of the ductus arteriosus to close results in blood flowing from the higher pressure aorta into the lower pressure pulmonary trunk. This additional fluid moving toward the lungs increases pulmonary pressure and makes respiration difficult. Symptoms include shortness of breath (dyspnea), tachycardia, enlarged heart, a widened pulse pressure, and poor weight gain in infants.

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