text:
Special Correspondent
To be effective from this year
Relaxation of norms for BDS course
Land Reforms Act to be amended
THIRUVANANTHAPURAM: The Kerala Cabinet on Wednesday decided to raise the retirement age of doctors in medical colleges from 55 to 60 years.
Chief Minister V.S. Achuthanandan told the media after the weekly Cabinet meeting that the decision would take effect from this year.
The relaxation of norms for the Scheduled Tribes for admissions to the MBBS course would be made applicable to the BDS course as well. An ordinance would be issued to change the rules in that regard.
The Cabinet sanctioned Rs.50 lakh for paying compensation for the properties damaged in the accident and explosion involving a gas tanker near Karunagapally recently. This would be in addition to the Rs.50 lakh provided by Indian Oil Corporation as compensation.
The Tranvancore Devaswom Board would be requested to provide Rs.5 lakh each as solatium to the dependents of those killed in the accidents on their way to Sabarimala on Tuesday.
Mr. Achuthanandan said the Land Reforms Act would be amended to address the problems faced by Karayma kudians (tenants) as suggested by the High Court. The court had held that the amendment made to the Act in 1999 was ultra virus of the Constitution. So, the Cabinet decided to have a fresh amendment to protect the interests of the tenants.
He said the Cabinet had approved a proposal to allow local self-governments to use funds earmarked as maintenance grant and development fund for 2009-10 and 2010-11 for road works this year itself. It also approved a revised estimate of Rs.56 crore for the bus terminal complex of the Kerala State Road Transport Corporation at Thampanoor in Thiruvananthapuram. The Kerala State Transport Finance Development Corporation would be undertaking the work. Besides, the Cabinet sanctioned 31 new posts for the taluk hospital at Mavelikara and decided to increase the bed strength by 100.
Replying to questions about the attack on writer Paul Zacharia, the Chief Minister said he did not agree with Mr. Zacharia's comments about communists. However, he had the right to expression as a citizen. That was not being denied.


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OASIS Program Web Library
Welcome to GSA's OASIS Program Web Library. GSA provides and maintains this resource for all federal agency personnel involved in acquiring complex professional services through the OASIS and OASIS Small Business (SB) IDIQ contracts. The website and materials are available and accessible through the Contract Administration Fees (CAF) assessed on OASIS and OASIS SB task orders.
GSA will expand the resource base as necessary to meet our customers' needs for support in planning and acquiring professional services to meet their agencies' missions. Users can email firstname.lastname@example.com to place a request for additional resource types.
Please see the OASIS reference material shown below for additional information:
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- OASIS Ordering Guide [PDF - 946.86KB]; and
- OASIS SB Ordering Guide (June 2014) [PDF - 786.56KB].
Creating the Statement of Work (SOW):
- Seven Steps to Performance-Based Acquisition;
- Best Practices for Multiple Award Task and Delivery Order Contracting; and
- Increasing Competition and Structuring Contracts for the Best Results [PDF, 103.90KB].
After the Award:
Sustainability Reporting:
- Model Sustainability Reporting for Task Orders [PDF - 105.95KB]; and
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Top Chef Chicago-- Do you have a favourite yet?
- h
- hungrystudent257 Apr 19, 2008 06:09 PM
I love Jen, Andrew, Mark, and Stephanie
I think Lisa has a lot of work to do do bring herself to the top of the pack, but she shows promise.
Dale would be so much more likeable if he wasn't so self righteous all the time. Stop complaining about everyone else and comparing them to you.
I've barely noticed Antonia so far.
Does anyone else think that Richard might be overqualified?
Nikki isn't good enough to be there. Period. Never was. I can't believe she made it this far.
I hate Spike with the burning passion of a thousand suns. If he was a good enough cook, he wouldn't have to make snide comments and bring other people down--- Charcuterie platter? Come on.
Your thoughts?
re: Phaedrus
I like Stephanie and Antonia seems okay but I will reserve judgement until I see more from her...not seasoning the beef was pretty terrible. Don't hate anyone either, I do find Andrew grating in that tweaker, suck up kind of way but hate....no. Nikki is a giant yawn and for the life of me I cannot figure out why she has stuck it out this long, her food looks so dull. Spike had me at the street taco he made that sent Bayless swooning but has lost me with his, "I'm too real" attitude. Richard seems like a very edgy chef but I'm just not into that kind of food....seems to lack soul and needs a dash of passion. Who else? Lisa is that the bacon girl? That bacon sounded so delicious I can overlook the negative grumbles for now. I still like the show but so far 1 & 3 seemed to have better chefs.
re: Phaedrus
Andrew is jumpy and seems to be jacked on cocaine all the time
Spike has an annoying accent, a stupid hat and an undeserved superior air
re: hungrystudent257
correction--spike has many, many hats. sometimes he wears more than one per episode.
re: Phaedrus
I know Stephanie from her restaurant which was walking distance from my house. Shame it closed. She does good work.
Anyway I'm leaning in her direction, but also very impressed with Richard's kitchen and people skills.
Stephanie has been my favorite since the first episode. I like her calm, cool collectedness (not a word, but it works for me). She's a good leader, and is able to turn around a potential mishap (shopping in WF and seeing someone else buy shrimp and changing the menu on the fly) and keep everyone on a mostly even keel.
Richard is inventive, and he's grating less on me. I also like Mark, but he's the exact opposite to Stephanie when it comes to organization and thought pattern.
Dale's good - but I agree - his "in your face" business is more obnoxious than Hung was last year. Hung had the chops to win; but I'm not sure Dale does.
Dislike Andrew and Spike both because of their "I'm better than all of you" (but then can't understand why they don't win every time when their food sucks). I also disliked Zoi and Ryan, but they're both outta there, so that's a moot point.
Antonia, until Ep. 6, was sort of invisible. Nikki should have been gone a long time ago - she's been lucky because others have cooked worse that she has. But her stats prove she can't hang with the big boys/girls.
re: LindaWhit
No one is more obnoxious than Hung was!! Dale doesn't come even remotely close.
Kiwi Mark gets my vote thus far. Seems like a drama-free person who'd be fun to crack a beer with. There are likely better cooks in the group, but I like that they cast somewhat of an outsider. Props to him for being self taught and finding his way from a sheep farm to NYC. He almost got booted for being a mess at the tailgate, but hey - I can totally relate. Who among us can't BBQ a new meal for a big group without being totally covered in sauces, tasting things with the fingers and generally managing chaos?
re: tastyjon
"Who among us can't BBQ a new meal for a big group without being totally covered in sauces, tasting things with the fingers and generally managing chaos?"
Apparently all the other contestants.
re: tastyjon
oh, i agree. i think mark is a dark horse. i just like his palate, it's very different. and he seems quite competent and well-skilled, especially for being self-taught.
