Consideration of the planned changes has been delayed while the House committee has awaited the crucial verdict of the Clinton administration on the proposed reforms. Impact of the pulmonary artery catheter in critically ill patients. Related Papers. Others said that the state may be attrac- tive for manufacturing, partly because wages are lower there. Ensure that you update this again very soon. It is pretty worth enough for me. Comfirmation of needle cricothyroidotomy using an esophageal detector devices in a porcian model.
 
 

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There are many and different reasons for extubation to fail, starting from mechanical iatrogenic lesions due to difficult intubation up to patient’s inhability to sustain spontaneous breathing and unassisted ventilation, going through extubation associated respiratory and cardiovascular complications, local mechanic or inflammatory factors, surgical techniques and accidental events.

Recent literature has clearly shown that if critical events associated with difficult intubation have lower incidence thanks to guidelines diffusion and implementation, extubation related accidents did not change incidence and consequences in last couple of decades. This observation has led to developement of dedicated extubation guidelines and to attention from Scientific Community to promote culture of safety and anticipation, with predicted difficult extubation concept and protected extubation strategies, by using pharmacological and technical approach.

Aim of this paper is to review data for extubation related accidents, to provide overview with existing guidelines and description of approaches to predict difficult extubation, techniques to provide best extubation strategies including pharmacologic, non pharmacologic and instrumental techniques. Radmilo Jankovic. Andrijana Vceva. Miroslav Milankov. Abdul Zahoor , Nauman Ahmad. Vladan Zivaljevic , Branko Milakovic. Sanja Mazic. Amina Valjevac.

Sabaheta Hasic. Vladan Zivaljevic. Gustavo Fabregat. Robert Feneck. Hans-Joachim Priebe. Vesna Bumbasirevic. Daniela Veleska. Zlata Mujagic. Nevenka Ilic. Constantin Apintiliesei. Log in with Facebook Log in with Google. Remember me on this computer. Enter the email address you signed up with and we’ll email you a reset link. Need an account? Click here to sign up. Download Free PDF. Prothrombin complex concentrate versus fresh-frozen plasma in dilutional coagulopathy: a case report.

Related Papers. Vojnosanitetski pregled Reliability and relationship of colposcopical, cytological and hystopathological findings in the diagnostic process. Vojnosanitetski pregled Transference patterns and working alliance during the early phase of psychodynamic psychotherapy. Vojnosanitetski pregled Nasal septum extramedullary plasmacytoma.

Medicinski pregled Sonothrombolysis: is the story t old or just the beginning. Protective mechanical ventilation in patients without or with lung injury. Safe extubation and reintubation in operatory room and ICU patients. Acta chirurgica iugoslavica Preoperative preparation of patients with arterial or pulmonary hypertension in noncardiac surgery.

Acta chirurgica iugoslavica Preoperative preparation of patients with infectious and restrictive respiratory diseases as comorbidities. Seeberger Role of biomarkers in cardiac risk assessment for non2cardiac surgery R.

Voga Critical Ultrasound in prehospital settings: where the benefit of ultrasound use is even greater G. Koszek Bleeding in patients with congenital disorders of haemostasis. Djordjevic Fluid resuscitation in sepsis: What do the data show M. Mostic Ultrasound of the lumbar spine 2 a new challenge for obstretic anaesthetists M. Kendrisic Peripartum cardiomyopathy I. Velickovic Morphine renesanse for postcaesarean pain releif — spinal and epidural application B.

Markovic Minimal flow techniques in anesthesia C. Kalezic Specifics of anaesthesia in surgeries on the pituitary gland B. Milakovic Assessment of perioperative risk in patients with diabetes mellitus V.

Malenkovic Hemodynamic disturbances during thyroidectomy M. Stojanovic Risk factors for perioperative hypertension in patients undergoing parathyroidectomy V. Sabljak Anesthesia aspects of surgical treatment of pheochromocytoma M.

Jovanovic Heart transplantation — anesthesia and perioperative treatment M. Flick Safety in Paediatric Anaesthesia E. Were are the gaps? T Xanthos Post2resuscitation Care: current therapeutic concepts J. Milan Interventional treatment for musculoskeletal pain Z. Ladjevic Imagine living without pain…Understanding pain genetics D.

Louis School of Medicine, St. Louis, USA E mail: kangrgai wustl. Since the first successful OLT in [1], the number of liver transplants has been steadily increasing, both in the United Sates and globally. Almost 24,00 liver transplants were performed worldwide in according to the World Health Organization [2], and more than one fourth of those were performed in the US.

AUNOS bylaw mandates that transplant centers appoint a Director of Liver Transplant Anesthesia and establishes the directorship criteria, based largely on the recommendations by the American Society of Anesthesiologists.

This decision by UNOS was motivated by the emerging evidence that standardized care by a dedicated liver transplant anesthesia team may influence outcomes and resource utilization, including blood transfusion, length of mechanical ventilation, and ICU and hospital stay.

Most had perioperative protocols. Variability in team membership criteria, structure and responsibilities were associated with center volume, likely reflecting resource availability. The limited utilization of living donation in the US may reflect access to deceased donors, living donor safety concerns and increased cost.

Similarly, the percentage of DCD donations has plateaued, largely due to outcome and resource utilization concerns. The outcomes of OLT have improved dramatically over the years, reflecting advances in perioperative care and immune suppression. Despite the overall success of the national organ transplant program, transplant centers and perioperative teams face multiple challenges maintaining OLT outcomes in the changing regulatory and economic environment.

Recipient data analysis demonstrates rapidly changing demographics of liver transplant candidates, with continued trend towards older and sicker recipients. Whereas implementation of MELD has been highly successful in its primary goal, reduction of waiting list mortality and the number of patients on the active waiting list, it has resulted in much sicker patients presenting for OLT.

This increased severity of recipient illnessis associated with worse outcomes, longer lengths of hospital stay and greater utilization of intensive care unit, ventilator support and dialysis [10], thus putting more pressure on transplant centers.

The sustained shortage of liver donors has necessitated the expansion of the donor pool. As general indices of donor quality,such as the donor risk index DRI [10], correlate with outcomes and resource utilization, use of extended criteria donors has significant implications. Medical and economic implications of recipient severity of illness and donor quality vary markedly within the US. The median national MELD score in was 27, ranging from 21 to 35, reflecting the wide geographic disparity.

Stroke volume response to volume loading is blunted as administered fluids are quickly redistributed to splanchnic circulation, worsening bleeding during the dissection phase of OLT. Restrictive fluid management and use of vasopressors, such as vasopressin or adrenergic receptor agonists, restore central filling volume, stroke volume and organ perfusion, but decrease portal flow and splanchnic hyperemia, and contribute to reduced bleeding during the dissection phase.

Diastolic dysfunction is associated with severity of the post reperfusion syndrome [13], and with development of post transplant heart failure. Similarly, platelet numbers are often reduced but upregulation of Factor VIII and von Willebrand Factor may offset the effects of thrombocytopenia. Clinically, both coagulopathy and pro thrombotic states are common in ESLD. Low grade fibrinolysis occurs frequently in OLT recipients providing a rationale for the use of antifibrinolytics.

Conventional tests, prothrombin time and activated thromboplastin time do not reflect the clotting function or predict bleeding in OLT [15]. Whole blood clotting assays, such as rotational thromboelastometry or thromboelastography, may better inform of the status of the clotting function and are commonly used as point of care tests to help guide a protocolized hemostatic management strategy [16].

Prothormbin complex and fibrinogen concentrates are being investigated as attractive alternatives to fresh frozen plasma and cryoprecipitate, as the association of transfusion with morbidity and mortality in ELSD is well established. The number of transplants performed in individual centers is relatively small compared to other major surgeries. Consequently,most of the current evidence is based on data from small, non randomized series. Consensus on the best approach to common perioperative practices in OLT, such as transfusion practices, fluid management, etc.

Few health care disciplines are scrutinized as rigorously as the US transplant. Mandatory data reporting and state of the art analysis, result in the largest national outcomes report, the SRTR.

Thereport comparestrue outcomes with a rigorously developed, risk adjusted model based on multiple donor and recipient risk factors. Whereas the SRTR report provides critical information to inform governmental regulatory agencies, insurers and policymakers, it falls short of a comprehensive outcomes and quality database that would allow systematic examination of current practice and lead to quality improvement processes in liver transplantation [17].

One good example is perioperative blood transfusion,a factor strongly associated with mortality after liver transplantation. The program has developed a standardized approach to quality improvement with demonstrated potential for reduction in postoperative morbidity and mortality. Conclusions Orthotopic liver transplantation is a well established, effective treatment for patients with ESLD. Although outcomes of liver transplantation are robust, transplant centers face significant challenges, including trends toward sicker and older recipients, increased use of marginal donors due to persistent donor shortage, and stricter regulatory and financial environment.

Current efforts are directed towards refining quality metrics and risk adjusted outcomes, and developing a standardized approach to quality improvement in perioperative care of liver transplant patients. Homotransplantation of the liver. Transplantation ; 5 Suppl : — Designated liver transplant anesthesia team reduces blood transfusion, need for mechanical ventilation, and duration of intensive care. Liver Transpl ; Reduced use of intensive care after liver transplantation: influence of early extubation.

Anesthesia for liver transplantation in US academic centers: institutional structure and perioperative care. Liver Transpl ; 18 6 : A model to predict survival in patients with end stage liver disease. Hepatol ; Axelrod D. Economic and financial outcomes in transplantation: whose dime is it anyway?

Curr Opin Organ Transplant. Cardiovascular complications of cirrhosis. Postgrad Med J. A comparison of intra operative blood loss and acid base balance between vaso pressor and inotrope strategy during living donor liver transplantation. Anaesthesia ; — Influence of preoperative diastolic dysfunction on hemodynamics and outcomes of patients undergoing liver transplantation. Int J Clin Exp Med ; 6: 7. Diastolic dysfunction in patients with end stage liver disease is associated with development of heart failure early after liver transplantation.

Transplantation ; Lisman T, Porte RJ. Rebalanced hemostasis in patients with liver disease: evidence and clinical consequences.

Blood ; 6 : Coagulation management with factor concentrates in liver transplantation: a single center experience. Transfusion ; e published: doi Am J Transpl ; 6: Blood transfusion requirement during liver transplantation is an important risk factor for mortality. J Am Coll Surg ; 1 6. Louis, USA E mail vannucca wustl. While apparently a simple principle, the mechanisms of success and failure with direct laryngoscopy are still actively debated 2 Video laryngoscopy is performed with instruments that allow visualization of the glottis independently from the alignment of the line of sight with the laryngealstructures glottis and supporting cartilages.

