Cardiopulmonary bypass in pediatric patients with congenital heart disease requires special considerations due to physiological differences from adults. These include smaller blood volumes, higher oxygen demands, and the presence of intracardiac and extracardiac shunting. The bypass plan must account for the specific anatomy and physiology of each patient's heart defect to ensure adequate perfusion and protection during surgery. Flow rates, temperature management, venting strategies, and cardioplegia administration may need to be modified from standard adult protocols. Close monitoring is important to detect any issues with oxygen delivery or end-organ perfusion during bypass.
Cardiopulmonary bypass development and history
Indication of cpb
Hardware in cpb
Arterial and venous cannulation
Oxygenator
Heat exchanger
Filter
How to conduct cpb and problems in cpb
Cardioplegia
Cardiopulmonary bypass development and history
Indication of cpb
Hardware in cpb
Arterial and venous cannulation
Oxygenator
Heat exchanger
Filter
How to conduct cpb and problems in cpb
Cardioplegia
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Struggling with intense fears that disrupt your life? At Renew Life Hypnosis, we offer specialized hypnosis to overcome fear. Phobias are exaggerated fears, often stemming from past traumas or learned behaviors. Hypnotherapy addresses these deep-seated fears by accessing the subconscious mind, helping you change your reactions to phobic triggers. Our expert therapists guide you into a state of deep relaxation, allowing you to transform your responses and reduce anxiety. Experience increased confidence and freedom from phobias with our personalized approach. Ready to live a fear-free life? Visit us at Renew Life Hypnosis..
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
2. Cardiopulmonary Bypass
• Cardiopulmonary bypass (CPB) isolates the cardiopulmonary system to
facilitate surgical repair, oxygenates blood, and removes carbon dioxide
without causing permanent damage to the blood, cardiopulmonary system
or end organs
• CPB must perform the functions of the intact system for a finite period of time, providing
gaseous exchange and adequate perfusion to all organs without doing any permanent
damage.
• Pediatric perfusion plan requires an array of equipment matched to the patient size,
expected pump flow rates and diagnosis specific factors.
3. CPB for infants vs adults
• Immature organ systems
• Smaller circulation blood volumes
• Higher oxygen consumption rate
• Reactive pulmonary vascular bed
• Presence of intracardiac and extracardiac shunting
• Impaired temperature control
• Poor tolerance to microemboli
4.
5. Physiological differences between Immature and Mature Myocardium
• Energy Substrate
Adult myocardium under aerobic condition derives 95% ATP, from oxidation of long chain fatty
acids
Neonatal heart derives ATP from oxidation of Glucose in aerobic (36 ATP) as well as anaerobic
conditions(2 ATP) indicates its greater tolerance to ischemia.
Substrate change from glucose to free fatty acids is due to in 5’AMP activated protein kinase, in
this period uptake of glucose reduces leading to increase in insulin and more glycogen storage
subsequently less ischemia tolerance
6. CALCIUM METABOLISM
• More sensitive and dependent on extracellular calcium,
• Less developed sarcoplasmic reticulum
• ReducedSarcoplasmic reticularCa+ ATPaseactivity that
active transport of calcium in the luminal side of SR
• Decrease calcium storage reduced RYANODINE
RECEPTOR ACTIVATION
7. ENZYME SYSTEM
ANTIOXIDANT
• Superoxide dismutase, catalase, glutathione
reductase
• Scavenges oxygen free radicals( superoxides,
hydrogen peroxide, lipid peroxide, hydroxyl
radical) that cause peroxidation of
phospholipids in cell membrane resulting in
cell damage.
• Reduced in immature myocardium,esp TOF
5’NUCLEOTIDASE
• Catalyzes the conversion of adenosine
monophosphate to adenosine which passes
easily into extracellular space depleting the
adenosine nucleotide pool which helps in
postischmeic recovery.
• Reduced in immature myocardium more
tolerant to ischemia
8. Catecholamine sensitivity
• Decreased sensitivity
• Uncertain
Ischemic Preconditioning
• Adaptive mechanism induced by brief
period of reversible ischemia
increasing the hearts resistance to a
subsequent longer period of ischemia
• Protective for mature myocardium
• Chronic hypoxia reduced tolerance to
myocardial ischemia
9.