As I was telling a friend I don't find anyone on the show particularly likeable. Ryan was a joke from the start. He appeared to me to be one of those people who is in love with idea of cooking and not with cooking itself. Thus he has all these bright ideas but doesn't have the chops to pull them off. Lisa and Stephanie both definitely have good chops but both are a bit abrassive to me. Why must anyone (and women in particular) use the f-bomb so casually. Nimma and Nikki are just underqualified and never belonged on the show.
re: Chinon00
While I completely agree with you on Lisa's abrasiveness, I can't see how you can consider Stephanie to be the same way. That I can recall, she's never dropped the F-bomb, and is relatively calm, cool and collected - even to the point of resolving issues between Lisa and Dale a few episodes back.
re: LindaWhit
The amuse-biatch blog actually counted profanities in an early episode, and Stephanie actually beat out Andrew and everyone else. I have no memory of what words were actually bleeped. I agree that Steph is coming across as calm, cool, and controversy-smoothing. She's definitely anti-abrasive in my book, and my current fave.
re: momjamin
Stephanie and the Bleep-O-Meter? LOL I'd have to go back and watch that episode - I honestly can't recall her doing that!
re: momjamin
Hey I think of myself as a level-headed person (in the kitchen or elsewhere) but I swear like a sailor (when not at work or on Chowhound ;) ). I guess that can be seen as a bad trait but the swearing doesn't bother me at all. It's a kitchen...if you've ever worked in a kitchen or restaurant you realize that a lot of the time curses are being thrown around left and right (and usually in multiple languages).
re: Elyssa
It's the cursing in the kitchen AND during one on one interviews that can become tiresome (and contrived looking).
re: Chinon00
"Why must anyone (and women in particular) use the f-bomb so casually"
I agree that the F-bomb is thrown around wayyyyyy too much this season, but I don't see why it is worse when women do it. Professional kitchens are among the most verbally vulgar places in the world, so it is unsurprising that the profanities are flowing so freely, however.
re: Greyhoundgrrl
This is way off topic but I see it as an attempt by some to blur gender in society. You see it in women's athletics too.
gotta go with richard. i really appreciate how inventive his food is. as i said in the most recent episode's thread, few of the top chef contestants make what i'd call boring food, but everything he makes gets me really interested, and wanting to not only eat but cook.
I am definitely on Team Steph!!
She's a CT girl, glad to see she's representing us all so well :)
to win, i like stephanie, richard, dale-- in no particular order. they are the top tier. it would be cool to see stephanie win because it's top chef chicago and her restaurant is in chicago. dale also has hometown rights.
wildcards: antonia, jen. i think jen could do better if she focussed a little. i think they both are solid cooks who have turned out some nice things, great palates, but they might not have technical chops to pull out the big wins at the end.
and the rest:
nikki sUUUUUUUUUUUcks with her boring housewife food
spike sUUUUUUUUUUUcks with his cluelessness, condescending attitude toward his audience and the other contestants. he's that guy from some backwater who moves to nyc for a year and then proceeds to talk down to everyone in the entire world because they don't live in nyc. meanwhile his cooking isn't nearly as sophisticated as he thinks it is-- botched summer roll, for goodness sake(?). he can't execute nearly as well as he thinks he can (everybody else just doesn't get it), and he suffers from the delusion in team challenges that his teammates are working *for* him (poor memo).
andrew drives me nuts with the constant tweaking and 12 year old sense of humor, but i have to say he cooks better than other people in the competition. maybe he could pull a 3rd place if he'd just chill a little bit. oh, and if he *never* pulls the tapioca box out for the rest of the competition. or dresses like a "little chef". or wears a silly helmet while cooking.
mark is definitely playing with bigger dogs than himself, but he's shown interesting innovation, perspective, and flavor. heck he can use marmite in fine cooking successfully. he's really taken a beating lately, and it shows in his attitude and execution. he's a goner if he doesn't adjust his attitude and clean up his work area--as the competition tightens i'd wager mark gets eliminated for a small oversight or error, or for a more serious one, like sanitation, that he doesn't seem to focus on.
i almost forgot about lisa because she's such a black hole, personality-wise. she has good execution but seems to have trouble conceptualizing whole dishes & plating. we've seen her rely heavily on stephanie in team competition, her individual plates tend to fall flat. i don't think she'll be in the competition much longer unless she can step it up.
as long as nikki and spike go next i'll be stoked to follow along. it should get more interesting as the fat gets trimmed and the contestants have more opportunity to shine individually.
re: soupkitten
Soupkitten, that's really odd because I have the exact same take of the contestants as you do! And I mentioned in another TC thread about your take of the episode coincided with mine (pretty much word for word).
Yes, Nikki and Spike must go! Nikki reminds me of a more homemade version of Sandra Lee. And the more I see Spike, the more I get annoyed with him -- probably because I know so many people like him. They just move to NY and think they're so cool and they like to "keep it real."
re: Miss Needle
that's so funny, twice now! i love your posts too Miss Needle btw! we are on the same wavelength halfway across the country & that's why i love these boards! :)
re: Miss Needle
Perhaps y'all are doppelgangers.
re: Phaedrus
separated at birth! :)
re: soupkitten
Ha ha. Yeah, it's really eerie. : )
re: paris221966
I agree, this is the weakest group.
Not sure the winner of this seasoun could even touch any of the previous losers.
re: HarryK
Richard and Dale, they seem to come up with real 'inventive' dishes
Stephanie has executed pretty well, but so far i haven't seen anything creative or something I haven't seen that could potentially come out of a cookbook
re: attractivekid
"Stephanie has executed pretty well, but so far i haven't seen anything creative or something I haven't seen that could potentially come out of a cookbook"
Given that chefs author many cookbooks I'm not sure that this is a negative.
re: attractivekid
A few judges said on the movie challenge that it seemed like a real original idea. I think that was the challenge at least.
Well, hate's too important an emotion to waste on someone you don't even like (or know, for that matter...)
My favorite, going away, is Stephanie. I also like Richard and Mark. Antonia seems to be peeking through.
I don't care for either Spike or Andrew. Spike is just nasty. Is Andrew on Speed?
The others are just "there," imho. Dale is probably the best of the rest imho. His attitude is tiring, more than anything. Old stuff.
I think Stephanie and Richard show that they have lots of head chef experience. Richard isn't overqualified by TC standards, or they would not have accepted him for the show. He probably is the most experienced chef of the bunch. and he has a lot of poise. Stephanie seems more confident now that in the earlier episodes. I hope she wins.
I'm a big fan of Stephanie's, plus, she's a hometown girl! I'm also really digging what Richard does. I think the top 3 will be Stephanie, Richard and Dale.
Speaking of Spike, he is opening up a restaurant in DC in May. I wonder if he is doing this with his Top Chef winnings? Hmmm....
re: Phaedrus
Oh please no. He cannot win. Please.