These three separate components of a successful intubation have become more recognized by clinicians since the widespread adoption of video laryngoscopes in the clinical practice. In fact, it is a quite common problemwith the use of these devices tobe able to easily visualize the glottis,while facing difficulties in advancing the tube beyond the vocal cords. While adverse events at the induction of anesthesia have become progressively less frequent and severe, problems at the extubation appear to be an unresolved patient safety issue 9 Practice guidelines have had an important role in reinforcing the principle of planning in advance, suggesting modalities for airway assessment, establishing priorities in difficult airway management, proposing a sequence ofinterventions to adopt in case of difficulties, and endorsing the use of advanced tools to gain control of the airway, or, at least, to maintain oxygenation.

However, there is still a limited experience with the use of this algorithm and, at this point, it is not known if it is having an impact on clinician practices and patient outcomes. Developing technology and increasing efforts by National and International Societies in designing and diffusing effective guidelines have significantly contributed to reduce adverse outcomes.

References: 1. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.

Greenland KB. A proposed model for direct laryngoscopy and tracheal intubation. Levitan RM. The mystique of direct laryngoscopy. Respiratory care. Epstein SK. Decision to extubate. Intensive Care Med.

Use of non invasive ventilation to wean critically ill adults off invasive ventilation: meta analysis and systematic review. Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta analysis.

Management of the difficult airway: a closed claims analysis. Closed claims’ analysis. Part 1: anaesthesia. British journal of anaesthesia. Cavallone LF, Vannucci A. Extubation of the Difficult Airway and Extubation Failure. Anesth Analg. The difficult airway with recommendations for management Part 2 Difficult airway.

Canadian Journal of Anesthesia. Frova G, Sorbello M. Algorithms for difficult airway management: a review. Minerva Anestesiol. Predicting difficult intubation in apparently normal patients: a meta analysis of bedside screening test performance. Review article: video laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?

A survey assessing the procurement, storage and preferences of airway management devices by anaesthesia departments in German hospitals. Eur J Anaesthesiol. Mendonca C. Sugammadex to rescue a ‘can’t ventilate’ scenario in an anticipated difficult intubation: is it the answer?

Crosby ET. An evidence based approach to airway management: is there a role for clinical practice guidelines? The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices. Annals of emergency medicine. Cooper RM. Complications associated with the use of the GlideScope videolaryngoscope. Palatal injury associated with the GlideScope. Anaesthesia and intensive care. Avoiding palatopharyngeal trauma during videolaryngoscopy: do not forget the ‘blind spots’.

Acta anaesthesiologica Scandinavica. Preoperative endoscopic airway examination PEAE provides superior airway information and may reduce the use of unnecessary awake intubation. Kristensen MS. Ultrasonography in the management of the airway. Connor CW, Segal S. The importance of subjective facial appearance on the ability of anesthesiologists to predict difficult intubation. Accurate classification of difficult intubation by computerized facial analysis.

Is video laryngoscope assisted flexible tracheoscope intubation feasible for patients with predicted difficult airway? A prospective, randomized clinical trial. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness.

Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Brief review: Supplementing oxygen through an airway exchange catheter: efficacy, complications, and recommendations.

Incidence and severity of respiratory insufficiency detected by transcutaneous carbon dioxide monitoring after cardiac surgery and intensive care unit discharge. The accuracy, precision and reliability of measuring ventilatory rate and detecting ventilatory pause by rainbow acoustic monitoring and capnometry.

Seeberger unibas. In vitro and animal models suggested that administration of volatile anesthetic prior to myocardial ischemia reduced myocardial infarct size. Nevertheless, a recent meta analysis of randomized trials strongly suggest that volatile anesthetics provide clinically relevant anesthetic preconditioning in patients undergoing coronary artery bypass graft surgery.

However, studies on the clinical value of preconditioning by volatile anesthetics in noncardiac surgery are scarce. To obtain scientific data on the value of preconditioning in patients at coronary risk who undergo major noncardiac surgery, we performed a study in three centers in Switzerland University Hospital Basel, Kantonsspital Solothurn, Kantonsspital Liestal. Between and , we enrolled patients at increased cardiovascular risk.

Patients were randomized to maintenance of anesthesia either with sevoflurane or propofol. To assess occurrence of perioperative ischemia, we recorded continuous ECG for 48 hours perioperatively and measured troponin T on postoperative day 1 and 2. To assess the occurrence of major adverse cardiac events MACE , the patients were contacted by phone 6 and 12 months after surgery. MACE were defined as a composite of cardiac death, acute coronary events syndrome, and congestive heart failure or arrhythmia requiring hospitalization.

Patients and outcome assessors were blinded. Myocardial ischemia occurred in 75 Within 12 months, 14 7. The incidence of delirium did not differ The results of this study were published in the journal Circulation in Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery.

N Engl J Med ; 8. Cardiac risk stratification for high risk vascular surgery. Circulation ; 5. Analysis of risk factors for myocardial infarction and cardiac mortality after major vascular surgery. Anesthesiology ; Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med ; Effects of extended release metoprolol succinate in patients undergoing non cardiac surgery POISE trial : a randomised controlled trial. Lancet ; Statins decrease perioperative cardiac complications in patients undergoing noncardiac vascular surgery: the Statins for Risk Reduction in Surgery StaRRS study.

J Am Coll Cardiol ; Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Slogoff S, Keats AS. Randomized trial of primary anesthetic agents on outcome of coronary artery bypass operations. Does choice of anesthetic agent significantly affect outcome after coronary artery surgery?

Anesthetic induced preconditioning: previous administration of isoflurane decreases myocardial infarct size in rabbits. Isoflurane mimics ischemic preconditioning via activation of K ATP channels: reduction of myocardial infarct size with an acute memory phase. Volatile anesthetics protect the ischemic rabbit myocardium from infarction.

Isoflurane pretreatment has immediate and delayed protective effects against cytokine induced injury in endothelial and vascular smooth muscle cells. Anaesthetic drugs and survival: a Bayesian network meta analysis of randomized trials in cardiac surgery. Br J Anaesth ; Effects of propofol, desflurane, and sevoflurane on recovery of myocardial function after coronary surgery in elderly high risk patients.

Cardioprotective properties of sevoflurane in patients undergoing coronary surgery with cardiopulmonary bypass are related to the modalities of its administration. Anaesthetics and cardiac preconditioning. Part II. Clinical implications. Sevoflurane but not propofol preserves myocardial function during minimally invasive direct coronary artery bypass surgery.

Anesth Analg ; 6, table of contents. Preconditioning with sevoflurane decreases PECAM 1 expression and improves one year cardiovascular outcome in coronary artery bypass graft surgery. Circulation ; Randomized comparison of sevoflurane versus propofol to reduce perioperative myocardial ischemia in patients undergoing noncardiac surgery. Risk scores and indices In the past 30 years, several risk indices, based on multivariable analyses of observational datato represent the relationship between clinical characteristics and perioperative cardiac mortality and morbidity, have been developed.

Between them, the indices developed by Goldman et al. The Lee index, or revised cardiac risk index, is a modified version of the original Goldman index and it was designed to predict complications such as postoperative myocardial infarction, pulmonary oedema, ventricular fibrillation or cardiac arrest, and complete heart block. The Lee index has been developed from prospectively collected data from a total of patients divided into a derivation and a validation cohort,and it was considered by many clinicians and researchers to be the best currently available cardiac risk prediction index in noncardiac surgery.

It [9]. Biomarkers A biomarker biological marker is defined as a substance used as an indicator of a biological state, which can be objectively measured and evaluated as an indicator of normal biological processes, pathologic processes, or pharmacologic responses to a therapeutic intervention.

According to World Health Organization definition, a biomarker is any parameter chemical, physical or biological which can be used to measure the interaction of environmental agents and biological systems.

National Institutes of Health defines biomarkers as molecular indicators of specific biological and biochemical characteristics which can be used to assess disease progression or treatment effects. The ideal biomarker should have specific characteristics: a ability to differentiatewith high accuracy healthy and a illpatient; b opportunity to be present in early stage of disease so to achieve effective and early therapeutic interventions ; c to be present in high enough level and in an easily accessible tissue fluid; d tolead to the development of tests that will ultimately impact in reduced mortality.

Due to these precise characteristics, an ideal biomarker is difficult to find. In the perioperative setting, especially in cardiac risk assessment for non cardiac surgery, biomarkers can be divided into markers focusing on myocardial ischaemia and damage, inflammation and LV function.

Inflammatory markers, such is C reactive protein CRP , might pre operatively identify those patients with increased risk of unstable coronary plaque. CRP has been implicated in many aspects of atherogenesis and plaque vulnerability, and it is also expressed in smooth muscle cells within diseased atherosclerotic arteries. However, in the surgical setting, no data are currently available to recommend use of CRP as a marker for the initiation of risk reduction strategies [13].

Cardiac troponins T and I cTnT and cTnI, respectively remain the preferred markers for the diagnosis of myocardial infarction because of demonstrated higher sensitivity and tissue specificity if compared with other available biomarkers. Existing evidence suggests that even small increases in cTnT in the perioperative period reflect clinically relevant myocardial injury with worsened cardiac prognosis and outcome[12,15 16].

Development of new biomarkers, including high sensitivity troponins, will likely further enhance the assessment of myocardial damage. However, for the combined endpoint, the AUC for hsTnT was larger but this difference did not reach statistical significance [12]. Conclusion Today, biomarkers play pivotal role in cardiac risk assessment for non cardiac surgery. Very recent guidelines stipulate that the assessment of both cardiac troponins and natriuretic peptides measurements may be considered for obtaining independent prognostic information for peri operative and late cardiac events in high risk patients.

The impact of these guidelines on perioperative management of patients who must undergo non cardiac surgery is still to be determined, but these recommendations clearly set up the beginning of use of biomarkers as part of peri operative management. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet ; — A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med ; — Association between postoperative troponin levels and 30 day mortality among patients undergoing noncardiac surgery.

JAMA ; — Naughton C, Feneck RO. The impact of age on 6 month survival in patients with cardiovascular risk factors undergoing elective noncardiac surgery.

Int J ClinPract ; — Eur J Anaesthesiol ; Eur J Anaesthesiol ; — Multifactorial index of cardiac risk in noncardiac surgical procedures. Cardiac assessment for patients undergoing noncardiac surgery. A multifactorial clinical risk index. Arch Intern Med ; — Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.