10. Normal vs Stressed myocardium
• Normal neonatal myocardium is more tolerant to ischemia but not the stressed
myocardium
• Stressors like severe hypoxemia , chronic cyanosis, ventricular hypertrophy are
present in neonates and infants causing depletion of high energy phosphates,
glycogen and Krebs cycle intermediates.
• Volume and pressure loading increases myocardial oxygen demand and
ventricular hypertrophy leading to hypoperfusion of the subendocardium.
• Collaterals in Cyanotic lesions increased left heart return, rewarming and washing
of cardioplegia.
11. Ischemic tolerance of the immature heart
• Immature heart has a greater tolerance to hypoxia and
• ischemia than the adult
• : greater glycogen stores
• : improved anaerobic metabolism
• : better maintenance of ischemic calcium exchange
• : higher levels of adenosine triphosphate
• : increased amino acid substrate utilization
12. Myocardial protection
Hypothermia
• Hypothermia reduces myocardial
oxygen consumption
• MVO2:
working stage 6.7ml (adults 8ml),
empty beating heart 3.2ml
(adults5.6ml),
K arrested @37˚C 1.3ml (adults
1.1ml)
15˚C hypothermia 0.37ml
15˚C K arrested heart 0.32ml
Cardioplegia arrest
• Diastolic arrest
• Preserves myocardial function during
the arrest period and limits reperfusion
injury
• Blood cardioplegia: carry O2, buffer,
similar osmotic comp., free radical
scavenging
• Del nido: 30ml/kg, 4:1ratio, reduces
energy consumption, blocks calcium into
intracellular space, lower troponin T
release.
13. Smaller circulating blood volume
• Circuit capacity cannot be reduced proportionate to patient size
• Significant hemodilution
• → ↓ clotting factors, plasma proteins → dilutional coagulopathy
• → ↓ colloid osmotic pressure → interstitial edema
• → electrolyte imbalance
• → ↑release of stress hormones
• → activation of complement, WBC, platelets
• In neonate : as much as 200~300% of patient's blood volume
• In adults : about 25~33% of patient's blood volume
15. D. Whiting et 246 al. / Best Practice & Research Clinical Anaesthesiology 29 (2015) ;
BOSTON
16. significant decline was observed in mean
platelet count during the first hour of perfusion
and 3 h
At 24 h - comparable in albumin and control
circuits
Advantage of Albumin in Prime?
19. The authors reported significantly
less chest tube drainage
and shorter lengths of mechanical ventilation and intensive
care unit (ICU) stay in the FWB arm
Advantage of Fresh Whole Blood in Prime?
J Thorac Cardiovasc Surg 2008;136:1442-9
20. authors found patients managed with FWB had increased
ICU length of stay and more
fluid overload compared to the group receiving RWB in the
CPB prime
21. Pump Flow rate
• Extrapolated from adult data
• Less than 1.6L/m2/min - increase in lactate.
• At 2-2.4L/m2/min – no increase in lactate
In the absence of shunts
Serum lactate is measured during CPB to ensure
adequate systemic blood flow.
22. How to Assess flow in CPB in CHD adequate?
• Pediatrics with CHD
• anatomic heterogeneity of patients
• differences in age-based and weight-based flows.
• Mixed venous oxygen saturation –
• indicator of adequate systemic blood flow,
• but it does not directly measure the adequacy of cellular oxygenation
• Serum lactate –
• indicates the presence of anaerobic metabolism,
• better reflect the adequacy of cellular oxygenation.
• should routinely measured 10 min after the initiation of CPB and then every 30 min.
• urine output on CPB –
• Renal function is assessed by
23. How to minimize the need for transfusion in
pediatric congenital heart surgery
• Many methods
• use of near-infrared spectroscopy (NIRS) - allowed clinicians to tailor
blood transfusion intraoperatively based on real-time data during the
various stages of an operation.
Wiley-Blackwell; 2015.
26. Retrograde autologous priming feasible in children?
Still, the use of RAP in pediatrics, particularly
neonates and infants, appears to have limited practical
use and the technique has not been universally adopted.