But it also looks like family members (mother, father, siblings, cousins) are involved as well. Perhaps just cashing in on the potential success with Spike being on the show? And looks like his mother was a former chef as well and she and her husband have owned other restaurants.
re: LindaWhit
Given his demeanor as a "professional" chef, do you think he was adopted?
re: Phaedrus
I don't think they've actually filmed the finale yet.
re: Phaedrus
Don't worry.. they haven't even filmed the finale yet, and they go to elaborate lengths to prevent leaks, including redundant filming, etc. They aren't going to let a contestant go "Hey, I'm in the top 3.. lets open a restraurant!" I have a relative who works on the show, and that person is close lipped even when we the family members ask for a clue.
re: grant.cook
Since you're family, couldn't you blackmail them with unflattering childhood photos? Like posting that posed baby picture on a bearskin rug on Chowhound. :)
re: Phaedrus
No, they have to agree to "take my first born child" sort of penalties, so its not worth it. And it is exciting to watch the show, not knowing what might happen.. I can always ask about the backstory later..
re: Phaedrus
but richard has a new restaurant, too!
re: Phaedrus
I think the final is live.
The way I look at the cheftestants is by breaking them into groups/tiers
Top tier:
Dale, Richard, Stephanie and Antonia (being on the border between tiers).
I find that Dale and Richard have the basics and do take risk with their dishes. However, that might be their downfall too. They might try something new where it just won't fly and they're out.
Stephanie is very solid and seems to have a very good, sensible palate. She may win by playing it towards the safe side.
Anotnia has not seen much airtime, but she seems to have some solid skills too.
Middle Tier
Andrew, Jennifer and Mark/Lisa
Andrew seems to have good skills but can't seem to focus.
Jennifer seems to have her mind elsewhere.
Mark/Lisa are inconsistent. They do well and next they're making terrible stuff. These two can be middle or bottom tier. These two need more time ojt to mature their skills a bit.
Bottom Tier - the one trick pony group
Spike... Vietnamese spring rolls. Spike is definitely play the game as a game. He's trying to throw people off by being the abrasive, unlikeable sort. However, he doesn't have the skills to be the closer.
Nikki... handmade pasta
re: dave_c
"Spike ...He's trying to throw people off by being the abrasive, unlikeable sort. "
The funny thing is he thinks he's such a great upstanding guy.
re: Miss Needle
Kind of like Howie and Joey on Season 3?
re: Phaedrus
Similar -- except that Howie has kind of redeemed himself in my eye because he finally came to the realization he was a bit of an a**, even before he saw himself on TV. And I don't think Spike will ever come to that because he thinks he's so enlightened.
This pic of Spike with the old woman sealed the deal for me:
re: Miss Needle
<This pic of Spike with the old woman sealed the deal for me:>
heheheh if he likes the "older generation" so much, why wasn't he looking at the woman instead of the camera?
Send that boy home!
re: ChefJune
oh my god- the spelling in that caption made me want to die.
"i love the older *genertation,* *there* always so interesting *to."
im no grammatical genius but that's just terrible.
re: Phaedrus
I see Spike deliberately stirring the pot and pushing people's buttons more in an Ilan sort of way, while Howie and Joey both had big egos and butted heads with one another. Ilan, however, would incite other's on his behalf while he dropped back behind the scenes.
re: dave_c
That's a great comparison. I sometimes block Season 2 out of my head.
re: dave_c
Look how well it worked for bratty little Ilan.
I disagree about the chefs this season not being as good as other seasons. The top three will likely be some combination of Stephanie, Antonia, Dale or Richard. I'd put any three of them against the top three of any of the previous seasons.
I don't think (last year's) Dale, Casey, Ilan, Ilia, Marcel or Dave could challenge any of them. In my opinion only Harold, Tiffany and Hung are in their class.
Stephanie is unstoppable!
Looking at elimination results:
As of episode 6, she has 5 "highs" two of which are wins! No other cheftestant in the history of the show has such a stellar record.
To compare, as of episode 6 in past seasons:
Hung had 2 "highs" and zero wins
Ilan had two "highs" both of which were wins
Harold had two "highs" one of which was a win
Add to this her winning personality, her calm under pressure, and her wide range of skills, and I think we're looking at the first female Top Chef (just as long as she doesn't screw up the restaurant challenge).
And no, I don't keep track of all these numbers, that's what Wikipedia is for.
re: Morton the Mousse
compared to a lot of other folks in the mix since she's actually been a chef/owner of a restaurant already - hopefully she'll do well!
I'm cheering for Stephanie right now. She clearly has the chops, is funny and stears away from the drama.
I think Dale has some interesting ideas and doesn't seem to bother me as much as he does other people.
Andrew entertains me to no end plus I think he's a damn fine cook. I also think Jen can stay in for awhile longer, Mark too.
Lisa--annoys me. Her negative attitude really grates me the wrong way. Don't care how she cooks, I wouldn't want to be in the kitchen with her.
Antonia--She seems fine enough. She's not going to make it to the final 3 though.
Richard--I can't decide how I feel about him. I'm sure he's talented but I like things with a little less technology, smoke, and stuff.
Spike--BOOOOOOOOO! He (or his family---it's a little unclear) is opening up a burger joint near my office in DC and I hope I get a chance to meet him to see if he's really that big of a tool.
I like Mark. He brings an interesting perspective to the kitchen. I'd like to see him do well.


text: Pediatric Anatomy, Physiology & Pharmacology 848th FST Introduction Of primary importance to the pediatric anesthesia provider is the realization that infants and children are not simply a small adult. Their anesthetic management depends upon the appreciation of the physiologic, anatomic and pharmacologic differences between the varying ages and the variable rates of growth. Also of importance is a general knowledge of the psychological development of children to enable the anesthetist to provide measures to reduce fear and apprehension related to anesthesia and surgery. Definitions • Preterm or Premature Infant: < 37 weeks • Term Infant: 38-42 weeks gestation • Post Term Infant: > 42 weeks gestation • Newborn: up to 24 hours old • Neonate: 1-30 days old • Infant: 1-14 months old • Child: 14 months to puberty (~12-13 years) Body Size • The most obvious difference between children & adults is size • It makes a difference which factor is used for comparison: a newborn weighing 3kg is – 1/3 the size of an adult in length – 1/9 the body surface area – 1/21 the weight • Body surface area (BSA) most closely parallels variations in BMR & for this reason BSA is a better criterion than age or weight for calculating fluid & nutritional requirements Body Size Fetal Development • The circulatory system is the first to achieve a functional state in early gestation – The developing fetus outgrows its ability to obtain & distribute nutrients and O2 by diffusion from the placenta • The functioning heart grows & develops at the same time it is working to serve the growing fetus – At 2 months gestation the development of the heart and blood vessels is complete – In comparison, the development of the lung begins later & is not complete until the fetus is near term Fetal Circulation • Placenta – Gas exchange – Waste elimination • Umbilical Venous Tension is 32-35mmHg – Similar to maternal mixed venous blood – Result: • O2 saturation of ~65% in maternal blood, but ~80% in the fetal umbilical vein (UV) – Low affinity of fetal Hgb (HgF) for 2,3-DPG as compared with adult Hgb (HgA) – Low concentration of 2,3-DPG in fetal blood • O2 & 2,3-DPG compete with Hgb for binding, the reduced