Circulation ; — Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation ; — Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Ann Intern Med ; — Incremental value of highsensitive troponin T in addition to the revised cardiac index for perioperative risk stratification in noncardiac surgery.

Eur Heart J ; — C reactive protein and other emerging blood biomarkers to optimize risk stratification of vulnerable patients. Guidelines for preoperative cardiac risk assessment and perioperative cardiac management in noncardiac surgery. Cardiac biomarkers: a contemporary status report. Nat ClinPractCardiovasc Med ; — Third universal definition of myocardial infarction.

In addition, increased procoagulant activity, inflammation, as well as the plaque rupture and subsequent thrombosis may be the pathophysiological mechanism as well.

However, ideal strategy remains unattainable. The European guidelines for perioperative risk assessment and perioperative cardiac management in non cardiac surgery have been published recently. Also, stress response to surgery may lead to neuroendocrine disturbances, catecholamine release and consequent cardiovascular response tachycardia and hypertension , as well as altered balance between prothrombotic and fibrinolytic factors. All these elements, individually or combined, may cause heart failure and coronary thrombosis.

Vascular surgery is considered as one with the highest risk for the new cardiac events. Determination of functional capacity is indispensable step in assessing cardiac risk. Climbing two stairs equals 4 METs and this is used as a cutoff point for poor functional capacity.

Patients with less than 4METs are considered as patients with poor functional capacity, which can be related to increased mortality. On the other hand, prognosis is excellent when the functional capacity is high, even in the presence of stable coronary artery disease.

Several risk indices have been developed in order to define the relationship between clinical characteristics of the patients and new perioperative cardiac events. Nowadays, the Lee index,which is a modificationof the original Goldman index,is considered the best currently available. All factors are marked with one point and total sum of points gives the estimation of incidence of major perioperative cardiac complications 0.

Identifying the risk has major implications for perioperative care of the patients. Patients considered carrying low cardiac risk after the assessment could be operated on safely without any additional strategies for reducing the risk any further. Patients at higher risk could benefit from pharmacological treatment. Also, they could be candidates for additional testing such as non invasive cardiac imaging techniques.

However, any noninvasive testing which leads to surgery delay should be reserved only for those patients in whom results would influence management.

All efforts to assess perioperative cardiac risk in the past were focused in detection of myocardium at risk of ischemia that could lead to some cardiac treatment before surgery. Now, the focus has been put on cardioprotective measures during the surgery, which led to different pharmacological measures on order to decrease perioperative cardiac risk. Stepwise evaluation of exercises capacity, surgical risk, clinical risk factors and additional noninvasive testing has been used for assessing the perioperative cardiac risk.

Cardio protective measures in order to reduce the incidence of major cardiac complications are of particular interest. Literature 1 Devereaux P. Perioperative cardiac events in patients undergoingnoncardiac surgery: a review of the magnitudeof the problem, the pathophysiology of the eventsand methods to estimate and communicate risk. Surveillance and prevention of major perioperativeischemic cardiac events in patients undergoingnoncardiac surgery: a review.

CMAJ ; 7 Perioperative cardiac evaluation, monitoring, and risk reduction strategies in noncardiac surgery patients. Relationship between the inability to climb two flights of stairs andoutcome after major non cardiac surgery: implications for the pre operativeassessment of functional capacity. Anaesthesia ;— Br J Anaesth ; S1 :i3 i Clinical application of the cardioprotective effects of volatileanaesthetics: PRO — get an extra benefit from a provenanaesthetic free of charge.

Eur J Anaesthesiol ;— Clinical application of the cardioprotective effects of volatileanaesthetics: CON — total intravenous anaesthesia or not totalintravenous anaesthesia to anaesthetise a cardiac patient? Although this study has from the beginning been critisized because of major methodological issues2 the publication a few years later of another study demonstrating a similar beneficial effect of perioperative beta blocking therapy3 seemed to confirm the protective effects of such therapy.

In the following years several randomized controlled trials were published, some of them showing a beneficial effect of perioperative beta blocking therapy4 10, whereas others failed to demonstrate such an effect11 15 and even reported adverse effects such as perioperative bradycardia and hypotension and an increased rate of perioperative stroke.

Despite these contradictory findings, it became generally accepted that beta blockers provided protection against perioperative cardiac events and improved perioperative morbidity and mortality16 18 finally resulting in guidelines that recommended very liberal use of beta blocking therapy in the perioperative period19, In the meantime critical signals with respect to the liberal use of perioperative beta blockade came from systematic reviews and meta analyses.

In this study over 10, patients with increased cardiac risk undergoing non cardiac surgery were randomized to receive either placebo or metoprolol.

The results were straightforward: beta blocked patients suffered less perioperative myocardial infarction but this was at the expense of an increased mortality duet o perioperative stroke which seemed to be initiated by the occurrence of intra operative hypotension and bradycardia.

These observations underscored the call for caution expressed in recent meta analyses and shifted the attitude towards peri operative beta blocking therapy together with a call to revise the current guidelines on this topic,24 which in the meantime has been done. There are several issues to take into account when analyzing data form randomized controlled trials with regard to perioperative beta blocking therapy.

These issues will be discussed in the presentation and include: 1. In those trials with low risk of bias the magnitude of the beneficial effects on perioperative beta blocking therapy on occurrence and extent of myocardial ischemic events and myocardial infarction rate are far less prominent and risk of stroke important.

There are several data indicating that there is an inverse relationship between the occurrence of adverse events and the length of the titration period. The gene coding fort his enzyme is highly polymorphic resulting in an important variation in acticvity. As a consequence patients can be divided in thos who are good metabolizers and those who are poor metabolizers of for instance metoprolol.

The consequence is that for the same dose plama concntrations may vary substantially and hence hemodynamic side effects may occur in some patients and not in others. VGKG Compact greaser ETP. LAGD 60 60 ml 2. Lubricant included.

The canister and battery pack may be used even at 12 months setting if acti- vated 3 years from production date. SKF has taken the knowledge and expertise of Vogel Lubrication and developed three solutions for grease- lubricated fan and blower bearings.

Fan and blower bearings are often critical to the operation of industrial manufacturing facilities. In some cases, they are in hard-to-access locations. The SKF grease lubrication units for fans can help users ensure that these bearings are being lubricated properly. These units are designed to deliver grease from 2 to 20 points consistently and effectively, providing the right amount of lubrication for extended bearing life. Ordering details Part no. When ordering, specify the number of points A separate pump element is required for each outlet.

Three pump elements with different delivery rates are available so that the volume of grease can be adjusted to the needs of the individual circuits. This feature ensures that every lube point is supplied with an adequate amount of grease in each lubrication cycle.

Control is provided by an integral IGI control and monitoring unit; it can be operated in a time- or load- pulse dependent mode, and with or without monitoring.

Please order cable harness separately. Temperatures and pressures that deviate from these figures lead to different delivery rates.

The indicated values must be taken as a basis in the design of a centralized lubrication system. The completely autonomous unit with integrated control system and feeder can supply as many as 20 lube points with exactly metered quantities of grease. Ordering details Integrated control unit with Standard version with Maximum number of Weight visual and acoustic warning filling level monitoring outlet points including grease Order no.

Order no. M10 x 1 VGKP VL-1 Single injector Three injector manifold. Typical Vent Manifold Injector inlet outlet 0. VL Stand alone VL These units deliver a continuous flow of cooled and filtered oil directly to the bearing. The metered pump flow is matched to the bearing and housing size, preventing oil leaks and excessive heat associated with oversized pumping systems.

The SKF circulating oil lubrication unit provides the right amount of cool, clean oil directly to each bearing. The use of circulating oil lubrication may also reduce bearing vibration associated 30 liter tank — basic unit, no controls with the use of grease lubricant at higher speeds. The SKF circulating oil lubrication units are available in three tank sizes; 30 liter 7.

Product selection – important note The following table is only a guide to assist in selecting the appropriate SKF circulating oil lubrication unit. Please consult SKF Application Engineering before purchasing and installing this product to ensure the proper unit has been selected based on all operating and application parameters.

Ordering details Housing no. Description Specification. Single-circuit pumps The pump units specified in this section are lubricant delivery pumps without pressure relief fixtures and are designed for continuous operation in circulating and hydrostatic lubrication systems.

These pump units may also be used for hydraulic tasks to the extent permitted by the pressure and viscosity ranges stated in the tables. The permissible pressure and Explanation of the delivery rates vary with the viscosity. The leaves flanged port R2 open — contrary for further information.

If air external port R1. Flanged port R2 of may become thin-bodied or highly is entrained due to low oil level in the the return duct discharges directly into viscous due to changes in temperature.

Use a special sealed pump for horizontal flange-mounting of the unit beneath oil level. Figure 1 Figure 2 Figure 3. Single-circuit units complete with reservoir see page DIN and special reservoirs on request. Return line R screw-plugged before delivery. The base is made of durable aluminum. The flow tube is made of glass, so high temperatures and the use of synthetic oils should present no problems. The Safeflow flowmeter has a straight glass flow tube with an internal calibrated cone extending along its vertical axis.

The float is cylindrical, its O. In operation, the calibrated cone extends through the annular opening in the float, creating the variable orifice needed for measurement as the float moves with flow changes. Because the oil flows Flow change alarm system switch, which identifies the location through the float, rather than around of a metal float in the tube. The The oil flow through each Safeflow it as in ordinary flowmeters, the float monitoring unit contains the terminals flowmeter can be remotely and is always clearly visible.

A white Teflon and the power supply for ten sensors. The alarm ring on the float marks the reading The system transmits either a single system consists of one alarm sensor point and wipes the inside wall of the alarm from each bank of meters or a for each flow tube and one monitoring glass tube.

For use with. Various versions are available to meet the different requirements necessary for the monitoring of fluid levels. Before the second switching point is reached, there is still enough oil in the reservoir for a shift to be completed without having to stop the machine or interrupt work. Pay attention to the viscosity of oil! If necessary, the contact tube can be used to trigger a signal that calls for the reservoir to be topped off.

The level switch WS The first switching point issues the advance warning. The second switching point can, after the float travels roughly 25 mm, break a connected command link and thus shut down a machine. The advance warning remains in effect. Contact 1 — 3 closes after the fluid After the level of fluid drops to 25 rises to a maximum level; mm above the minimum filling level, Contact 1 — 2 opens after the fluid contact 1 — 3 closes; if the level of fluid drops to a minimum level.

