...ARDSnet OXYGENATION GOAL: PaO2 55-80 mmHg or SpO2 88-95% Use a minimum PEEP of 5 cm H2O. Consider use of incremental FiO2/PEEP combinations such as shown below (not required) to achieve goal. Lower PEEP/higher FiO2 FiO2 0.3 0.4 0.4 PEEP 5 5 8 0.5 8 0.9 16 0.5 10 0.9 18 0.6 10 1.0 18-24 0.7 10 0.7 12 NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary FiO2 PEEP 0.7 14 0.8 14 0.9 14 INCLUSION CRITERIA: Acute onset of 1. PaO2/FiO2 ≤ 300 (corrected for altitude) 2. Bilateral (patchy, diffuse, or homogeneous) infiltrates consistent with pulmonary edema 3. No clinical evidence of left atrial hypertension PART I: VENTILATOR SETUP AND ADJUSTMENT 1. Calculate predicted body weight (PBW) Males = 50 + 2.3 [height (inches) - 60] Females = 45.5 + 2.3 [height (inches) -60] 2. Select any ventilator mode 3. Set ventilator settings to achieve initial VT = 8 ml/kg PBW 4. Reduce VT by 1 ml/kg at intervals ≤ 2 hours until VT = 6ml/kg PBW. 5. Set initial rate to approximate baseline minute ventilation (not > 35 bpm). 6. Adjust VT and RR to achieve pH and plateau pressure goals below. Higher PEEP/lower FiO2 FiO2 0.3 0.3 0.3 PEEP 5 8 10 FiO2 PEEP 0.5 18 0.5-0.8 20 0.3 12 0.8 22 0.3 14 0.9 22 0.4 14 1.0 22 0.4 16 1.0 24 0.5 16 __________________________________________________________ PLATEAU PRESSURE GOAL: ≤ 30 cm H2O Check Pplat (0.5 second inspiratory pause), at least q 4h and after each change in PEEP or VT. If Pplat > 30 cm H2O: decrease...
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...Case Study Three 1. What is the definition of ARDS? Acute respiratory distress syndrome (ARDS) occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs. More fluid in your lungs means less oxygen can reach your bloodstream. This deprives your organs of the oxygen they need to function. Acute Respiratory Distress Syndrome (ARDS) is also known as shock lung, wet lung, post perfusion lung and a variety of other names related to specific causes. What are the associated clinical indicators? The first signs and symptoms of ARDS are feeling like you can't get enough air into your lungs, rapid breathing, and a low blood oxygen level. Other signs and symptoms depend on the cause of the ARDS. They may occur before ARDS develops. Sometimes, people who have ARDS develop signs and symptoms such as low blood pressure, confusion, and extreme tiredness. This may mean that the body's organs, such as the kidneys and heart, aren't getting enough oxygen-rich blood. 2. What conditions did this patient experience that are common risk factors ssociated with ARDS? Brain present with near drowniess syndrome that lead to his diagnosis of ARDS. 3. Describe the major pathophysiological alterations in ARDS. Increased capillary permeability is the hallmark of ARDS. Damage of the capillary endothelium and alveolar epithelium in correlation to impaired fluid remove from the alveolar space result in accumulation of protein-rich fluid inside the...
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...Sepsis Related ARDS and PTSD Sepsis Related ARDS and PTSD Acute respiratory distress syndrome (ARDS) is a traumatic life-altering illness that can be caused by sepsis. It can be especially traumatic if it is acquired as a young adult and Post-traumatic stress disorder (PTSD) develops as a person enters into later life. Re-living or even a perception, or fear of a reoccurrence of a traumatic event can manifest itself into PTSD. My PICO question asks: for sepsis related ARDS patients, does the use of counseling reduce the risk of PTSD, compared with patients without counseling? My research on this question could not be fully supported. It is suggested that biological influences and life experience play a much larger role in PTSD than counseling. Post-traumatic stress disorder is a psychological and physical response to a life-threatening trauma. The perception of the trauma is characterized as an individual perception and is different for each person. The psychological response can include re-experiencing the trauma, intrusive thoughts and memories, overwhelming fear, depression and disassociations with the trauma. The physical response can include, but are not limited to, nausea, headache, palpitations, diarrhea, vomiting and insomnia. Without treatment, psychological disabilities can manifest into substance abuse, physical abuse and mental disorders. In order for patients to recover, learning how to expand on the relationship between mental health and physical health and...