affinity of HgF for 2,3-DPG causes the Hgb to bind to O2 tighter – Higher fetal O2 saturation Fetal Circulation • P50 is 27mmHg for adult Hgb, but only 20mmHg for fetal Hgb – This causes a left shift in the O2 dissociation curve • Because the bridge between arterial & tissue O2 tension crosses the steep part of the curve, HgF readily unloads O2 to the tissue despite its relatively low arterial saturation Fetal Circulation Fetal Circulatory Flow • Starts at the placenta with the umbilical vein – Carries essential nutrients & O2 from the placenta to the fetus (towards the fetal heart, but with O2 saturated blood) • The liver is the first major organ to receive blood from the UV – Essential substrates such as O2, glucose & amino acids are present for protein synthesis – 40-60% of the UV flow enters the hepatic microcirculation where it mixes with blood draining from the GI tract via the portal vein • The remaining 40-60% bypasses the liver and flows through the ductus venosus into the upper IVC to the right atrium (RA) Fetal Circulatory Flow • The fetal heart does not distribute O2 uniformly – Essential organs receive blood that contains more oxygen than nonessential organs – This is accomplished by routing blood through preferred pathways • From the RA the blood is distributed in two directions: – 1. To the right ventricle (RV) – 2. To the left atrium (LA) • Approximately 1/3 of IVC flow deflects off the crista dividens & passes through the foramen ovale of the intraatrial septum to the LA Fetal Circulatory Flow • Flow then enters the LV & ascending aorta – This is where blood perfuses the coronary and cerebral arteries • The remaining 2/3 of the IVC flow joins the desaterated SVC (returning from the upper body) mixes in the RA and travels to the RV & main pulmonary artery • Blood then preferentially shunts from the right to the left across the ductus arteriosus from the main pulmonary artery to the descending aorta rather than traversing the pulmonary vascular bed – The ductus enters the descending aorta distal to the innominate and left carotid artery – It joins the small amount of LV blood that did not perfuse the heart, brain or upper extremities Fetal Circulatory Flow • The remaining blood (with the lowest sat of 55%) perfuses the abdominal viscera • The blood then returns to the placenta via the paired umbilical arteries that arise from the internal iliac arteries – Carries unsaturated blood from the fetal heart • The fetal heart is considered a "Parallel" circulation with each chamber contributing separately, but additively to the total ventricular output – Right side contributing 67% – Left side contributing 33% • The adult heart is considered "Serial" Fetal Circulatory Flow Fetal Circulatory Flow Cardiac Malformations • The parallel nature of the two ventricles enables fetuses with certain types of cardiac malformations to undergo normal fetal growth & development until term because systemic blood flow is adequate in utero – Complete left to right heart obstruction does not impede fetal aortic blood flow – The foramen ovale & ductus arteriosus provide alternate pathways to bypass obstruction Fetal Circulatory Flow • Summary: – Ductus Venosus shunts blood from the UV to the IVC bypassing the liver – Foramen Ovale shunts blood from the RA to the LA – Ductus Arteriosus shunts blood from the PA to the descending aorta bypassing the lungs – Fetal circulation is parallel – Blood from the LV perfuses the heart & brain with well oxygenated blood Fetal Pulmonary Circulation • Fetal Lungs – Extract O2 from blood with its main purpose to provide nutrients for lung growth • Neonatal Lungs – Supply O2 to the blood • Fetal lung growth requires only 7% of combined ventricular output Fetal Pulmonary Circulation • Fetal pulmonary vascular resistance (PVR) is high & helps restrict the amount of pulmonary blood flow – If not for the low resistance ductus arteriosus (DA) & adjoining peripheral vascular bed the RV would need to pump against a higher pulmonary resistance than the LV – Instead, both ventricles face relatively low systemic vascular resistance established by the low resistance / high flow from the placenta Transitional & Neonatal Circulation • There are 3 steps to understanding transitional circulation – 1. Foramen Ovale: ductus arteriosus & ductus venosus close to establish a heart whose chambers pump in series rather than parallel • Closure is initially reversible in certain circumstances & the pattern of blood flow may revert to fetal pathways – 2. Anatomic & Physiologic: Changes in one part of the circulation affect other parts – 3. Decrease in PVR: The principal force causing a change in the direction & path of blood flow in the newborn Transitional & Neonatal Circulation • Changes that establish the newborn circulation are an "orchestrated" series of interrelated events – As soon as the infant is separated from the low resistance placenta & takes the initial breath creating a negative pressure (40-60cm H2O), expanding the lungs, a dramatic decrease in PVR occurs – Exposure of the vessels to alveolar O2 increases the pulmonary blood flow dramatically & oxygenation improves Transitional & Neonatal Circulation – Hypoxia and/or acidosis can reverse this causing severe pulmonary constriction – The pulmonary vasculature of the newborn can also respond to chemical mediators such as • Acetylcholine • Histamine • Prostaglandins – **All are vasodilators Transitional & Neonatal Circulation • Most of the decrease in PVR (80%) occurs in the first 24 hours & the PAP usually falls below systemic pressure in normal infants • PVR & PAP continue to fall at a moderate rate throughout the first 5-6 weeks of life then at a more gradual rate over the next 2-3 years • Babies delivered by C-section have a higher PVR than those born vaginally & it may take them up to 3 hours after birth to decrease to the normal range Transitional & Neonatal Circulation Transitional & Neonatal Circulation Persistent Pulmonary Hypertension (PPHN) • In 1969 a syndrome of central cyanosis was observed in neonates who had no: – Parenchymal pulmonary disease – Abnormal intracardiac relationships – Structural heart disease • The syndrome was called persistent fetal circulation (PFC) & was identified by: – Increased PVR – Patent foramen ovale – Patent ductus arteriosus Persistent Pulmonary Hypertension (PPHN) • A failure of the newborn's circulation system to change from normal intrauterine to extrauterine patterns results in an abnormal shunting of blood from right to left via persistent fetal pathways • However, because the placenta is no longer in continuity with the newborn's cardiovascular system – The condition is not really persistence of the fetal circulation – Therefore, the syndrome is more accurately referred to as persistent pulmonary hypertension of the newborn (PPHN) Persistent Pulmonary Hypertension (PPHN) Persistent Pulmonary Hypertension (PPHN) Persistent Pulmonary Hypertension (PPHN) • Treatment – Optimal oxygenation – Hyperventilation – Sedation – Paralysis – Extracorporeal membrane oxygenation (ECMO) • Reserved for severe & persistent cases only Persistent Pulmonary Hypertension (PPHN) • Implications for Anesthesia: – Pathophysiologic mechanisms that trigger this condition • Hypercarbia • Acidosis – Arterial Blood Sampling • Right radial artery or temporal arteries – More meaningful since these areas reflect the values in the blood reaching the brain & coronary arteries • Left radial artery – May be misleading because the left subclavian is very close to the ductus – Pulse Oximeter Probes • Should be placed on right upper limb or head Closure of the Ductus Arteriosus, Foramen Ovale & Ductus Venosus Ductus Arteriosus • Closure occurs in two stages – Functional closure occurs 10-15 hours after birth • This is reversible in the presence of hypoxemia or hypovolemia – Permanent closure occurs in 2-3 weeks • Fibrous connective tissue forms & permanently seals the lumen – This becomes the ligamentum arteriosum Persistent Ductus Arteriosus • Also referred to as Pathologic PDA – Requires surgical closure & differs from the normal ductus in tissue structure – The PDA in