Please observe preferred lengths. Preferred lengths for order length L: , , , , , , , , , , , mm. Using special lubricants, these systems have been developed to lubricate belt conveyor surfaces, as well as the conveyor guides, for the transport of products on bottling and packaging conveyors. With these systems, it is not special lubricant.

Injection points for guides Guide. Coating plate for surface. Pre-adjusted piston Adjustable piston Main line distributors for guides distributors for surface. Compact units for oil Group MKU — 0. Ordering details Order no.

Group 0. For single-line total-loss to cover the total oil demand can then Different distributor groups can be be further regulated via the lubricating used in one installation. Please note: Seal material: NBR. To meet the required quantities In general, the operating conditions Piston distributors meter out and and comply with spatial constraints, specified for the respective pump units distribute the oil delivered by an it is possible to choose among four will also apply to the distributors.

The amount needed. Piston distributors, group 0. Piston distributors available only with metering nipples installed Order no. Metering nipple with O-ring, exchangeable Related metered Marking on the Order no. To order: Please note: The order no. The piston distributors comprising To complete the order no. Order key: 2 4 4 5 3 Order no. Secondary line connections Attention! Only in the case of the for plastic tubing: piston distributors shown here is it permissible to close unneeded ports.

Secondary line Socket union connections Tapered ring Ports on progressive feeders for steel tubing: Reinforcing sleeve must not be closed! Feeders would block! Socket union. Main line connections for steel tubing: Socket union Screw plug Double tapered sleeve or adapter when main line for plastic tubing: is continued Socket union Adapter or or threaded socket Washer banjo fitting Tapered sleeve when connected to Reinforcing socket a further piston distributor.

Flow monitors with various designs are used for this job. These flow monitors are designed for a. VGDC Flow monitor 1. Only permissible for the use of preassembled fittings. We recommend use of a preassembled EO-2 screw union. Example: GA Flow rate Order no. The and air mixing point. The oil-streak monitoring. To achieve such small quantities of oil per unit of time, what Ordering details was originally a relatively large drop of Order no.

Tubing 6 x 1. U2 – delivery rate 0. U3 – delivery rate 0. Suitable metered quantities from 0. The gloves are packed in a handy box containing 50 pairs.

Easy to install and ready for use. Available for standard SKF 18 and 50 kg 39 and lb drums. Can be items including 3, mm They can have up to six delivery outlets and are suited perfectly for industrial machines with several lubrication lines.

They make it possible to plan simple and compact centralized lubrication systems with no need to maintain multiple lubricant containers. They work in harsh operating conditions or in severe environments. The GSE drum pump units come without a pump element.

These pump elements, type GS The drum pump units are initially delivered without pump elements. The pump elements have to be ordered separately.

Follower plate order no. It is 1 performed from outside by means of a counter nut and a set screw, which 7 adjusts the valve piston stroke. It uses one energy source air and can deliver greases up to NLGI grade 2 from Ordering details different size containers.

Therefore you have to indicate when ordering, the inner diameter in mm of the lubricant drum you intend to use. At the same time, you have to select the material of the wiper seal, which corresponds the best to your lubricant. We are currently offering a FPM or a nitrile wiper seal. For any further technical information, please contact SKF. PTEX extruder pump for 25 kg drum electric equipment Distributors and quick connectors.

Adapter with cylindrical thread Adapter with tapered thread. Ordering details Adapters with cylindrical thread Order no. Ordering details Adapters with tapered thread Order no. Banjo fittings with cylindrical thread Banjo fittings with tapered thread Elbows with tapered thread. Ordering details Banjo fittings with cylindrical thread Order no. Ordering details Banjo fittings with tapered thread Order no. Ordering details Elbows with tapered thread Order no. Length delivered 5 m.

Stainless steel tubing on request. Ordering details Plastic tubing Smallest permissible Perm. Burst Order no. Color: natural colors, black lettering. Tubing thermal aging. For screwed tubing joints, only use At room temperature good resistance to diluted At higher temperatures, the pressure drops in unions with reinforcing sockets.

For main lines connection: pump-feeder and secondary lines connection: feeder-lubrication point.

 

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Mr Leach, whose committee is considering radical propos- down,oad to deregulate financial services, said the need for жмите had been given greater urgency by the announcement on Monday of the proposed merger between Bankers Trust a New York investment bank, and the securities com- pany, Alex.

 
 

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Other Japanese carmakers plan to follow suit but the volume of exports is likely be low as most of the companies already manufacture cars there. Under the agreement, Japanese carmakers can export 7, cars to Taiwan by the end of , of which Nissan’s allocation was 1, units. Nissan said it would begin exporting the 4, cc Inflnltl Q45 next month. The company has a Taiwan production and sales base.

Yulong Motor, which manufactures six Nissan sedan and truck models. A total of 68JXX Nissan cars were sold there in Toyota, Japan’s largest carmaker, said it was currently selecting models to be exported to Taiwan.

The new agreement allows Toyota to export up to L cars this year, but it has not yet decided when it will start the exports. In , Toyota sold about 90, cars. Including those made in the US, in Taiwan. The company also manufactured about 79, cars at a local venture last year.

Honda said it was also considering exporting cars to Taiwan and Mitsubishi Motors said it was considering exporting a sport utility vehicle. It is the second trolley bus contract wan by Skoda in the US – it is supplying 54 bases to Dayton, Ohio. Vincent Boland. The sanctions begin on April Talks in Washington aimed at defusing the dispute will I continue today. Japan has admitted that Japanese port practices are in need of reform but Is seeking to have the sanctions scrapped or at least postponed.

The trip will include a stop in Belo Horizonte. Reuter, Washington EU help for Andean states The European Union yesterday extended trade privileges granted to five Andean nations and said greater effort would be made to increase European investment in the region. In a statement following a meeting of the EU with the foreign ministers of Venezuela, Colombia, Ecuador, Peru and Bolivia, in Noordwijk, in the Netherlands, the EU said the generalised system of preferences GSP trade privileges on agricultural and fisheries products would remain in force indefinitely.

The GSP privileges have been granted chiefly to encourage the replacement of narcotic-drug production with food fanning. The statement said there had been an increase in business opportune tes for investors from both Europe and Latin America which could be directly linked to the GSP privileges. Reuter, Noordzogk cheaply into world markets in order to maintain produc- tion. It has faced complaints of steel dumping even from low-cost producers such as Thailand, Chile and China.

The quotas include , tonnes of steel coils for re- rolling. Quotas will be removed by the end of provided Rus- sia has implemented the nec- essary competition and envi- ronmental legislation. If Russia introduces the new rules – or Joins the World Trade Organisation – before , nffldals said the agree- ment would be reviewed, and the EU might open its market earlier.

The EU will provide tech- nical assistance, under the Tacis programme, to Russia in drawing up legislation, and in improving Russian steel products so they can compete at global prices. The deal also includes a “double-checking” arrange- ment for other Russian steel products not covered by quo- tas, in an attempt to avoid complaints about dumping.

Some 14 per cent of Rus- sian and Ukrainian steel imparts into the EU are cur- rently covered by quotas. Before the collapse of the Soviet Union, the BU exported 5m tonnes of steel there annually, mostly for pipelines. The Soviet Union exported virtually no steel to the EU. Since , however, the situation has reversed.

EU exports to Russia have dwin- dled to hardy As it does in much of the rest of Asia, the war continues to infect rela- tions between China and Japan. But in recent years Japan has emerged as by far the most successful foreign busi- ness power in central China, eclipsing the US and Euro- pean investors in Shanghai Previously lukewarm to China.

Japanese manufac- turers have flocked to the Yangtze delta since Forced by the strong Japa- nese yen to look overseas for potential production sites, they have found the area a nearby, low-cost venue with a potentially vast market for their goods. The service Industries, which came in small num- bers after Sino-Japanese relations were restored in , have grown on the back of the manufacturing exodus.

The US. Of the eight foreign banks this year awarded the first licences to conduct business in local Chinese currency, four were Japanese. The People’s Bank of China ear- lier this month ranked the 40 foreign banks in Shanghai. Mr Terumasa Ihara, far- mer head of Mitsubishi in central China and the likely president of a planned new trading joint venture based in Shanghai, puts it simply. Sanwa Bank and Daiichi-Kangyo Bank won a licence to wort: in local currency Is purely practical- The scale of Japa- nese investments – predomi- nantly in manufacturing — in the area gives Japanese financial institutions the largest immediate client base for Chinese yuan busi- ness.

Less charitable explana- tions for Japan’s success are to be found among foreign rivals, who argue that China overlooks the past because the Japanese are prepared to slash prices and offer sub- stantial finandai rewards to get into the market When the hanking licences were first issued, some west- ern bankers were quick to point out that Japan has an impressive record of conces- sional lending to China for infrastructure and economic development, suggesting a quid pro quo far access to the domestic banking sector.

In joint venture agree- ments. US and European businessmen say the Japa- nese do not show the rigour when it comes to contractual arrangements – particularly over issues of liability and environmental protection – that has become standard for western companies. As western companies have developed reputations as sticklers for contractual detail, Japanese companies are known to sign broad agreements and iron out the problems as they arise. When asked what first came to mind when Japan was mentioned, Mr Itsuo Hashimoto.

Japan’s consul general in Shanghai, acknowledges that passions run deep between the two countries. The UK aero engine maker win help the Moscow-based Lyulka-Satum concern adapt its jet engine, which powers the Sukhoi 27 fighter, for use in power generation. Both partners will contrib- ute expertise and financial resources to the joint venture although the sums involved have not been pub- lished. A joint marketing company has been estab- lished to sell the engine, ini- tially In Russia and eventu- ally abroad.

Mr Victor The pkin , presi- dent of Lyulka-Satum, said the deal, which took three years to negotiate, would lay the platform for further col- laboration between the two companies. Bob Sunerton, manag- ing director of Rolls-Royce industrial and marine power, said his company was attracted to Russia because of the tremendous- potential in the energy field.

A team of Rolls-Royce engineers has helped adapt the Lyulka-Saturn engine applying dry low-emission technology to reduce pollu- tion levels. The Senior Executive Course. For those who don’t set limits. For those high flyers who have aspirations to go even higher, the Senior Executive Course at Manchester Business School, which attracts like-minded leading business people from all over the world, will prove invaluable.

E-mail: P. Ogden fs2. The Boeing continues to change the way the world flies. On March 31st, a flew from Seattle to Kuala Lumpur without stopping. No other jetliner has flown farther. The then continued its flight and set a world speed record for circumnavigating the globe. Of course, speed and distance are only part of the story.

