it involves the general principles of poisoning treatment and various basic principles of management of poisoning IT IS USEFULL FOR THE IV.PHARM D STUDENTS AND MEDICAL STUDENTS
Role of Pharmacognosy in various systems of medicineRamaiah Maddi
Role of Pharmacognosy in Allopathy (Modern medicine)
Role of Pharmacognosy in Ayurveda
Role of Pharmacognosy in Unani System of Medicine
Role of Pharmacognosy in Siddha System of Medicine
Role of Pharmacognosy in Homeopathy
Role of Pharmacognosy in Chinese Medicine System
In this ppt the viewers will understand the pharmacognosy of HONEY drug which obtained from honey comb. Honey is having lot of saccharides in it and it is having various medicinal uses.
Portion covered:
1. Synonyms of Honey
2. Biological Sources of Honey
3. Geographical Sources of Honey
4. Collection of Honey
5. Chemical Constituents of Honey
6. Chemical Tests of Honey
7. Uses of Honey
Atropine is a core medicine in the World Health Organization's (WHO) "Essential Drugs List", which is a list of minimum medical needs for a basic health care system.
Role of Pharmacognosy in various systems of medicineRamaiah Maddi
Role of Pharmacognosy in Allopathy (Modern medicine)
Role of Pharmacognosy in Ayurveda
Role of Pharmacognosy in Unani System of Medicine
Role of Pharmacognosy in Siddha System of Medicine
Role of Pharmacognosy in Homeopathy
Role of Pharmacognosy in Chinese Medicine System
In this ppt the viewers will understand the pharmacognosy of HONEY drug which obtained from honey comb. Honey is having lot of saccharides in it and it is having various medicinal uses.
Portion covered:
1. Synonyms of Honey
2. Biological Sources of Honey
3. Geographical Sources of Honey
4. Collection of Honey
5. Chemical Constituents of Honey
6. Chemical Tests of Honey
7. Uses of Honey
Atropine is a core medicine in the World Health Organization's (WHO) "Essential Drugs List", which is a list of minimum medical needs for a basic health care system.
Med chem lecture on Anticholinergic drugs for B.Pharm level in Nepal
Content from Foye's Principle of medicinal chemistry, my own thoughts and some articles
In this presentation Pharmacology III Unit V covered
Following points are included;
Various Definitions:
Acute toxicity
Subacute toxicity
Chronic toxicity
Genotoxicity,
Carcinogenicity,
Teratogenicity
Mutagenicity
General principles of treatment of poisoning
Clinical symptoms and management of various poisoning conditions.
like Barbiturate poisoning, Morphinpoisoning, Organophosphoruspoisoning, Lead poisoning, mercury poisoning, Arsenin poisoning, And its specific antidote
Water Content of Drug?
Impact Of Water Content Of Drug.
Methods Of Determining Water Content Of Drug.
Formula for Water Content Determination.
Calculation With Lab Practical Demo.
Loss On Drying of Drug?
Impact Of LOD Of Drug.
Formula of LOD Determination.
Calculation With Lab Practical Demo.
Basic Difference.
The aim of this lecture is to provide
an overview of the management of various toxic exposures.
emergency medical services that should be immediately contact to provide advanced life support for patient with unstable vital signs resulting from a poisoning exposure.
Medicinal plants have been identified and used throughout human history. Plants make many chemical compounds that are for biological functions, including defence against insects, fungi and herbivorous mammals. At least 12,000 such compounds have been isolated so far; a number estimated to be less than 10% of the total.Chemical compounds in plants mediate their effect on the human body through processes identical to those already well understood for the chemical compounds in conventional drugs; thus herbal medicines do not differ greatly from conventional drugs in terms of how they work. it is important to know various factors that affects medicinal plant cultivation.
Parasympatholytics are the drugs that block or inhibit the actions of acetylcholine at postganglionic nerve endings and cholinergic receptors. They are also referred to as anticholinergics or cholinergic blocking agents or antispasmodics.