the preterm infant is due to a weak vasoconstrictor response to O2 and should be considered a normal not pathologic response • This PDA may still need surgical correction • A left to right shunt through the ductus can flood the lungs of the premature infant prolonging mechanical ventilation, eventually leading to pulmonary edema & right sided heart failure Persistent Ductus Arteriosus • Anesthetic Considerations – Excessive fluids may reopen a ductus or permit excessive left to right shunting through an already open ductus – Intraoperative short falls • Strict fluid management • Attention to acid base balance • Oxygenation • Ventilation – All are very important in premature infants to avoid reopening the ductus & causing CHF Persistent Ductus Arteriosus • A PDA may also be beneficial – In cyanotic congenital heart malformations with right to left & decreased pulmonary blood flow • The PDA may be the major route by which the blood reaches the pulmonary arteries to receive O2 • In this case closure of the DA causes severe cyanosis, tissue hypoxia & acidemia • To keep the ductus open prior to palliative or corrective surgery of the heart malformation, PGE 1 (0.05- 0.1mcg/kg/min) can be administered IV • To help close the ductus prior to surgical intervention to ligate the PDA, Indomethacin (0.1-0.2mg/kg) can be administered – This is an inhibitor of PGE synthesis Foramen Ovale • Increased pulmonary blood flow & left atrial distention help to approximate the two margins of the foramen ovale – This is a flap like valve & eventually the opening seals closed – This hole also provides a potential right to left shunt – Crying, coughing & valsalva maneuver increases PVR which increases RA & RV pressure – A right to left atrial & intrapulmonary shunt may therefore readily occur in newborns & young infants Foramen Ovale • Probe Patency – Is present in 50% of children < 5 years old & in more than 25% of adults – Therefore, the possibility of right to left atrial shunting exists throughout life & there is a potential avenue for air emboli to enter the systemic circulation – A patent FO may be beneficial in certain heart malformations where mixing of blood is essential for oxygenation to occur such as in transposition of the great vessels – Patients who rely on the patency of the foramen require a balloon atrial septoplasty during a cardiac cath or a surgical atrial septectomy Ductus Venosus • This has no purpose after the fetus is separated from the placenta at delivery Cardiovascular Differences in the Infant • There are gross structural differences & changes in the heart during infancy – At birth the right & left ventricles are essentially the same in size & wall thickness – During the 1st month volume load & afterload of the LV increases whereas there is minimal increase in volume load & decrease in afterload on the RV • By four weeks the LV weighs more than the RV • This continues through infancy & early childhood until the LV is twice as heavy as the RV as it is in the adult Cardiovascular Differences in the Infant • Cell structure is also different – The myocardial tissues contain a large number of nuclei & mitochondria with an extensive endoplasmic reticulum to support cell growth & protein synthesis during infancy • The amount of cellular mass dedicated to contractile protein in the neonate & infant is less than the adult – 30% vs. 60% • These differences in the organization, structure & contractile mass are partly responsible for the decreased functional capacity of the young heart Cardiovascular Differences in the Infant • Both ventricles are relatively noncompliant & this has two implications for the anesthesia provider – 1. Reduced compliance with similar size & wall thickness makes the interrelationship of the ventricular function more intimate • Failure of either ventricle with increased filling pressure quickly causes a septal shift & encroachment on stroke volume of the opposite ventricle Cardiovascular Differences in the Infant – 2. Decreased compliance makes it less sensitive to volume overload & their ability to change stroke volume is nearly nonexistent • CO is not rate dependent at low filling pressures but small amounts of fluid rapidly change filling pressures to the plateau of the Frank-Starling length tension curve where stroke volume is fixed – This changes the CO to strictly being rate dependent – Additional small amounts of fluid can push the filling pressure to the descending part of the curve & the ventricles begin to fail – The normal immature heart is sensitive to volume overloading Cardiovascular Differences in the Infant • Functional capacity of the neonatal & infant heart is reduced in proportion to age & as age increases functional capacity increases – The time over which growth & development overcome these limitations is uncertain & variable – When adult levels of systemic artery pressure & PVR are achieved by age of 3 or 4 years the above limitations probably no longer apply Autonomic Control of the Heart • Sympathetic • Parasympathetic innervation of the innervation has been heart is incomplete at shown to be complete birth with decreased at birth therefore we cardiac catecholamine see an increased stores & it has an sensitivity to vagal increased sensitivity to stimulation exogenous norepinephrine – It does not mature until 4-6 months of age Autonomic Control of the Heart • The imbalance between sympathetic & parasympathetic tone predisposes the infant to bradycardia – Anything that activates the parasympathetic nervous system such as anesthetic overdose, hypoxia or administration of Anectine can lead to bradycardia – If bradycardia develops in neonates & infants always check oxygenation first Autonomic Control of the Heart • Atropine may inhibit vagal stimulation – Is always given prior to, or at the same time, that Anectine is given or anytime that vagal stimulation will be present such as in an awake intubation • Dose of Atropine is 20mcg/kg where the minimum dose for children is 0.1mg – Anything less than 0.1mg can cause paradoxical bradycardia which may occur secondary to a dose dependent (low dose) central vagal stimulating effect of the drug Circulation • The vasomotor reflex arcs are functional in the newborn as they are in adults – Baroreceptors of the carotid sinus lead to parasympathetic stimulation & sympathetic inhibition – There are less catecholamine stores & a blunted response to catecholamines • Therefore neonates & infants can show vascular volume depletion by hypotention without tachycardia Cardiovascular Parameters • Parameters are much different for the infant than for the adult – Heart rate: higher • Decreasing to adult levels at ~5 years old – Cardiac output: higher • Especially when calculated according to body weight & it parallels O2 consumption – Cardiac index: constant • Because of the infants high ratio of surface area to body weight – O2 consumption: depends heavily on temperature • There is a 10-13% increase in O2 consumption for each degree rise in core temperature Circulation Variables in Infants Respiratory System • Neonatal adaptation of lung mechanics & respiratory control – Takes several weeks to complete • Beyond this immediate period the lungs are not fully mature for another few years – Formation of adult type alveoli begins at 36 weeks postconception • Represents only a fraction of the terminal air sacs with thick septa • It takes more than several years for functional and morphologic development to be complete Respiratory System • Neural & chemical controls of breathing in older infants & children are similar to those in adolescents & adults – A major exception to this is found in neonates and young infants, especially in premature infants less than 40-44 weeks postconception • In these infants, hypoxia is a potent respiratory depressant, rather than a stimulant • This is due either to central mediation or to changes in respiratory mechanics • These infants tend to develop periodic breathing or central apnea with or without apparent hypoxia – This is most likely because of immature respiratory control mechanisms Respiratory System • During the early years of childhood, development