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...Sepsis leads to ARDS – Sepsis is the leading cause of ARDS because bacterial cells can activate inflammatory mediators leading to bronchoconstriction, increased alveolar capillary permeability, and vascular narrowing and obstruction. This causes a migration of blood cells and fluids from capillaries leading to pulmonary edema and impaired gas exchange all leading to ARDS. (Lewis med surg 1757) good Sepsis and DIC – protein c levels are decreased in sepsis and DIC. Protein c is anticoag meaning a deficiency could lead to increased bleeding good expand Sepsis to CVA – body’s response to microorganism is exaggerated, increased inflamm and coag and decrease in fibrinolysis. Toxins from microorganism cell wall release cytokines (tnf, il1, il6) and PAF. PA F microthrombi formation and obstruction of microvasculature. Good - set up house in brain....
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... IT MAY NOT WORK IN POLITICS Member of Congress who has been charged with ethics violations. State ethics investigators have charged Lt. Gov. Ken Ard with 69 counts of spending campaign money for his personal use and 23 counts of failing to disclose campaign expenses. Ard, who took office in November, has been under scrutiny since taking office for thousands of dollars of purchases, including meals and hotel rooms – particularly those made post-election – listed on his campaign finance reports. In a news release, the State Ethics Commission said it found probable cause for the charges and likely will send out a hearing notice. As lieutenant governor, Ard fills a part-time position with little real power, presiding over the state Senate and overseeing the state’s Office on Aging. The lieutenant governor also becomes governor should the governor die or resign from office. ethics investigators have charged Lt. Gov. Ken Ard with 69 counts of spending campaign money for his personal use and 23 counts of failing to disclose campaign expenses. Former South Carolina Lt. Gov. Ken Ard received 5 years probation, a 5,000 fine, and 300 hours in community services after pleading guilty to seven counts of violating the State Ethics Act. Ard pleaded to four counts of unlawful reimbursement of campaign contributions, two counts of falsely filing campaign reports, and one...
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...Stem Cells as a Treatment Overview: Stem cell research is a highly promising field of study. Its most important applications include medicine and therapy. These will be the focus of this paper. To begin: an overview of stem cells, alternatives to embryonic stem cells, and recent advances. Stem cells are amazing for their capacity for self-renewal and, most of all, the ability to become any of millions of cell types in the human body. There are various types of stem cells, each with different potential. This includes embryonic stem cells. These totipotent cell lines come from the inside of the cell mass of a human embryo. These embryos are taken specifically from fertilized eggs not used by in-vitro fertilization (1). At this point, they are just a blastocyst, meaning an embryo composed of approximately one hundred cells. The cells on the inside of the blastocyst are undifferentiated but eventually will multiply and differentiate extensively to make all of the different required cells. Adult stem cells cells also have this same ability. They are found throughout the body and are able to dived to replenish dying cells and regenerate damaged tissues (1). Adult stem cells are able to renew themselves and create a variety of cells, but are usually multipotent, meaning that they only are able to specialize into a small selection of cells. ‘Totipotent’ stem cells can be transformed into any type of cell in the human body, however, there is a great amount of controversy...
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...special education services. Parents or legal guardians of the student are involved in each stage of the process and are given a copy of procedural safeguards, which summarized state and federal requirements for special education services. Once an evaluation is completed, the results are presented in an ARD meeting within 30 days of the time the written report was completed. The ARD committee discusses the results and an Individualized Education Plan or IEP is developed. Annual goals are set, placement is determined, and any accommodations are considered at this time. The Role of the Principal The principal is responsible for implementing any and all decisions made in an ARD or Admission, Review, Dismissal meeting, even if he/she designates an administrative assistant in his/her place. The principal must assure that educational decisions are made in the best interest of the child, and decisions further meet federal and state guidelines; as well as district and campus policies. The Importance of FAPE FAPE or Free Appropriate Public Education is a required component of The Individual with Disabilities Act or...