The Boeing has set a new standard for passenger comfort and efficient, reliable service. The record set by the does two things. It demonstrates that this remarkable airplane keeps getting better and better, and explains why you can fly nonstop more places faster on a Boeing than ever before. Republicans have also linked the chemical weapons accord to their broader which include the stream- lining of tha State Depart- ment and other foreign pol- icy institutions, and a more ambi tions a ptiAanfeHe mis- sile defence programme.

Yet when a Latin American nation lets its current account go into the red, warning flags are raised. Although memories of the The government – faced with limited options and elections next year – win have to decide soon if it needs to take action to stem the import flow. After running a trade surplus for many years, the effects of trade liberalisation and a con- sumer boom pushed Brazil witn the red in But just how si gnificant are these figures?

Mr Franco believes it is wrong to draw broad conclusions from the headline level of the current account deficit. Economists should also look at the quality of c a pit al account, and in particular the amount of direct foreign investment.

Political analysts say the decision two weeks ago to impose restrictions on the short-term financing of imparts suggests the gove rn ment is becoming worried about the trade deficit However, its room for man- oeuvre is limited. The government has already actively promoted exports. It has reduced taxes on many exports, is planning to introduce export insur- ance anri the National Development Bank BNDES has expanded the credits available to exporters.

Meanwhile, senior ministers have travelled to the US and Europe, com- plaining about the trade barriers Brazilian goods face. Short of more aggressive financing of exports, which the BNDES recently signalled, there Is little else the gov ern ment am do an this front. Some economists fear the new reg- ulations on import financing will herald greater government attention on import rules.

However, Brazil, which Is already in hot water over its tariff policies for cars and toys, would face intense internation al pres s ure if it chose to raise tariffs further. An actual Interest rate rise Is thought to be unlikely, in part hpremsp qf the pres su re higher inter- est payments would put an the bud- get deficit However, the government could put specific curbs on con- sumer financing, as it did two years ago, such as reducing installment payments or curbing the use of credit cards.

The gover n ment would not want consumers to feel the bite in the run-up to n«rt year’s presiden- tial elections. If the gov ernm ent decides the trade deficit might seriously threaten medium- term economic stability, it will be undo: pressure to move before the end of the second quarter.

Geoff Dyer US wholesalers reported sharply lrigtuw sales and a fall hi stock levels in Febru- ary, a further indication the pace of economic growth is likely to remain strong mov- ing into the second. The incre as e followed a solid 08 per cent rise in January.

As a result, the stocks-to-sales ratio fell to 1. The ratio is significant because it indicates the extent to which wholesalers win be able to meet future demand by running down their supplies in the ware- house. With such relatively low stock levels in Febru- ary. That suggests the current strung pace of growth, in overall demand is likely to cont inu e at least until the summer and perhaps beyond. Wholesalers reported strong sales almost across the board. Durable goods sales rose 2. Nan-durable goods sales rose L4 per cent.

Increases in sales of food, paper, clothing and drags offset small declines in chemicals and petroleum. The figures indicate that the US economy is growing at aw annual rate of about per cent, well above Its long-term potential trend rate. If that continues, it win put further pressure an the Federal Reserve to raise Interest rates. The new outrage was prompted by an amateur video broadcast on the Hobo television ch enrol whi c h a p pe ar ed to show police officers initio da Janeiro h i t ting cffifeanl lined up against a wall with pieces of wood and betts.

The pictures fallow a similar video broadcast by Globdlaat week showing SSo Paulo police apparently beating the drives of several cars stopped at a roadblock and , allegedly murdering a passenger. Mr Chrfttien said he hoped Congress would act soon to give the president authority to negotiate free trade in the Americas, Two-way trade had soared and , trade friction had been consldBrably reduced by the US-Canada and North America free trade pacts,.

Chesterton found that US law firms have taken, or are looking for. The consultants say this is the equivalent of more than one hect- are of floor space. US law firms occupied just , square feet The average size of US law firm offices also seems to be increasing dramatically. At the start of the year there were 30 US law firms with offices In the City, each occupying an average of slightly more than 6, sq ft. The seven firms currently seek- ing space are looking for an aver- age of sq ft, a rise of per cent.

Chesterton’s Mr Mark Bourne said the rale of thumb was that US law required sq ft per law- yer. That implied that the US law firms would be taking on another lawyers to fill the , sq ft they have taken or are looking for. The awards are aimed at encouraging oil companies to explore the sea to the west of the Shetland Islands – off the north-east coast of Scotland – as the established North Sea fields decline. The awards have been made in time for the success- fill bidders to start seismic surveys during the summer.

The awards, the 17th round of licensing for UK offshore exploration rights, were given in 25 tranches to 14 companies. Fourteen of the tranches awarded, covering 76 blocks, are for an area off the Heb- rides – on Scotland’s west coast – called the Rock all Trough. A further seven tranches, covering 28 blocks, lie north of Shetland.

Just four tranches, covering 10 blocks, are in the North Sea. Of the blocks on offer. Enterprise Oil said the bid- ding reflected the impor- tance of the Atlantic areas to oil companies. Green- peace intended to use its licences to cany out wildlife surveys. Mr Page said its applica- tion had been rejected on the grounds that licences awarded under the Petro- leum Production Act ; required applicants to intend to carry out oil and gas exploration.

The plan was commissioned by an insurance company concerned that it might have problems meet- ing future claims, and is designed to ease financial pressures on the company and protect policyholders who otherwise might have to wait years for payments if it failed.

The company declined to be identified. Insolvency professionals charged with Uqnhkrting those that could not meet r-laWnw have been learn- ing the lessons of a costly and cumbersome process. Several have introduced schemes for insolvent insurers which pay a percentage of all the im« earlier than might normally be expected and at less expense.

Price Waterhouse may shortly set a. It is preparing a plan which will require the policy- holders of a still solvent insurance company, assuming they agree, to provide estimates for present and future claims against it. The scheme devised by Price Waterhouse would use the existing assets of the insurer to make a single, final payment, called a commutation, to policyholders and head off the difficulties which could result in Insolvency.

The pressures which have forced insur- ers from run-off into liquidation are intense. All of them are vul- nerable to claims getting worse, reinsurers foiling , and the costs of managing a to- year process. The government wants to see fewer insolvencies and is encour- aging preventative cures. The prob- lem is estimating what they will have to pay years in the future” he said.

The criticism was made in a report by Professor Hugh Pennington. The government said it accepted all the 32 recommendations and would implement some of them soon, it accepted that raw meat and cooked meat prod- ucts should be kept separate at all stages of production and storage, with the two types of food handled if pos- sible by different staff.

It noted that the government had a preference for deregu- lation and a presumption against prescription. Mr Michael Forsyth, chief minister for Scotland, who commissioned the report, said there was too much reg- ulation, and confusion about how regulations were to be applied. Labour said the report vin- dicated its charge that the government had focused too heavily on the interests of the industry to the detri- ment of consumers. The public accounts com- mittee said it was concerned that a government grant scheme to encourage new rail freight facilities had foiled to make much impact over the past 10 years.

The committee accused the Department of Transport of failing to promote the scheme, and of using out- dated environmental crite- ria to assess rail projects. The MPs said they were “concerned that freight facility grants may be hav- ing less impact than the government and parliament intended”. The transport department pays grants for new rail freight terminals according to the environmental bene- fits, calculated by setting rates for truck miles removed from roads. Bat the committee said the department had foiled to revalue truck mile rates “for many years”, and had not revalued them to take account of inflation, as min- isters promised in Freight transferred to rail as the result of grants has fallen from 16m tonnes a year in to about 10m tonnes a year in The growing strength of Asian markets is good news for business everywhere.

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In particular, the association is catling for a single retail regulator to replace the current two-level system, in which a lead regulator, the Securities and Investments Board, oversees a handful of self-regulating bodies. The association also proposes a switch in regulatory emphasis from detailed rules to broad princi- ples supported by detailed guid- ance. This is broadly in line with the proposals of both Labour and consumer groups. But there are still differences between what the industry and the Labour party wants.

He said the elderly would be liv- ing in acute poverty into tbe next century in a pensions crisis that will peak in Although the criti- cisms were not formally agreed by the bank’s board of directors, many were aware of the comments and did not express their disapproval.

Most senior trade union leaders are on the board. The party is also commit- ted to retaining the state eamings- related pensions scheme as an option. The manifesto proposes higher taxes to pay for improved public services, a scheme to create up to , jobs, and calls for Wales to have its own “powerhouse parliament.

The party won four seats in the last general election, held in , with 9 per cent of the vote. It gained 17 per cent – more than the Conservatives – in the European elections three years’ ago. It has been an appalling government, and their attitude and perfor- mance in Wales has been totally unacceptable. It has ditched all the principles it stood for and cannot, or will not, deliver the policies that Wales needs. The Conservatives described Plaid Cymru as living in a fantasy world and Labour protested that the last thing Wales needed was more taxes.

The government says a Welsh parliament would jeopardise the continuing revival of the economy by raising costs and deterring investment. Inward investment has given Wales a modern industrial base, with a a big- ger manufacturing sector proportionately than the UK as a whole. Welsh industries Include in consumer elec- tronics, automotive compo- nents, aerospace engineer- ing and healthca r e products. Despite big job losses in coal mining and steel, overall unemployment has fallen to about the national average.

Shares that might benefit from a Labour win in tbe May 1 general election rose by 0. The worst performer was Brit- ish Steel, down 4. FTSG bxtex ‘ qg – -» Star. Mr Major told a press conference in Birmingham that the reforms, which would be introduced in the first year of a new Conservative government, would transfer some of the burden on small companies to larger ones. A total of , companies could expect to make savings. Payments could be as low as 1. It said many UK companies wanted the intro- duction of a st a t u tory right to interest on overdue bills, Katharine Campbell writes.

The survey said UK com- panies pay on average 18 days late. Over half of all invoices were paid after they were due; only Portu- guese and Irish companies showed a worse record. Mr McCartney accused the Conservatives of “covering up their betrayal of Britain’s businesses by telling lies about Labour”.

Editorial comment. The AIWS represents 24 commercial weather service pro- viders and claims that the Met Office’s membership of Ecomet, an EU-ap proved body promoting cooperation between EU govern- ment weather services, is anti- competitive. Oceanroutes, a Scotland-based weather consultancy which heads the AIWS, said the Met Office was free to set prices in the absence of an independent regulator.

The European Commission said it could not pursue the complaint because there was no evidence of price fixing and no legal ground on which it could proceed. The weather data gathered by the Met Office, which is funded by the UK Ministry of Defence, was freely available before tbe Ecomet agreement It is now charged to independent organisations, includ- ing its own commercial section, at 15 per cent of turnover.