of the lungs continues at a rapid pace – This is with respect to the development of new alveoli • By 12-18 months the number of alveoli reaches the adult level of 300 million or more – Subsequent lung growth is associated with an increase in alveolar size Respiratory System • Lung volumes of infants is disproportionately small in relation to body size – Since the infant's metabolic rate, in relation to body weight, is twice that of the adult, more marked differences are seen in respiratory frequency and in alveolar ventilation – The higher level of alveolar ventilation in relation to FRC makes the FRC a less effective buffer between inspired gases & pulmonary circulation • Any interruption of ventilation will lead rapidly to hypoxemia & the function of anesthetic gases in the alveolus will equilibrate with the inspired fraction more rapidly than occurs in adults Respiratory System • Functional Residual Capacity (FRC) – Determined by the balance between the outward stretch of the thorax & the inward recoil of the lungs • In infants, outward recoil of the thorax is very low – They have cartilaginous chest walls that make their chest walls very compliant & their respiratory muscles are not well developed • Inward recoil of the lungs is only slightly lower than that of an adults Respiratory System • The FRC of young infants in conditions such as apnea , under general anesthesia and/or in paralysis decrease to 10-15% of TLC – Total Lung Capacity (TLC) is normally ~50% of an adults – 10-15% TLC is incompatible with normal gas exchange because airway closure, atelectasis & ventilation/perfusion imbalance result • Awake infants are normally as capable of maintaining FRC as older children & adults – This is important because it limits O2 reserve during apnea and greatly reduces the time before you see a drop in oxygen saturation Respiratory System • Breathing Patterns of Infants – Less than 6 months of age • Predominantly abdominal (diaphragmatic) and the rib cage (intercostal muscles) contribution to tidal volume is relatively small (20-40%) – After 9 months of age • The rib cage component of tidal volume increases to a level (50%) similar to that of older children & adolescents, reflecting the maturation of the thoracic structure – By 12 months • Chest wall compliance decreases • The chest wall becomes stable & can resist the inward recoil of the lungs while maintaining FRC • This supports the theory that the stability of the respiratory system is achieved by 1 year of age Anatomic Differences in the Respiratory System • Anatomic Airway Differences are Many • Upper Airway: the nasal airway is the primary pathway for normal breathing – During quiet breathing the resistance through the nasal passages accounts for more than 50% of the total airway resistance (twice that of mouth breathing) – Except when crying, the newborns are considered "obligate nose breathers" • This is because the epiglottis is positioned high in the pharynx and almost meets the soft palate, making oral ventilation difficult – If the nasal airway becomes occluded the infant may not rapidly or effectively convert to oral ventilation • Nasal obstruction usually can be relieved by causing the infant to cry Anatomic Differences in the Respiratory System • The Tongue: is large & occupies most of the cavity of the mouth & oropharynx – With the absence of teeth, airway obstruction can easily occur – The airway usually can be cleared by holding the mouth open and/or lifting the jaw – An oral airway may also be helpful Anatomic Differences in the Respiratory System • Pharyngeal Airway: is not supported by a rigid bony or cartilaginous structure – Is easily collapsed by: • The posterior displacement of the mandible during sleep • Flexion of the neck • Compression over the hyoid bone – Chemoreceptor stimuli such as hypercapnia & hypoxia stimulate the airway dilators preferentially over the stimulation of the diaphragm so as to maintain airway patency Anatomic Differences in the Respiratory System • Laryngeal Airway: this maintains the airway & functions as a valve to occlude & protect the lower airway – In the infant the larynx is located high (anterior & cephlad) opposite C-4 (adults is C-6) – The body of the hyoid bone is between C2-3 & in the adult is at C-4 – The high position of the epiglottis & larynx allows the infant to breathe & swallow simultaneously • The larynx descends with growth • Most of this descent occurs in the 1st year but the adult position is not reached until the 4th year – The vocal cords of the neonate are slanted so that the anterior portion is more caudal than the posterior Anatomic Differences in the Respiratory System • Laryngeal Reflex: is activated by stimulation of receptors on the face, nose & upper airways of the newborn – Reflex apnea, bradycardia & laryngospasm may occur – Various mechanical stimuli can trigger response including: • Water • Foreign bodies • Noxious gases – This response is very strong in newborns Anatomic Differences in the Respiratory System Anatomic Differences in the Respiratory System Anatomic Differences in the Respiratory System Anatomic Differences in the Respiratory System • Narrowest area of the airway – Adult is between the vocal cords – Infant is in the cricoid region of the larynx • The cricoid is circular & cartilaginous and consequently not expansible • An endotracheal tube may pass easily through an infants vocal cords but be tight at the cricoid area – The limiting factor here becomes the cricoid ring – This is also frequently the site of trauma during intubation • 1mm of edema on the cross sectional area at the level of the cricoid ring in a pediatric airway can decrease the opening 75% vs. 19% in an adult • There should be an audible air leak at 15-20cm H2O airway pressure when applied Anatomic Differences in the Respiratory System Anatomic Differences in the Respiratory System • Trachea – Infant: the alignment is directed caudally & posteriorly – Adult: it is directed caudally • Cricoid pressure is more effective in facilitating passage of the endotracheal tube in the infant Anatomic Differences in the Respiratory System • Newborn Trachea – Distance between the bifurcation of the trachea & the vocal cords is 4-5cm • Endotracheal tube (ETT) must be carefully positioned & fixed • Because of the large size of the infant's head the tip of the tube can move about 2cm during flexion & extension of the head • It is extremely important to check the ETT placement every time the baby's head is moved Anatomic Differences in the Respiratory System Anatomic Differences in the Respiratory System Anatomic Differences in the Respiratory System • Tonsils & Adenoids – Grow markedly during childhood • Reach their largest size at 4-7 years & then recedes gradually • This can make visualization of the larynx more difficult Anatomic Differences in the Respiratory System • The compliant nature of the major airways of the infant are also different than adults – The diameter of infant airways changes more easily when exposed to distending or compressing forces • With obstruction at the level of the larynx, stridor will be heard mainly on inspiration • With obstruction at the level of the trachea (foreign body), stridor may be heard during both inspiration & expiration • In contrast, during lower airway obstruction (asthma or bronchiolitis), most of the collapse occurs during expiration thus producing expiratory wheeze Anatomic Differences in the Respiratory System • The configuration of the thoracic cage differs in the infant & adult – Infant: ribs are horizontal & do not rise as much as an adult's during inspiration • The diaphragm is more important in ventilation & the consequences of abdominal distention are much greater • As the child grows (learns to stand) gravity pulls on the abdominal contents encouraging the chest wall to lengthen – Now the chest cavity can be expanded by raising the ribs into a more horizontal position Anatomic Differences in the Respiratory System • Lower Airway – Diaphragmatic & intercostal muscles of infants are more liable to fatigue than those of adults • This is due to a difference in muscle fiber