Anticholinergic drugs include atropine and related drugs- atropine is the prototype. Atropine is obtained from the plant Atropa belladonna. Atropine and scopolamine (hyoscine) are the belladonna alkaloids. They compete with acetylcholine for muscarinic receptors and block this receptors-they are muscarinic antagonists.
Med chem lecture on Anticholinergic drugs for B.Pharm level in Nepal
Content from Foye's Principle of medicinal chemistry, my own thoughts and some articles
In this presentation Pharmacology III Unit V covered
Following points are included;
Various Definitions:
Acute toxicity
Subacute toxicity
Chronic toxicity
Genotoxicity,
Carcinogenicity,
Teratogenicity
Mutagenicity
General principles of treatment of poisoning
Clinical symptoms and management of various poisoning conditions.
like Barbiturate poisoning, Morphinpoisoning, Organophosphoruspoisoning, Lead poisoning, mercury poisoning, Arsenin poisoning, And its specific antidote
Water Content of Drug?
Impact Of Water Content Of Drug.
Methods Of Determining Water Content Of Drug.
Formula for Water Content Determination.
Calculation With Lab Practical Demo.
Loss On Drying of Drug?
Impact Of LOD Of Drug.
Formula of LOD Determination.
Calculation With Lab Practical Demo.
Basic Difference.
The aim of this lecture is to provide
an overview of the management of various toxic exposures.
emergency medical services that should be immediately contact to provide advanced life support for patient with unstable vital signs resulting from a poisoning exposure.
Medicinal plants have been identified and used throughout human history. Plants make many chemical compounds that are for biological functions, including defence against insects, fungi and herbivorous mammals. At least 12,000 such compounds have been isolated so far; a number estimated to be less than 10% of the total.Chemical compounds in plants mediate their effect on the human body through processes identical to those already well understood for the chemical compounds in conventional drugs; thus herbal medicines do not differ greatly from conventional drugs in terms of how they work. it is important to know various factors that affects medicinal plant cultivation.
Parasympatholytics are the drugs that block or inhibit the actions of acetylcholine at postganglionic nerve endings and cholinergic receptors. They are also referred to as anticholinergics or cholinergic blocking agents or antispasmodics.
Anticholinergic drugs include atropine and related drugs- atropine is the prototype. Atropine is obtained from the plant Atropa belladonna. Atropine and scopolamine (hyoscine) are the belladonna alkaloids. They compete with acetylcholine for muscarinic receptors and block this receptors-they are muscarinic antagonists.
Chap 1 General principles involved in the management of poisoningChanukya Vanam . Dr
1. General principles involved in the management of poisoning
2. Antidotes and the clinical applications.
3. Supportive care in clinical Toxicology.
4. Gut Decontamination.
5. Elimination Enhancement.
6. Toxicokinetics.
Complications of anesthesia
This topic aim to provide information on some common clinical condition that occur to the patients after anesthetized required procedure
INTRAOPERATIVE BRONCHOSPASM by Dr M.Karthik EmmanuelMKARTHIKEMMANUEL
Funny way to learn
Easy way to understand
Pictorial representation to learn quick
Smart way of creating complicated things into normal and simple and crazy way to learn
Tissues definition and classification, function & location of of epithelium tissues, connective tissues, muscular tissues, nervous tissue etc.. it is usefull for the diploma in pharmacy students , bachelor of pharmacy students and doctor of pharmacy students