29. Ultrafiltration
• Excess volume in the cardiotomy venous reservoir –
• crystalloid component of cardioplegia,
• crystalloid valve testing solutions
• Conventional UF is utilized in nearly all pediatric bypass cases.
• MUF allows the ultrafiltration of CPB circuit volume as well as the patient's
blood volume after weaning from CPB.
• The major advantage of MUF over CUF is that it allows hemoconcentration
to continue once CPB has been terminated allow greater degree of
hemoconcentration than CUF alone.
37. Aortic regurgitation/insufficiency
• Single venous cannulation
• Dual Venous cannulation – If associated with other lesion
• Flow 3.5L/m2/min (higher than normal)
• Cardioplegia –
• 1.5–2 times the normal dose (to account for volume lost
to regurgitation)
• direct administration if the initial root dose is not
effective.
38. • LV vent
• AI increases the blood from the aortic cannula will flow retrograde to the LV
• Decompress LV distension due to AR
• amount of LV vent return - rough surrogate for degree AR.
• Go on bypass slowly to prevent LV distention secondary to
• the AI andor
• VF due to a cool prime directly perfusing the coronaries.
• If the patient fibrillates before an LV vent is placed,
• immediately decrease the pump flow to prevent LV distention
39. • Increased risk of systemic hypoperfusion
• if a significant amount of forward flow is lost retrograde across the aortic
valve to a left ventricular vent.
• pressure may increase suddenly and significantly
• Once the aortic cross clamp is on (and loss to the ventricle is prevented),
• BP fluctuations can occur
• Surgical work at aortic sinus to transverse arch - may stimulates the aortic
baroreceptors - may produce acute changes in BP on bypass.
• cautious in treating such fluctuations - quite temporary.
40. • higher than normal blood pressure during rewarming and myocardial
reperfusion
• to aid in coronary blood flow & to prevent VF if the ventricle is hypertrophied.
• BP low - When allowing for ejection
• aorta has been opened surgically
41. Aortic Stenosis
• bypass pump should be primed and kept ready
• CPR difficult
• Flow – 2.5- 3l/min/m2
• Cardioplegia
• higher cardioplegia delivery pressures/flows if significant ventricular
hypertrophy exists - ensure proper myocardial distribution of cardioplegia.
• more than the standard cardioplegia dose (ventricular hypertrophy)
• Keep Blood pressure low
• While coming off bypass/post op (aorta suture lines)
• But maintain perfusion pressure to avoid VF in hypertrophy.
42. Aortopulmonary collaterals
• MAPCA ligation before CPB – should be tried
• Otherwise Systemic flow compromised
• Flow increased – 3.5-5L/min/m2
• Anticipate oxygenator/cannula
• Flow will be increased 1st to increase BP
• NIRS
• Ventricular distension
• Dec EF (low temp, dec Ca+ due to hemodialation)
• LV vent+
44. • Blood products – kept in hand
• Due to increase in blood flow, reservoir can become empty
• ALFA AGONIST - debate
• Increase BP
• Systemic vasoconstriction lead to decrease systemic circulation, increase
pulmonary circulation
45. bidirectional Glenn shunt
• SVC cannula will be placed in the innominate vein or high in the SVC
• lower cannula may be placed in the atrium instead of the IVC if no additional intracardiac
work is needed.
• Cardioplegia is not normally required
• LV vent normally is not needed.
• Be aware of the status of the BTS or Sano
• Control immediately on bypass
• If not
• increased pump flows to compensate for pulmonary runoff.
• displayed CVP value - unusable
• if an applied SVC clamp includes the catheter
46. Fontan procedure
• High Hct
• may not need blood in the prime
• may receive FFP - correction of factor deficiencies
• Cardioplegia - required for lateral tunnel technique
• Bicaval cannulation
• SVC cannulation - higher than normal/innominate vein)
• IVC cannulation lower than normal to facilitate creating
the intra-atrial baffle or extracardiac conduit.
• displayed CVP value - unusable if an applied SVC clamp
includes the catheter.