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...The American Association of Critical Care Nurses is an organization created to promote quality and safety in a critical care setting along with promoting the latest evidence-based practice in critical care. The association offers many articles for health care providers to utilize to ensure safe and quality care to patients. For example, the AACN provides articles that involve encouraging bedside report, implementing mock codes into effect to prepare the staff in the event of a real emergency, safe transport of an ICU patient while being transported to tests, and early mobility. Drahnak and Custer (2015) discussed in length the importance of critical care nurses knowing the benefits of prone positioning in combating Acute Respiratory Distress...
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...point. (2) In its 2001 Horizontal Guidelines it therefore provided guidance on when it considered standard setting to be unproblematic. Since the adoption of the 2001 standardisation Guidelines, a number of issues have come to the fore. It became increasingly clear that malpractic‑ es were occurring in the standard setting process which could lead to serious distortions of com‑ petition. (3) In response, the Commission revised the Guidelines in 2010 to provide more guid‑ ance to standards bodies on how they could de‑ sign their rules so as to avoid restrictive effects on competition. (4) This purpose of this article is to provide the full picture on standard‑setting. It starts by outlining why competition law is concerned at all by stand‑ ards. It then covers in more detail some of the is‑ sues that have arisen. The extended guidance in the revised Guidelines is then fleshed out in more de‑ tail. Finally, some thought is given to the future of standardisation. Standards have a positive effect in the economy insofar as they promote economic interpenetra‑ tion in the common market or encourage the de‑ velopment of new markets and improved supply conditions. Standards tend to increase competition and allow lower output and sales costs, thus ben‑ efiting the economy as a whole. These benefits are (1) The content of this article does not necessarily reflect the official...
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...The Alternative Dispute Resolution (ADR) allows an opportunity for the LRC and the CRC to resolve this dispute without the court. The ADR is faster, does not cost as much and the stress of the ARD is nowhere near to going to court. An ADR has a high level of satisfactory results. An ADR is good for solving disputes in business and partnerships that are in disputes. There are three methods that can be pursued with this ADR case. The three methods are Arbitration, Mediation, and Case Evaluation. A person in the ADR process is someone who is trained, neutral in the case, and chosen by both the LRC and the CRC or the court. Mediation The ARD uses a mediator to assist each party to come to a resolution that is acceptable to both in the dispute. The mediator is not the one who decides but mediates it for them to decide how to resolve. What is unique about the ARD is it allows both parties to express themselves in a confidentially to work out a resolution with flexibility. Arbitration This method allows for a arbitrator to hear the arguments, look over the evidence and make decisions that will resolve the disputes. The difference in arbitration and having someone to mediate is that arbitration is less formal, quicker, while cheaper than a traditional lawsuit. There are two types of arbitration, non-binding and binding. A binding arbitration results in the arbitrator's decision being the final decision which can be no trials to appeal the decision...
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...tachycardia, dyspnea, increased blood pressure and patient-ventilator dyssynchrony. Prolonged anxiety levels can also induce psychological effects such as increased fear and inhibitions. This can ultimately affect the patient’s overall capacity to cope with difficult emotions and situations (Richart-Martinez & Perpina-Galvan, 2009). These effects can lead to the need for more sedation which can hinder weaning attempts. The longer a patient is mechanically ventilated the greater the risk of developing Ventilator Associated Pneumonia, (VAP), and Adult Respiratory Distress Syndrome (ARDS). VAP is a pneumonia that develops 48 hours or longer after mechanical ventilation. It results from the invasion of the lower respiratory tract and lung parenchyma by microorganisms. Intubation compromises the integrity of the oropharynx and trachea and allows oral and gastric secretions to enter the lower airways. ARDS is a life-threatening lung condition that prevents enough oxygen from getting into the blood. The purpose of this study is to evaluate the effectiveness of stress reducing, non-pharmacologic interventions on mechanically ventilated patients when used in conjunction with pharmacologic interventions to decrease overall anxiety. Research efforts of...