A Commission official said pri- vate companies such as Ocean- routes would like to receive the information collated by the Met Office free, as happens in the US. Tbe Commission said that ideally the Met Office should set up a sub- sidiary company to perform its commercial activities. The Com- mission added that it lacked the legal tools to require such a change. It stressed that the Met Office was required to present accounts so that they could be rhaeteeri for evidence of cross-subsidies.

Ford saw r its share of the March market drop again to IBS per cent from John Griffiths. London It’s pure Scandinavian. Oril SAS on A ritualised, long-winded Joke, usually with a dark twist at the end, the anekdot reached its apex in the Soviet era, when the cruel incom- petence of the poUtbnro provided rich material for black humour.

Even in this new era of raw capital- ism, the deeply cynical anekdot remains a favoured genre – although it has shifted its sights to Russia’s brash nouveanx riches.

Rot this sea- son ike lords of the airwaves have decided that nowadays, when they turn on their television sets, Russians are searching for tighter fare. That, at least, seems to be the ratio- nale behind a new crop of sitcoms, the first comic serials ever to be made in Russia. The most ubiquitous, with twice daily broadcasts ou one of the main national channels, is Strawberry Cafe Kbtbnichka.

Strawberry Cafe’s producers have dearly done their time in the video library watching old American sitcoms and they seem to have paid partic ular attention to dusty copies of Cheers.

Cheers’ Russian cousin is resolutely light-hearted. Customers are more likely to order elegant cups of coffee than vodka and the paterfamilias, who works as the chef, is slender, long- haired and perpetually bopping to the rhythm of his Walkman. Taken together, it is a sufficiently alien envi- ronment to prompt one reviewer to wonder whether it was set in some imagined utopia, in which Russia had conquered Italy, or maybe Spain. This week, smmy Strawberry Cafe set out to tackle one of the gritty reali- ties of post-communist Russia: violent crime.

With the iron predictability that rules the world of sitcoms, bis hoa x is followed by the real tiling: as soon as Stasik leaves, an armed robber in an identical mask, storms in. In a sugared version of the boy-who- cried-wolf. The robber is petted, hugged, kissed, drenched with maternal tears and offered money and gifts.

Of course, Stasik eventually reappears and the mistaken identity is revealed, bat the outpouring of hot Russian emotion has forged a band between the thief and his would-be victims and they all part as friends. Canned laughter and predictably amiable endings are. Yet even by the relaxed stan- dards of the idiom. Strawberry Cafi is strikingly out of synch with the soci- ety which has produced it The tear- soaked sentimentality of the caffe has no place on the mean streets of post- Soviet Russia, where policemen are as likely to rob as to protect and head- kerchiefed babushkas fight their way to the front of queues with all the delicacy of Arnold Schwarzenneger.

It is thus imminently satisfying that Strawberry Cafi, billed by its creators as one of the most sophisticated, west- ern-style new offerings, has been roundly panned by Russian critics. Russians, who avidly consume re-rnns of Santa Barbara, a US soap, and steamy Latin American serials, appear to be unconvinced by the effort to transplant the glitz and banality of western television life to a domestic setting.

Indeed, innocuous Strawberry Cafi is so offensive to the Russian psyche that it prompted one reviewer to write in apocalyptic tones of the decline of a nation which once spent its evenings with Chekhov, Tolstoy and Lermontov bat had now descended to weakly aping American mass cul- ture. S urprisingly the nostalgic cho- rus was joined this week by Igor Ugolnikov, one of the rising young stars of the Rus- sian airwaves.

Ugolnikov hosts Good Evening Dobryi Vechery. Are yon dis- gusted by the gum-chewing, mobfle- telephone-talking new Rnssians in the seats next to yon? His guests are boring, the music is out-dated by at least two decades, the jokes are Bmp and the visual gags predictable. On Monday Ugolnikov played host to two ageing divas and a mathematics professor who is a fireworks aficio- nado. He had the sort of polite, routine chat with each of them that yon might strike up on the train.

The songbirds’ brief p erfor ma nces were a Hash-beck to the Soviet-era: s yrupy love lyrics, a strobe-lit disco ball and elevator music melodies. Another correspondent, Liudmila Alexandra vna, a pensioner from St Petersburg, proved to be one of Good Evening’s rare fans. The letters were genuine, sad and fanny – all of the qualities the rest of the programme lacked.

Good Evening is produced by the video wizards who performed magic last year by conjuring up the intelli- gent, heartfelt campaign clips which convinced Russians to reelect the sick and unpopular Boris Yeltsin as presi- dent. What they have not yet grasped is the more trivial art of popular television entertainment, which needs a dash of irony and a stylish setting in tune with the Zeit- geist to save it from utter Insignifi- cance.

For that failure the good view- ers of Russia – who prefer Chekhov and Tolstoy anyway – should perhaps be grateful. Is there anyone else getting the same RSS problems? Anyone that knows the answer can you kindly respond? The issue is something that not enough men and women are speaking intelligently about.

Everybody has to begin at the beginning at some point. On that observe, lets begin learning about internet hosting. Internet hosting companies preserve large networks of high-powered internet server computers in a physical location known as a knowledge center.

These computer servers are related to a very fast, and generally redundant, Web connection. The info centers have main and backup energy, a quick connection to the Web, and a security monitoring staff. The hosting companies present a share of disk space and out there bandwidth to a customer for a month-to-month fee. The monthly fee the web hosting company charges is far less than what it would value to run a server out of your personal dwelling or information center. That is the reason these companies exist.

They care for all the hardware, software, and other technical wants for you. Shared hosting is the most well-liked type of hosting. Shared hosting is a portion of disk area and bandwidth provided to you by the web hosting firm on a high-powered server.

There are numerous different websites hosted on this server, and the hosting company is likely to have quite just a few of those servers in a big information center.

The sources of the server are shared by as many different websites as are allotted to that computer. A private-label plan allows the reseller to keep the total monthly payment of the net-hosting buyer, but the reseller must pay a month-to-month price to the bigger internet hosting firm for the reseller space.

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However, lubricating grease. Ten deep groove ball SKF has decided to increase that to bearings are fitted into 5 housings and 1, N in order to make the test filled with a given quantity of grease. The test is undertaken at a pre— determined speed and temperature.

False brinelling Both an axial and radial load is applied Anti—fretting properties of a grease and the bearings run until failure.

The can be relevant for certain applications. Two ball thrust bearings the grease life. This information can are loaded and oscillated. The wear be used to determine relubrication on each bearing is then measured. Greases offer good fretting protection when the measured wear is below 7 mg. LDTS 1 oil has been especially developed for the automatic lubrication of conveyors in the food processing industry. The base oils and additives of this lubricant comply with the FDA regulations and can be used according to EC regulations for incidental contacts with foodstuffs.

Number and registered by the phenomenon. LDTS 1 has an anti-wear bacterial development in equipment effect on partially worn conveyors. Product packaged in 5 liter cans; 4 cans per case. Specific gravity 0. Available pack sizes 5 liter can — ml automatic ml automatic ml automatic liter drum 0.

Available pack sizes — g tube — ml cart. It provides an easy and clean alternative to manual grease packing of open bearings. Screw in the gun tube changing cartridges, and proceed as 6. Close the toggle-type fastener The piston pumps with a block feeder follows: 7. Open the toggle-type fastener rod up to the stop stackers and construction machinery as 2.

Unscrew the gun tube 8. Change the cartridge lubricant outlets depending on the Ordering details block feeder. Every stroke of the lever Complete unit Number of outlets delivers 2 cm3 of lubricant to the feeder. VGBL VGBL 1 Gun only. The level of the lubricant in the cartridge can be checked by pulling See Accessories chapter for tubing, fittings and connectors. See Lubricants chapter for grease cartridges.

When the cartridge is full, the piston rod can be pulled out approximately mm. Ordering details Function diagram Progressive feeder Number of Number of plug outlet pairs maximum hexagon socket SW 3 pistons outlets.

O-ring Dimensions of carrying case W x D x H x x mm Single—point automatic lubricators LAGE and Reliable, reusable lubricator system meets many needs.

Accurate calculation of DialSet 4. After Russian, Chinese and Thai. DialSet 4. From www. SYSTEM MultiPoint automatic lubricator LAGD Multiple grease lubrication installations with multiple lubrication accuracy, makes it an excellent solution points, this can be a time—consuming for longer bearing life and increased points made easy and costly process.

The upper reservoir allow you to effectively adjust the is an airtight container storing correct oil level during running replacement oil. Through its extended conditions, optimizing machine neck, which dips into the oil of the performance and increasing the service lower reservoir, the two reservoirs life of the applications.

Furthermore, are in direct contact with each other. Compact, automatic, dependable With our compact greaser we have succeeded in developing an automatic, electrically driven centralized lubrication system especially designed for linear guide systems.

The ETP compact greaser does not require a separate control unit. Unlike Permadose dispensers, the compact greaser lubricates only when the machine is running. The compact greaser is easy to install due to its small dimensions and low Ordering details weight.

Number of Outlet Metering mm3 outlets assignment outlet no. PA tube, 1. Adaptors for 2. VGKG M6 x 0. VGKG Compact greaser ETP. LAGD 60 60 ml 2. Lubricant included. The canister and battery pack may be used even at 12 months setting if acti- vated 3 years from production date. SKF has taken the knowledge and expertise of Vogel Lubrication and developed three solutions for grease- lubricated fan and blower bearings.

Fan and blower bearings are often critical to the operation of industrial manufacturing facilities. In some cases, they are in hard-to-access locations. The SKF grease lubrication units for fans can help users ensure that these bearings are being lubricated properly. These units are designed to deliver grease from 2 to 20 points consistently and effectively, providing the right amount of lubrication for extended bearing life.

Ordering details Part no. When ordering, specify the number of points A separate pump element is required for each outlet. Three pump elements with different delivery rates are available so that the volume of grease can be adjusted to the needs of the individual circuits.

This feature ensures that every lube point is supplied with an adequate amount of grease in each lubrication cycle. Control is provided by an integral IGI control and monitoring unit; it can be operated in a time- or load- pulse dependent mode, and with or without monitoring.

Please order cable harness separately. Temperatures and pressures that deviate from these figures lead to different delivery rates. The indicated values must be taken as a basis in the design of a centralized lubrication system. The completely autonomous unit with integrated control system and feeder can supply as many as 20 lube points with exactly metered quantities of grease. Ordering details Integrated control unit with Standard version with Maximum number of Weight visual and acoustic warning filling level monitoring outlet points including grease Order no.