47. PDA
Normally closed without CPB
CPB – Complicated PDA, associated with other defects
Closed before CPB
If NOT
• Flow increased – 3.5-5L/min/m2
• Flow to be increased 1st to increase BP
• NIRS
• Ventricular distension
• LV vent+
• Rectal Temperature – not recommended (Runoff/ associated COA)
• ALFA AGONIST - Better avoid
• BP -unacceptably high once the duct is ligated.
48. Coarctation of the aorta
• left heart bypass
• LA to the descending aorta/femoral artery for
isolated coarctation repair
• Flow to DTA to be titrated depending upon
upper body circulation
• If complete bypass
• Flow to be decreased when DTA was clamped
to avoid overflow to the cerebral circulation
49. Interrupted aortic arch
• Two arterial cannula –
• ascending aorta and PDA are needed for true
interrupted arches
• Cardioplegia required
• circulatory arrest for correction
• Regional perfusion techniques -
• pump flows of 20–60 cc/kg/min through the
arterial cannula with flow directed to the cerebral
• Cerebral and somatic NIRS monitoring is commonly
used
50. LSVC
• If bridging vein is present or if the LSVC flow is
minimal
• pump sucker IN RV
• low flow sucker can be placed in the LSVC
• LSVC may be ligated below the bridging vein
• bridging vein absent/small
• third venous cannula may be needed.
51. TAPVC/PAPVC
• sucker in the left atrium/ LV vent
• LA/LV may be undersized
• large variations in filling pressures with minimal change in volume status
during weaning
• careful not to overfill during separation from bypass.
• Scimitar syndrome
• form of PAPVC
• The right lung is commonly hypoplastic and its blood supply is via MAPCAs.
52. Truncus arteriosus
• Truncal valve regurgitation
• require direct coronary delivery of cardioplegia.
• 1.5–2 doses of cardioplegia
• LV vent – to decompress LV
• flow - 3.5 L/min/m2
• Systemic blood pressure can be low (before cross clamp)
• Increase by increasing the flow
• After cross clmap – increase in blood pressure
• Flow to be adjusted
• Pulmonary arteries - controlled before or soon after commencing
bypass (runoff to the pulmonary circulation can compromise systemic perfusion)
• Aortic pressure - kept in low normal while coming Off bypass and
Post CPB - as aorta was open
53. Aortopulmonary window
• Single venous cannulation (dual stage if available)
• flow - 3.5 L/min/m2
• to compensate for pulmonary runoff until the window is
controlled.
• branch pulmonary arteries Controlled - before or soon after
commencing bypass
• since runoff to the pulmonary circulation can compromise
systemic perfusion (like a PDA, BTS, or MAPCAs)
• LV vent
• Terminate CPB with low BP – aorta is open
54. Anomalous left coronary artery from the
pulmonary artery
• Flow rate - 3.0 L/min/m2
• cardioplegia
• flow to the aortic and pulmonary roots in order to adequately
arrest and protect the heart.
• LV vent
• Cardioplegia is frequently given
• left and right pulmonary arteries controlled before cross
clamping
• to ensure cardioplegia delivery into the pulmonary root reaches
the anomalous coronary artery
• Increased hematocrit before coming off bypass
• sick myocardium.
55. THANK YOU
Children with CHD – huge anatomic heterogeneity of heart
differences in age-based and weight-based flows.
Check
For adequacy of flows
Editor's Notes
PLATELETS initially adhered to the artificial surfaces of the system, re-appeared in the circulating blood.
lost much of their a-granula content, and circulate as nonfunctional platelet ghosts.
Head and neck MAPCA – addressed 1st – otherwise cerebral compromise
MONITOR LOOKS BE GOOD , BUT LACTATE AND BASE DEFICIT WILL INCREASE IN ALFA BLOCKERS.
Head and neck MAPCA – addressed 1st – otherwise cerebral compromise
Head and neck MAPCA – addressed 1st – otherwise cerebral compromise
Head and neck MAPCA – addressed 1st – otherwise cerebral compromise
Head and neck MAPCA – addressed 1st – otherwise cerebral compromise
Head and neck MAPCA – addressed 1st – otherwise cerebral compromise