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...INTERNET VS STORE-BASED SHOPPING: THE GLOBAL MOVE TOWARDS OMNICHANNEL RETAILING Euromonitor International August 2014 INTERNET VS STORE -BASED SHOPPING: THE GLOBAL MOVE TOW ARDS OMNICHANNEL RETAILING Passport I LIST OF CONTENTS AND TABLES Executive Summary ..................................................................................................................... 1 Growth Drivers .......................................................................................................................... 1 Internet Retailing Trends .......................................................................................................... 2 Chart 1 Global Internet Sales by Category 2013....................................................... 2 Behaviour and Characteristics of Online Shoppers .................................................................. 3 Retailer Strategies .................................................................................................................... 4 Outlook ..................................................................................................................................... 6 Summary 1 Opportunities and Threats to Retailers ......................................................... 6 Introduction................................................................................................................................... 7 A New Way of Shopping ...................................................
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...INTERNET VS STORE-BASED SHOPPING: THE GLOBAL MOVE TOWARDS OMNICHANNEL RETAILING Euromonitor International August 2014 INTERNET VS STORE -BASED SHOPPING: THE GLOBAL MOVE TOW ARDS OMNICHANNEL RETAILING Passport I LIST OF CONTENTS AND TABLES Executive Summary ..................................................................................................................... 1 Growth Drivers .......................................................................................................................... 1 Internet Retailing Trends .......................................................................................................... 2 Chart 1 Global Internet Sales by Category 2013....................................................... 2 Behaviour and Characteristics of Online Shoppers .................................................................. 3 Retailer Strategies .................................................................................................................... 4 Outlook ..................................................................................................................................... 6 Summary 1 Opportunities and Threats to Retailers ......................................................... 6 Introduction................................................................................................................................... 7 A New Way of Shopping ...................................................
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...dazu beigetragen, dass die Deutschen ein gelassenes Bild ihrer Mentalität und Gewohnheiten gewinnen konnten", erklärte Lammert. Die ARD-Vorsitzende Monika Piel erinnerte an die "unnachahmliche Komik und Intelligenz" des "feinsinnigen Humoristen und Humanisten", der es verstanden habe, "Menschen aller Generationen zu unterhalten - ihnen auch manches Mal den Spiegel vorzuhalten - ohne dabei zu verletzen". Seine zeitlosen Sketche und Filme seien nicht nur Teil der deutschen Fernsehgeschichte, viele Dialoge hätten längst ihren Platz in unserem Alltag gefunden. Vicco von Bülow werde unvergessen bleiben. FOTOSTRECKE * * * 14 Bilder Loriot: Der große deutsche Humorist ist tot Loriot galt als Deutschlands erfolgreichster und nobelster Humorist, durch Bücher, mit Karikaturen und satirischen Prosastücken, Filmauftritten, Fernsehserien und Spielfilmen erreichte er ein Millionenpublikum. Seine zahlreichen Sketche sind legendär - etwa die Nudel im Gesicht beim verpatzten Rendezvous, der missglückte Auftritt des Lottogewinners Erwin Lindemann oder die Cartoons "Herren im Bad" und "Das Frühstücksei". Auch seine beiden Kinofilme "Ödipussi" (1988) und "Pappa ante Portas" (1991) begeisterten Millionen Menschen. Loriot wurde zunächst mit Zeitschriften-Cartoons und Knollennasen-Männchen bekannt. Später kamen die Fernsehsketche, etwa in der ARD-Serie "Loriot I-VI" (Erstausstrahlung 1976-1979), hinzu. In Sketchen wie über die Familie...
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...As I checked the food supply and water supply of my dive system. I noticed that i forgot to fill the water supply. This of course is really important since it will be the food and drinks I will be living from for the upcoming weekend. The dive system is a system which allows you to let your consciousness enter a game. This of course became popular real quick. It was expensive though, it cost 15000 dollar! It cost me an entire 2 years of saving while practically living of nothing to buy the system. There were other cheaper options but they were not that good compared to the 15000 dollar system. There are allot of games for this platform but I mostly only play ARD. It is the standard fantasy game, but it was the first game in it’s genre which did things just right. I of course played the hell out of this...
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