Order no. M10 x 1 VGKP VL-1 Single injector Three injector manifold. Typical Vent Manifold Injector inlet outlet 0. VL Stand alone VL These units deliver a continuous flow of cooled and filtered oil directly to the bearing. The metered pump flow is matched to the bearing and housing size, preventing oil leaks and excessive heat associated with oversized pumping systems. The SKF circulating oil lubrication unit provides the right amount of cool, clean oil directly to each bearing.

The use of circulating oil lubrication may also reduce bearing vibration associated 30 liter tank — basic unit, no controls with the use of grease lubricant at higher speeds. The SKF circulating oil lubrication units are available in three tank sizes; 30 liter 7. Product selection – important note The following table is only a guide to assist in selecting the appropriate SKF circulating oil lubrication unit. Please consult SKF Application Engineering before purchasing and installing this product to ensure the proper unit has been selected based on all operating and application parameters.

Ordering details Housing no. Description Specification. Single-circuit pumps The pump units specified in this section are lubricant delivery pumps without pressure relief fixtures and are designed for continuous operation in circulating and hydrostatic lubrication systems.

These pump units may also be used for hydraulic tasks to the extent permitted by the pressure and viscosity ranges stated in the tables. The permissible pressure and Explanation of the delivery rates vary with the viscosity.

The leaves flanged port R2 open — contrary for further information. If air external port R1. Flanged port R2 of may become thin-bodied or highly is entrained due to low oil level in the the return duct discharges directly into viscous due to changes in temperature. Use a special sealed pump for horizontal flange-mounting of the unit beneath oil level.

Figure 1 Figure 2 Figure 3. Single-circuit units complete with reservoir see page DIN and special reservoirs on request. Return line R screw-plugged before delivery. The base is made of durable aluminum. The flow tube is made of glass, so high temperatures and the use of synthetic oils should present no problems. The Safeflow flowmeter has a straight glass flow tube with an internal calibrated cone extending along its vertical axis.

The float is cylindrical, its O. In operation, the calibrated cone extends through the annular opening in the float, creating the variable orifice needed for measurement as the float moves with flow changes.

Because the oil flows Flow change alarm system switch, which identifies the location through the float, rather than around of a metal float in the tube. The The oil flow through each Safeflow it as in ordinary flowmeters, the float monitoring unit contains the terminals flowmeter can be remotely and is always clearly visible. A white Teflon and the power supply for ten sensors.

The alarm ring on the float marks the reading The system transmits either a single system consists of one alarm sensor point and wipes the inside wall of the alarm from each bank of meters or a for each flow tube and one monitoring glass tube. For use with. Intravenous administration of recombinant tissue plasminogen activator, fastest and widely feasible treatment in acute ischemic stroke induces arterial recanalization, a prerequisite for neurological recovery.

The addition of microspheres can further improve thrombolytic effect. International multicenter CLOTBUST trial showed that acute ischemic stroke patients treated with sonothrombolysis had higher rate of arterial recanalization and dramatic clinical recovery without increasing risk of symptomatic intracranial hemorrhage. A microsphere dose-escalation study called TUCSON showed that rates of recanalization and clinical recovery tended to be higher in target groups compared with controls Sanamed Medical journal.

Even in surgical patients without lung injury, the postoperative pulmonary complications PPCs are frequent. Respiratory monitoring is very helpful for optimizing mechanical ventilator setting to prevent VALI and early detect PPCs during the perioperative period. Sanamed Medical journal , Radmilo Jankovic. Each intubation should result in an extubation at end of procedure, and each extubation, theoretically, could represent a potential reintubation due to extubation manoeuvre failure.

There are many and different reasons for extubation to fail, starting from mechanical iatrogenic lesions due to difficult intubation up to patient’s inhability to sustain spontaneous breathing and unassisted ventilation, going through extubation associated respiratory and cardiovascular complications, local mechanic or inflammatory factors, surgical techniques and accidental events.

Recent literature has clearly shown that if critical events associated with difficult intubation have lower incidence thanks to guidelines diffusion and implementation, extubation related accidents did not change incidence and consequences in last couple of decades. This observation has led to developement of dedicated extubation guidelines and to attention from Scientific Community to promote culture of safety and anticipation, with predicted difficult extubation concept and protected extubation strategies, by using pharmacological and technical approach.

Aim of this paper is to review data for extubation related accidents, to provide overview with existing guidelines and description of approaches to predict difficult extubation, techniques to provide best extubation strategies including pharmacologic, non pharmacologic and instrumental techniques. Radmilo Jankovic. Andrijana Vceva. Miroslav Milankov. Abdul Zahoor , Nauman Ahmad. Vladan Zivaljevic , Branko Milakovic. Sanja Mazic.

Amina Valjevac. Sabaheta Hasic. Vladan Zivaljevic. Gustavo Fabregat. Robert Feneck. Hans-Joachim Priebe. Vesna Bumbasirevic. Daniela Veleska. Zlata Mujagic. Nevenka Ilic. Constantin Apintiliesei. Log in with Facebook Log in with Google. Remember me on this computer. Enter the email address you signed up with and we’ll email you a reset link. Need an account? Click here to sign up. Download Free PDF. Prothrombin complex concentrate versus fresh-frozen plasma in dilutional coagulopathy: a case report.

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Protective mechanical ventilation in patients without or with lung injury. Safe extubation and reintubation in operatory room and ICU patients. Acta chirurgica iugoslavica Preoperative preparation of patients with arterial or pulmonary hypertension in noncardiac surgery.

Acta chirurgica iugoslavica Preoperative preparation of patients with infectious and restrictive respiratory diseases as comorbidities.

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Koszek Bleeding in patients with congenital disorders of haemostasis. Djordjevic Fluid resuscitation in sepsis: What do the data show M. Mostic Ultrasound of the lumbar spine 2 a new challenge for obstretic anaesthetists M. Kendrisic Peripartum cardiomyopathy I. Velickovic Morphine renesanse for postcaesarean pain releif — spinal and epidural application B. Markovic Minimal flow techniques in anesthesia C. Kalezic Specifics of anaesthesia in surgeries on the pituitary gland B.

Milakovic Assessment of perioperative risk in patients with diabetes mellitus V. Malenkovic Hemodynamic disturbances during thyroidectomy M. Stojanovic Risk factors for perioperative hypertension in patients undergoing parathyroidectomy V.

Sabljak Anesthesia aspects of surgical treatment of pheochromocytoma M. Jovanovic Heart transplantation — anesthesia and perioperative treatment M. Flick Safety in Paediatric Anaesthesia E. Were are the gaps? T Xanthos Post2resuscitation Care: current therapeutic concepts J. Milan Interventional treatment for musculoskeletal pain Z. Ladjevic Imagine living without pain…Understanding pain genetics D. Louis School of Medicine, St.

Louis, USA E mail: kangrgai wustl. Since the first successful OLT in [1], the number of liver transplants has been steadily increasing, both in the United Sates and globally. Almost 24,00 liver transplants were performed worldwide in according to the World Health Organization [2], and more than one fourth of those were performed in the US.

AUNOS bylaw mandates that transplant centers appoint a Director of Liver Transplant Anesthesia and establishes the directorship criteria, based largely on the recommendations by the American Society of Anesthesiologists. This decision by UNOS was motivated by the emerging evidence that standardized care by a dedicated liver transplant anesthesia team may influence outcomes and resource utilization, including blood transfusion, length of mechanical ventilation, and ICU and hospital stay.

Most had perioperative protocols. Variability in team membership criteria, structure and responsibilities were associated with center volume, likely reflecting resource availability. The limited utilization of living donation in the US may reflect access to deceased donors, living donor safety concerns and increased cost.

Similarly, the percentage of DCD donations has plateaued, largely due to outcome and resource utilization concerns. The outcomes of OLT have improved dramatically over the years, reflecting advances in perioperative care and immune suppression.

Despite the overall success of the national organ transplant program, transplant centers and perioperative teams face multiple challenges maintaining OLT outcomes in the changing regulatory and economic environment. Recipient data analysis demonstrates rapidly changing demographics of liver transplant candidates, with continued trend towards older and sicker recipients.

Whereas implementation of MELD has been highly successful in its primary goal, reduction of waiting list mortality and the number of patients on the active waiting list, it has resulted in much sicker patients presenting for OLT. This increased severity of recipient illnessis associated with worse outcomes, longer lengths of hospital stay and greater utilization of intensive care unit, ventilator support and dialysis [10], thus putting more pressure on transplant centers. The sustained shortage of liver donors has necessitated the expansion of the donor pool.

As general indices of donor quality,such as the donor risk index DRI [10], correlate with outcomes and resource utilization, use of extended criteria donors has significant implications. Medical and economic implications of recipient severity of illness and donor quality vary markedly within the US. The median national MELD score in was 27, ranging from 21 to 35, reflecting the wide geographic disparity.

Stroke volume response to volume loading is blunted as administered fluids are quickly redistributed to splanchnic circulation, worsening bleeding during the dissection phase of OLT. Restrictive fluid management and use of vasopressors, such as vasopressin or adrenergic receptor agonists, restore central filling volume, stroke volume and organ perfusion, but decrease portal flow and splanchnic hyperemia, and contribute to reduced bleeding during the dissection phase.

Diastolic dysfunction is associated with severity of the post reperfusion syndrome [13], and with development of post transplant heart failure. Similarly, platelet numbers are often reduced but upregulation of Factor VIII and von Willebrand Factor may offset the effects of thrombocytopenia. Clinically, both coagulopathy and pro thrombotic states are common in ESLD.

Low grade fibrinolysis occurs frequently in OLT recipients providing a rationale for the use of antifibrinolytics. Conventional tests, prothrombin time and activated thromboplastin time do not reflect the clotting function or predict bleeding in OLT [15]. Whole blood clotting assays, such as rotational thromboelastometry or thromboelastography, may better inform of the status of the clotting function and are commonly used as point of care tests to help guide a protocolized hemostatic management strategy [16].

Prothormbin complex and fibrinogen concentrates are being investigated as attractive alternatives to fresh frozen plasma and cryoprecipitate, as the association of transfusion with morbidity and mortality in ELSD is well established. The number of transplants performed in individual centers is relatively small compared to other major surgeries.

Consequently,most of the current evidence is based on data from small, non randomized series. Consensus on the best approach to common perioperative practices in OLT, such as transfusion practices, fluid management, etc.