general principles of poisoning ang introduction to clinical toxicology it is useful for the doctor of pharmacy students and pharmacology students master of pharmacy students and bachelor of pharmacy students
structure and functions of heart and different stages of cardiac cycle, Electrocardiograph and its significance it is useful for the diploma in pharmacy students and bachelor off pharmacy and Doctor of Pharmacy Students an also Basic physiology students
IT IS USEFUL FOR THE STUDENTS OF DIPLAMO IN PHARMCY AND BACHELOR OF PHARMACY SRUDENTS IT IS ALSO USEFULL FOR THE SECOND YEAR DOCTOR OF PHARMCSY STUDENTS
IT SI USEFULL FOR THE STUDENTS OF DIPLOMA IN PHARMCY AND BACHELOR OF PHARMACY AND DOCTOR OF PHARMACY STUDENTS
IT IS VERY USEFULL FORTHE II.B.PHARM SECOND SEMESTER STRUDENTSSOURCE OF CRUDE DRUGS
IT IS USEFULL FOR THE PHARMCY STUDENTS FOR BACHELOR OF PHARMCY AND DOCTOR OF PHARMCY STUDENTS FOR B.PHARM SECOND YEAR STUDENTS AND SECOND YEAR DOCTOR OF PHARMACY STUDENTS
it is usefull for the students of diploma in pharmacy, II.B.PHARM FIRST SEMESTER AND DOCTOR OF PHARMACY SECOND YEAR STUDENTS AND ALSO BASIC KNOWLEDGE FOR IDENTIFICATION OF CRUDE DRUGS
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
1. GENERAL PRINCIPLES INVOLVED
IN THE MANAGEMENT OF
POISONING
SURESH BABU EMAND M.PHARM
DEPARTMENT OF PHARMACOGNOSY
VIKAS INSTITUTE OF PHARMACEUTICAL SCIENCES
NEAR AIR PORT, RAJAHMUNDRY
3. WHAT IS POISON
• Refers to any substance
• injected into living body by any means (oral, i.v, inhalation/ dermal)
• causes local/systemic effects (or even both)
• results in ill-effects/ death of the individual
4. WHAT IS CLINICALTOXICOLOGY
IT IS Branch of science, that deals with PATLET of poison/poisoning
PATLET -Means :
i. P: Properties of poison
ii. A: Action of poison
iii.T: Toxicity of poison (poisoning features)
iv. L: Lethal dose
v. E: Estimation (How to confirm a particular poisoning)
vi. T: Treatment of the poisoning.
5. GENERAL PRINCIPLES OF POISONING MANAGEMENT
Includes the following major headings:
i. STABILIZATION & EVALUATION
ii. GUT DECONTAMINATION
iii. POISON ELIMINATION
iv. ANTIDOTE ADMINISTRATION
v. NURSING CARE
vi. PSYCHIATRIC CARE. STABILIZATION & EVALUATION
6. • Refers to assessment & correction of life-threatening problems associated
with the poisoning Always pay attention to ABCD of RESUSCITATION:
• A: Airway
• B: Breathing
• C: Circulation
• D: Depression of CNS.
7. A.AIRWAY
• Causes of death from airway block:
i. Airway obstruction
ii. Pulmonary aspiration of gastric contents
iii. Respiratory arrest.
8. Treatment involves:
Optimize airway position to force the flaccid tongue out.
Maximize airway opening (clear/suction airway)
Perform endotracheal intubation (nasotracheal/ orotracheal)
iv. https://www.youtube.com/watch?v=qzIyTCx1Mfw (watch for nasotracheal
intubation)
v. https://www.youtube.com/watch?v=-5UVpGjXZcI (watch for orotracheal
intubation) ENDOTRACHEAL INTUBATION TECHNIQUES
9. B.BREATHING
Breathing difficulties
contribute to morbidity & mortality in patients with poisoning
• Issues related to breathing include ventilatory failure, hypoxia &
bronchospasm.
VENTILATORY FAILURE:
Causes of VENTILATORY FAILURE:
Paralysis of ventilatory muscles
10. D.Depression of central respiratory drive
(CNS Depression)
Botulinum toxin Antihistamines NMBs Barbiturates Nicotine Clonidine
Organophosphates & carbamates Ethanol
Snakebite
Opioids Tetrodotoxin (found in puffer fish)
Phenothiazine antipsychotics
Sedative-hypnotics TCAs
How to treat ventilatory poisoning
• Endotracheal intubation
11. HYPOXIA
• Hypoxia is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the
tissue level.