type – Adult diaphragm has 60% of type I: slow twitch, high oxidative, fatigue resistant – Newborns diaphragm has 75% of type II: fast twitch, low oxidative, less energy efficient – The same pattern is seen in intercostal muscles • The newborn is more prone to respiratory fatigue & may not be able to cope when suffering from conditions that result in reduced lung compliance (RDS) Anatomic Differences in the Respiratory System • Ventilation/Perfusion Ratio (V/Q) – Infants & children: the distribution of pulmonary blood flow is more uniform than adults • Adults changes from base to apex because of gravity • Infants & children PAP is relatively high & the effect of gravity is less Anatomic Differences in the Respiratory System • V/Q changes in anesthesia – General anesthesia (GA) • FRC & diaphragmatic movements are reduced • Airway closure tends to be exaggerated & the dependent parts of the lung are poorly ventilated • Hypoxic pulmonary vasoconstriction, which diverts blood flow from areas of the lung that are under ventilated, is abolished during GA – This increases the hypoxic tendency Anatomic Differences in the Respiratory System • In General: – Rate & depth of respiration are regulated to expend the least amount of energy – At their given rates, both the infant & the adult expend about 1% of their metabolic energy in ventilation Anatomic Differences in the Respiratory System • Periodic Breathing – Can be observed in the normal newborn infant & frequently occurs during REM sleep – Manifested as rapid ventilation followed by a period of apnea of less than 10secs • During this period arterial oxygenation tension remains in the normal range – Usually not seen in healthy infants after 6 weeks of age Anatomic Differences in the Respiratory System – Apneic spells longer than 20secs are frequently seen in premature infants & are frequently associated with arterial desaturation & bradycardia • Episodes of apnea increase in frequency during stressful situations such as respiratory infection or the postanesthetic & postsurgical states • Apneic spells can be central (originating in the CNS) or obstructive (d/t upper airway obstruction) • Treatment with caffeine & theophylline has been show to be effective in reducing both types in preterm infants Anatomic Differences in the Respiratory System • Tidal Volume – 7-10ml/kg • Dead Space – 2-2.5ml/kg • These two measures remain constant between infants & adults Oxygen Transport • Blood volume of a healthy newborn is 70-90ml/kg • Hemoglobin tends to be high (approx. 19g/dl) – Consisting primarily of HgF – Hgb rises slightly in the first few days because of the decrease in extracellular fluid volume • Thereafter, it declines & is referred to as physiologic anemia of infancy – HgF has a greater affinity for oxygen than HgA – After birth, the total Hgb level decreases rapidly as the proportion of HgF diminishes (it can drop below 10g/dl at 2-3 months) creating the anemia Oxygen Transport – The P-50 rapidly increases at the same time the HgF is replaced by HgA which has a high concentration of 2,3- DPG & so insures efficient oxygen off-loading at the tissues • The gradual decrease in O2 carrying capacity in the first few months of life is thus well tolerated by normal, healthy infants – There is no consensus about the lowest tolerable Hgb concentration for an infant • The lowest limit will depend on factors such as duration of anemia, the acuity of blood loss, the intravascular volume & more important the impact of other conditions that might interfere with O2 transport Oxygen Transport Key Points • Respiratory control mechanisms are not fully developed until 42-44 weeks postconception • Most alveolar formation & elastogenesis occurs during the first year of life – The thoracic structure is insufficient to support the negative pleural pressure during the respiratory cycle until the infant develops muscle strength from upright posture around 1 year old Key Points • Weakness of the thoracic structure is partly compensated for by contractions of the intercostal & accessory muscles – Anesthesia abolishes this compensatory mechanism & the end expiratory lung volume (FRC) decreases to the point of airway closure & alveolar collapse • Infants are prone to upper airway obstruction – Due to anatomic & physiologic differences – Anesthesia depresses pharyngeal & other neck muscles which resist the collapsing forces in the pharynx Key Points • HgF has high oxygen affinity & limits oxygen unloading at the tissue level – This decreases O2 delivery to the tissues that have high oxygen demand – Infants & young children are prone to perioperative hypoxemia & tissue hypoxia Airway Management • The technique of endotracheal intubation in the neonate & small infant differs from that in the adult because of the baby's anatomical features – The large head & short neck may necessitate the need for a shoulder roll – The angle of the jaw is about 140° (adult is 120°) – The epiglottis is more "U" shaped, usually resembling the Greek letter omega • The epiglottis also protrudes over the larynx at a 45° angle – The larynx of an infant is high & has an anterior inclination • Straight (Miller or Phillips) blade is usually the best choice • The view can be markedly improved by applying cricoid pressure Airway Management • Selection of Endotracheal Tube Size – Diameter • Greater than 2 years old – In millimeters=Age+16÷4 – In french=Age+18 • 12-24 months=4.0 • 6-12 months=3.5-4.0 • Newborn-6 months=3.0-3.5 • Premie=2.0-3.0 – Cuffed tubes • After 8 years old add 2 Fr. sizes to diameter Airway Management • Distance or Depth to Tape Tube – If older than 2 years • Age÷2+12 – If younger than 2 years • 1-2-3-4 kg then it is taped at 7-8-9-10cm respectively • Newborn to 6 months = 10cm • 6 to 12 months = 11cm • 1 to 2 years = 12cm Renal Differences • Body Fluid Compartments – Full term infants have a large % of TBW & ECF – TBW decreases with age mainly as a result of loss of water in extracellular fluid Renal Differences • Significance for Anesthesia Provider – Higher dose of water soluble drug is needed due to the greater volume of distribution • However, due to the immaturity of clearance & metabolism the dose given is equal to the dose used in adults – In the fetus the placenta is the excretory organ • However, it still produces a large volume of hypotonic urine & helps amniotic fluid volume • It is only after birth that the kidney begins to maintain metabolic function Renal Differences • The healthy newborn has a complete set of nephrons at birth – The glomeruli are smaller than adults – The filtration surface related to body weight is similar – The tubules are not fully grown at birth & may not pass into the medulla Renal Differences • Glomerular Filtration Rate (GFR) – At birth is ~30% of the adult • It increases quickly during the first two weeks, but then is relatively slow to approach the adult level by the end of the first year – Low GFR in the full term infant affects the baby's ability to excrete saline & water loads as well as drugs • Full term infants can conserve Na+, as GFR increases so does the filtered load of Na+ increase & the ability of the proximal tubule to reabsorb the ion • In premature infants a glomerulotubular imbalance is present which may result in Na+ wastage & hyponatremia Renal Differences – Factors that contribute to the increase in GFR • Increase in CO • Changes in renovascular resistance • Altered regional blood flow • Changes in the glomeruli – Maturation of the glomerular function is complete at 5-6 months of age Renal Differences • Tubular Function & Permeability – Not fully mature in the term neonate & even less in the premature infant – The neonate can excrete dilute urine (50mOsm/L) • However, the rate of excretion of H2O is less & it cannot concentrate to more than 700mOsm/L (adult, 1200mOsm/L) • This is due, in part, to the lack of urea-forming solids in the diet, but mostly due to the hypotonicity of the renal medulla – Maturation of the tubules is behind that of the glomeruli • Peak renal capacity is reached at 2-3 years after which it decreases at a rate of 2.5% per year Renal Differences • The kidney