Few health care disciplines are scrutinized as rigorously as the US transplant. Mandatory data reporting and state of the art analysis, result in the largest national outcomes report, the SRTR. Thereport comparestrue outcomes with a rigorously developed, risk adjusted model based on multiple donor and recipient risk factors. Whereas the SRTR report provides critical information to inform governmental regulatory agencies, insurers and policymakers, it falls short of a comprehensive outcomes and quality database that would allow systematic examination of current practice and lead to quality improvement processes in liver transplantation [17].

One good example is perioperative blood transfusion,a factor strongly associated with mortality after liver transplantation. The program has developed a standardized approach to quality improvement with demonstrated potential for reduction in postoperative morbidity and mortality. Conclusions Orthotopic liver transplantation is a well established, effective treatment for patients with ESLD.

Although outcomes of liver transplantation are robust, transplant centers face significant challenges, including trends toward sicker and older recipients, increased use of marginal donors due to persistent donor shortage, and stricter regulatory and financial environment. Current efforts are directed towards refining quality metrics and risk adjusted outcomes, and developing a standardized approach to quality improvement in perioperative care of liver transplant patients.

Homotransplantation of the liver. Transplantation ; 5 Suppl : — Designated liver transplant anesthesia team reduces blood transfusion, need for mechanical ventilation, and duration of intensive care. Liver Transpl ; Reduced use of intensive care after liver transplantation: influence of early extubation.

Anesthesia for liver transplantation in US academic centers: institutional structure and perioperative care. Liver Transpl ; 18 6 : A model to predict survival in patients with end stage liver disease. Hepatol ; Axelrod D. Economic and financial outcomes in transplantation: whose dime is it anyway? Curr Opin Organ Transplant. Cardiovascular complications of cirrhosis. Postgrad Med J. A comparison of intra operative blood loss and acid base balance between vaso pressor and inotrope strategy during living donor liver transplantation.

Anaesthesia ; — Influence of preoperative diastolic dysfunction on hemodynamics and outcomes of patients undergoing liver transplantation. Int J Clin Exp Med ; 6: 7. Diastolic dysfunction in patients with end stage liver disease is associated with development of heart failure early after liver transplantation.

Transplantation ; Lisman T, Porte RJ. Rebalanced hemostasis in patients with liver disease: evidence and clinical consequences. Blood ; 6 : Coagulation management with factor concentrates in liver transplantation: a single center experience. Transfusion ; e published: doi Am J Transpl ; 6: Blood transfusion requirement during liver transplantation is an important risk factor for mortality. J Am Coll Surg ; 1 6. Louis, USA E mail vannucca wustl.

While apparently a simple principle, the mechanisms of success and failure with direct laryngoscopy are still actively debated 2 Video laryngoscopy is performed with instruments that allow visualization of the glottis independently from the alignment of the line of sight with the laryngealstructures glottis and supporting cartilages. These three separate components of a successful intubation have become more recognized by clinicians since the widespread adoption of video laryngoscopes in the clinical practice.

In fact, it is a quite common problemwith the use of these devices tobe able to easily visualize the glottis,while facing difficulties in advancing the tube beyond the vocal cords. While adverse events at the induction of anesthesia have become progressively less frequent and severe, problems at the extubation appear to be an unresolved patient safety issue 9 Practice guidelines have had an important role in reinforcing the principle of planning in advance, suggesting modalities for airway assessment, establishing priorities in difficult airway management, proposing a sequence ofinterventions to adopt in case of difficulties, and endorsing the use of advanced tools to gain control of the airway, or, at least, to maintain oxygenation.

However, there is still a limited experience with the use of this algorithm and, at this point, it is not known if it is having an impact on clinician practices and patient outcomes.

Developing technology and increasing efforts by National and International Societies in designing and diffusing effective guidelines have significantly contributed to reduce adverse outcomes. References: 1. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.

Greenland KB. A proposed model for direct laryngoscopy and tracheal intubation. Levitan RM. The mystique of direct laryngoscopy. Respiratory care. Epstein SK. Decision to extubate. Intensive Care Med. Use of non invasive ventilation to wean critically ill adults off invasive ventilation: meta analysis and systematic review.

Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta analysis. Management of the difficult airway: a closed claims analysis.

Closed claims’ analysis. Part 1: anaesthesia. British journal of anaesthesia. Cavallone LF, Vannucci A. Extubation of the Difficult Airway and Extubation Failure. Anesth Analg. The difficult airway with recommendations for management Part 2 Difficult airway. Canadian Journal of Anesthesia. Frova G, Sorbello M. Algorithms for difficult airway management: a review.

Minerva Anestesiol. Predicting difficult intubation in apparently normal patients: a meta analysis of bedside screening test performance. Review article: video laryngoscopy: another tool for difficult intubation or a new paradigm in airway management? A survey assessing the procurement, storage and preferences of airway management devices by anaesthesia departments in German hospitals.

Eur J Anaesthesiol. Mendonca C. Sugammadex to rescue a ‘can’t ventilate’ scenario in an anticipated difficult intubation: is it the answer? Crosby ET. An evidence based approach to airway management: is there a role for clinical practice guidelines? The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices.

Annals of emergency medicine. Cooper RM. Complications associated with the use of the GlideScope videolaryngoscope. Palatal injury associated with the GlideScope. Anaesthesia and intensive care. Avoiding palatopharyngeal trauma during videolaryngoscopy: do not forget the ‘blind spots’. Acta anaesthesiologica Scandinavica.

Preoperative endoscopic airway examination PEAE provides superior airway information and may reduce the use of unnecessary awake intubation. Kristensen MS. Ultrasonography in the management of the airway. Connor CW, Segal S. The importance of subjective facial appearance on the ability of anesthesiologists to predict difficult intubation.

Accurate classification of difficult intubation by computerized facial analysis. Is video laryngoscope assisted flexible tracheoscope intubation feasible for patients with predicted difficult airway?

A prospective, randomized clinical trial. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block.

Brief review: Supplementing oxygen through an airway exchange catheter: efficacy, complications, and recommendations. Incidence and severity of respiratory insufficiency detected by transcutaneous carbon dioxide monitoring after cardiac surgery and intensive care unit discharge. The accuracy, precision and reliability of measuring ventilatory rate and detecting ventilatory pause by rainbow acoustic monitoring and capnometry.

Seeberger unibas. In vitro and animal models suggested that administration of volatile anesthetic prior to myocardial ischemia reduced myocardial infarct size.

Nevertheless, a recent meta analysis of randomized trials strongly suggest that volatile anesthetics provide clinically relevant anesthetic preconditioning in patients undergoing coronary artery bypass graft surgery. However, studies on the clinical value of preconditioning by volatile anesthetics in noncardiac surgery are scarce.

To obtain scientific data on the value of preconditioning in patients at coronary risk who undergo major noncardiac surgery, we performed a study in three centers in Switzerland University Hospital Basel, Kantonsspital Solothurn, Kantonsspital Liestal.

Between and , we enrolled patients at increased cardiovascular risk. Patients were randomized to maintenance of anesthesia either with sevoflurane or propofol. To assess occurrence of perioperative ischemia, we recorded continuous ECG for 48 hours perioperatively and measured troponin T on postoperative day 1 and 2. To assess the occurrence of major adverse cardiac events MACE , the patients were contacted by phone 6 and 12 months after surgery. MACE were defined as a composite of cardiac death, acute coronary events syndrome, and congestive heart failure or arrhythmia requiring hospitalization.

Patients and outcome assessors were blinded. Myocardial ischemia occurred in 75 Within 12 months, 14 7. The incidence of delirium did not differ The results of this study were published in the journal Circulation in Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery.

N Engl J Med ; 8. Cardiac risk stratification for high risk vascular surgery. Circulation ; 5. Analysis of risk factors for myocardial infarction and cardiac mortality after major vascular surgery. Anesthesiology ; Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery.

N Engl J Med ; Effects of extended release metoprolol succinate in patients undergoing non cardiac surgery POISE trial : a randomised controlled trial.

Lancet ; Statins decrease perioperative cardiac complications in patients undergoing noncardiac vascular surgery: the Statins for Risk Reduction in Surgery StaRRS study. J Am Coll Cardiol ; Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Slogoff S, Keats AS. Randomized trial of primary anesthetic agents on outcome of coronary artery bypass operations. Does choice of anesthetic agent significantly affect outcome after coronary artery surgery?

Anesthetic induced preconditioning: previous administration of isoflurane decreases myocardial infarct size in rabbits. Isoflurane mimics ischemic preconditioning via activation of K ATP channels: reduction of myocardial infarct size with an acute memory phase.

Volatile anesthetics protect the ischemic rabbit myocardium from infarction. Isoflurane pretreatment has immediate and delayed protective effects against cytokine induced injury in endothelial and vascular smooth muscle cells.

Anaesthetic drugs and survival: a Bayesian network meta analysis of randomized trials in cardiac surgery. Br J Anaesth ; Effects of propofol, desflurane, and sevoflurane on recovery of myocardial function after coronary surgery in elderly high risk patients.

Cardioprotective properties of sevoflurane in patients undergoing coronary surgery with cardiopulmonary bypass are related to the modalities of its administration.

Anaesthetics and cardiac preconditioning. Part II. Clinical implications. Sevoflurane but not propofol preserves myocardial function during minimally invasive direct coronary artery bypass surgery. Anesth Analg ; 6, table of contents. Preconditioning with sevoflurane decreases PECAM 1 expression and improves one year cardiovascular outcome in coronary artery bypass graft surgery. Circulation ; Randomized comparison of sevoflurane versus propofol to reduce perioperative myocardial ischemia in patients undergoing noncardiac surgery.

Risk scores and indices In the past 30 years, several risk indices, based on multivariable analyses of observational datato represent the relationship between clinical characteristics and perioperative cardiac mortality and morbidity, have been developed.

Between them, the indices developed by Goldman et al. The Lee index, or revised cardiac risk index, is a modified version of the original Goldman index and it was designed to predict complications such as postoperative myocardial infarction, pulmonary oedema, ventricular fibrillation or cardiac arrest, and complete heart block.

The Lee index has been developed from prospectively collected data from a total of patients divided into a derivation and a validation cohort,and it was considered by many clinicians and researchers to be the best currently available cardiac risk prediction index in noncardiac surgery.

It [9]. Biomarkers A biomarker biological marker is defined as a substance used as an indicator of a biological state, which can be objectively measured and evaluated as an indicator of normal biological processes, pathologic processes, or pharmacologic responses to a therapeutic intervention.