Causes of HYPOXIA:
• Inert gases Cardiogenic pulmonary edema
• Cellular hypoxia Pneumonia/ non- cardiogenic pulmonary edema
• CO2 Beta-blockers CO Aspiration of gastric contents Methane Quinidine CN Aspiration of hydrocarbons
• Nitrogen TCAs
• Cocaine
• Verapamil
• Opioids
• Procainamide
• Sedative-hypnotics
• Smoke inhalation
12. BRONCHOSPASM
• Defined as a condition in which the lung muscles tighten restricts airflow
makes breathing difficult!
• Causes of BRONCHOSPASM:
• Beta-receptor antagonists Organophosphate poisoning
• Chlorine gas
• Dust particles
• Drugs that cause allergic reactions
• Smoke inhalation Hydrocarbon aspiration
13. How to treat Bronchospasm
Administer supplemental oxygen
Endotracheal intubation (if serious)
Discontinue the offending drug or agent causing bronchospasm
Remove patient from source of exposure to irritant gas/ dust particulate
Give beta-2 agonist: - Beta-2-agonist
Relaxes bronchial pathways
causes bronchodilation - Salbutamol (5-15 mg, over 1-hour nebulization)
For excessive cholinergic stimulation: - Give anticholinergic (ipratropium
bromide, 0.5 mg, every 4-6 hrs
14. Cholinergic overstimulation
• Increases secretion in respiratory pathways
causes bronchospasm - Anticholinergic
Reverses cholinergic effect (hypersecretion in airways)
Reduces bronchospasm.
For hyperreactive airways give inhaled/ oral steroids (anti-inflammatory effect)
For bronchospasm due to organophosphate/carbamate/other pesticide poisoning:
i. Give atropine i.v (anticholinergic)
ii. Ipratropium bromide (anticholinergic).
15. Stabilizations
• The initial survey should always be directed at the assessment and correction
of life-threatening problems, if present. Attention must be paid to the
airway, breathing, circulation, and depression of the CNS (the ABCD of
resuscitation).
16. Evaluation
• If the patient is not in crisis, i.e. he is alert with normal speech and pulse,
proceed to a complete, thorough, and systematic examination. As far as
treatment is concerned, the emphasis should be on basic supportive
measures.
17. Decontamination
• This is with reference to skin/eye decontamination, gut evacuation and
administration of activated charcoal.
18. Poison Elimination
• Depending on the situation, this can be accomplished by diuresis, peritoneal
dialysis, haemodialysis, haemoperfusion, etc.
20. Nursing And Psychiatric
• Care General nursing care is especially important in comatose patients and
those who have been incapacitated by the poison.
• Since some cases of poisoning leave behind persisting sequelae, adequate
follow-up for a period of time may be necessary.
• Psychiatric intervention is frequently essential in suicidal overdose.
21. Stabilisation
• ASSESSMENT
• The Airway and Breathing
• Symptoms of airway obstruction include dyspnoea, air hunger, and
hoarseness.
• Signs comprise stridor, intercostal and substernal retractions, cyanosis,
sweating, and tachypnoea.
22. • Normal oxygen delivery requires adequate haemoglobin oxygen saturation, adequate
haemoglobin levels, normal oxygen unloading mechanisms, and an adequate cardiac
output.
• Increasing metabolic acidosis in the presence of a normal PaO2 suggests a toxin or
condition that either decreases oxygen carrying capacity (e.g. carbon monoxide,
methaemoglobinaemia), or reduces tissue oxygen (e.g. cyanide, hydrogen sulfide).
• The immediate need for assisted ventilation has to be assessed clinically, but the
efficiency of ventilation can only be gauged by measuring the blood gases.
• Retention of carbon dioxide (PaCO2 > 45 mmHg or 6 Kpa), and hypoxia (PaO2 <
70 mmHg or 9.3 Kpa) inspite of oxygen being given by a face mask are indications
for assisted ventilation
24. Some drugs stimulate the respiratory centre:
Amphetamines
Atropine
Cocaine
Salicylates
Some drugs are associated with non-cardiogenic pulmonary oedema
• Characterised by severe hypoxaemia
• Bilateral infiltrates on
• Chest X-ray, and
• Normal pulmonary capillary wedge pressure
26. • Some drugs cause or exacerbate asthma.
• The most important among them include NSAIDs, antibiotics like penicillins,
cephalosporins, tetracycline, and nitrofurantoin, cholinergic drugs,
chemotherapeutic drugs, and some diuretics.
29. Depression of Central Nervous System
• This is generally defined as an unarousable lack of awareness with a rating of
less than 8 on the Glasgow Coma Scale (Appendix 1). However, the
European Association of Poison Centres and Clinical Toxicologists
(EAPCCT) are of the opinion that this scale while being very useful for
trauma patients is inappropriate for acute poisoning. Several other scales have
been proposed, including Reaction Level Scale, Comprehensive Level of
Consciousness Scale (CLOCS), Coma Recovery Scale, Innsbruck Coma
Scale, Reed’s Classification, etc., but the predictive value of all these scales
remains to be ascertained
30.
31. • There are numerous causes for coma of which one of the most important is acute
poisoning.
• A number of substances can induce coma, and it will require a great deal of
astuteness and expertise to pinpoint the poison.
• Before proceeding to an elaborate exercise in diagnosis however, it may be
desirable to first ascertain for sure that the patient is really comatose and not just
pretending (psychogenic or hysterical coma).
• This is often encountered in cases of “suicide gesture” in contrast to “attempted
suicide”
32. • The former is an attention drawing gambit, where there is no real intention
of ending one’s life. The telltale fluttering eyelids, the patient who is half-
walked, half-dragged in by relatives, an elaborate suicide note, a phone call to
a friend or relative informing them of the act, pill bottles strewn about, all
may point to such a suicide gesture.
• In addition, the signs and symptoms manifested by the patient usually are out
of proportion to the ingestion itself
• o the question is, how does the doctor humanely determine whether the
coma is true or fake?
33. • Several methods have been recommended of which the following constitute
barbaric acts and must never be employed
Pinching nipples or genitals, or repeatedly pinching any part of the body.
Slapping the face hard, repeatedly
• Cotton pledgets or sterile applicator tips soaked with ammonia solution being
inserted into the nostrils. Instead, the following steps are recommended: Perform a
quick physical examination with particular attention to the breathing, vital signs,
and the gag reflex. If these are normal, the coma is almost certainly psychogenic.
Another indication is a tightly clenched jaw when attempts are made to open the
mouth. However, first rule out seizure disorders.
35. Decontamination
• EYE Irrigate copiously for at least 15 to 20 minutes with normal saline or water.
• Do not use acid or alkaline irrigating solutions.
• As a first-aid measure at home, a victim of chemical burns should be instructed to
place his face under running water or in a shower while holding the eyelids open.
• During transportation to hospital the face should be immersed in a basin of water
(while ensuring that the patient does not inhale water).
36. SKIN
• Cutaneous absorption is a common occurrence especially with reference to industrial and
agricultural substances such as phenol, hydrocyanic acid, aniline, organic metallic
compounds, phosphorus, and most of the pesticides
• The following measures can be undertaken to minimise absorption*—
• ■ Exposed persons should rinse with cold water and then wash thoroughly with a non-
germicidal soap. Repeat the rinse with cold water.
• ■ Corroded areas should be irrigated copiously with water or saline for at least 15 minutes.
Do not use “neutralising solutions”.
• ■ Remove all contaminated clothes. It is preferable to strip the patient completely and
provide fresh clothes, or cover with clean bedsheet.
• Y Phosphorus burns should be treated with copper sulfate solution. Y For hydrofluoric
acid burns, use of intradermal or intraarterial calcium gluconate decreases tissue necrosis
37.
38. Elimination
• The various methods of eliminating absorbed poisons from the body include
the following:
■ Forced Diuresis
■ Extracorporeal techniques
Y Haemodialysis
Y Haemoperfusion
Y Peritoneal dialysis
Y Haemofiltration
Y Plasmapheresis
Y Plasma perfusion
Y Cardiopulmonary bypass.