does show some response to antidiuretic hormone (ADH), but is less sensitive to ADH than the cells of mature nephrons • Diluting Capacity – Matures by 3-5 weeks postnatal age – The ability to handle a water load is reduced & the neonate may be unable to increase water excretion to compensate for excessive water intake • They are very sensitive to over hydration – In infants & children, hyponatremia occurs more frequently than hypernatremia Renal Differences • Creatinine – Normal value is lower in infants than in adults • This is due to the anabolic state of the newborn & the small muscle mass relative to body weight (0.4mg/dl vs. 1mg/dl in the adult) • Bicarbonate (NaHCO3) – Renal tubular threshold is also lower in the newborn (20mmol/L vs. 25mmol/L in the adult) – Therefore, the infant has a lower pH, of about 7.34 • BUN – The infants urea production is reduced as a result of growth & so the "immature" kidney is able to maintain a normal BUN Hepatic Differences • Glucose from the mother is the main source of energy for the fetus – Stored as fat & glycogen with storage occurring mostly in last trimester • At 28 weeks gestation the fetus has practically no fat stored, but by term 16% of the body is fat & 35gms of glycogen is stored – In utero liver function is essential for fetal survival • Maintains glucose regulation, protein / lipid synthesis & drug metabolism • The excretory products go across the placenta & are excreted by the maternal liver – Liver volume represents 4% of the total body weight in the neonate (2% in adult) • However, the enzyme concentration & activity are lower in the neonatal liver Hepatic Differences • Glucose is the infants main source of energy – In the 1st few hours following delivery there is a rapid drop in plasma glucose levels • Hepatic & glycogen stores are rapidly depleted with fat becoming the principle source of energy • The newborn should not be kept for a long period of time from enteral or IV nutrition – The lower limit of normal for glucose is 30mg/dl in the term infant – Infants do not usually show neurological signs & symptoms, but may develop sweating pallor or tachycardia – A glucose level < 20mg/dl usually precipitates neurological signs such as apnea or convulsions – Premature infants may have a tendency for hypoglycemia for weeks Hepatic Differences • Increased hepatic metabolic activity – Occurs at about 3 months of age – Reaches a peak at 2-3 years by which time the enzymes are fully mature, then they start to decline reaching adult values at puberty • Renin, angiotensin, aldosterone, cortisol & thyroxine levels are high in the newborn & decrease in the first few weeks of life Hepatic Differences • Physiologic Jaundice – Increased concentrations of bilirubin occur in the first few days of life • This is excessive bilirubin from the breakdown of red blood cells & deficient hepatic conjugation due to immature liver function • Treatment is phototherapy & occasionally exchange transfusions • If left untreated it can lead to encephalopathy (kernicterus) Hepatic Differences • Coagulation – At birth, Vit K dependent factors (II, VII, IX & X) are at a level of 20-60% of the adult volume • This results in prolonged prothrombin times – Synthesis of Vit K dependent factors occurs in the liver which being immature leads to relatively lower levels of these factors even with the administration of Vit K • It takes several weeks for the levels of coagulation factors to reach adult values • Administration of Vit K immediately after birth is important to prevent hemorrhagic disease CNS Differences • The brain of the neonate is relatively large – 1/10 of the weight as compared to 1/50 of adult – The brain grows rapidly • Doubles in weight by 6 months • Triples in weight by 1 year – At birth ~25% of the neonatal cells are present – By one year the development of cells in the cortex & brain stem is complete CNS Differences • Myelination & Elaboration of Dendritic Processes – Continue into the third year of life – Incomplete myelinization is associated with primitive reflexes such as motor and grasp • Spinal Cord – At birth the spinal cord extends to L-3 – By one year old the infant spinal cord has assumed its permanent position at L-1 CNS Differences • Structure & Function of the Neuromuscular System – Incomplete at birth • There are immature myoneural junctions & larger amount of extrajunctional receptors – Throughout Infancy: • Contractile properties change • The amount of muscle increases • The neuromuscular junction & acetylcholine receptors mature CNS Differences • Junctions & Receptors – The presence of immature myoneural junctions might cause a predisposition to sensitivity – A large number of extrajunctional receptors might result in resistance – Within a short interval, (< 1 month) this variation diminishes & the myoneural junction of the infant behaves almost like that of an adult Temperature Regulation • Body Temperature – Is a result of the balance between the factors leading to heat loss & gain and the distribution of heat within the body • The potential exists for unstable conditions to progress to a positive feedback cycle – The decrease in body temperature will lead to a decrease in the metabolic rate, leading to further heat loss & diminished metabolic rate • The body normally safeguards against this unstable state by increasing BMR during the initial exposure to cold or by reducing heat loss through vasoconstriction Temperature Regulation Temperature Regulation • Central Temperature Control Mechanism – This is intact in the newborn • It is limited, however, by autonomic & physiologic factors • Is only able to maintain a constant body temperature within a narrow range of environmental conditions • O2 consumption is at a minimum when the environmental temp is within 3-5% (1-2°C) of body temp (an abdominal skin temp of 36°C) – This is known as the neutral thermal environment (NTE) – A deviation in either direction from the NTE will increase O2 consumption – An adult can sustain body temperature in an environment as cold as 0°C where as a full term infant starts developing hypothermia at about 22°C Temperature Regulation • Generation of Heat – Depends mostly on body mass • Heat loss to the environment is mainly due to surface area • Neonates have a ratio of surface area to mass about 3X's higher than that of adults – Therefore they have difficulty regulating body temperature in a cold environment Temperature Regulation • Premature Infants & Temperature Control – Are more susceptible to environmental changes in temperature – The preemie has skin only 2-3 cells thick & has a lack of keratin • This allows for a marked increase in evaporative water loss (in extremes this can be in excess of heat production) Temperature Regulation • Important Mechanisms for Heat Production – Metabolic activity – Shivering – Non-shivering thermogenesis • Newborns usually do not shiver – Heat is produced primarily by non-shivering thermogenesis • Shivering does not occur until about 3 months of age Temperature Regulation • Non-shivering Thermogenesis – Exposure to cold leads to production of Norepi • This in turn increases the metabolic activity of brown fat • Brown fat is highly specialized tissue with a great number of mitochondrial cytochromes (these are what provide the brown color) • The cells have small vacuoles of fat & are rich in sympathetic nerve endings – They are mostly in the nape & between the scapulae but some are found in the mediastinal (around the internal mammary arteries & the perirenal regions (around the kidneys & adrenals) Temperature Regulation – Once released Norepi acts on the alpha & beta adrenergic receptors on the brown adipocytes • This stimulates the release of lipase, which in turn splits triglycerides into glycerol & fatty acids, thus increasing heat production • The increase in brown fat metabolism raises the proportion of CO diverted through the brown fat (sometimes as much as 25%), which in turn facilitates the direct warming of blood – The increased levels of Norepi also causes peripheral vasoconstriction & mottling of the skin Temperature Regulation Temperature Regulation • Heat Loss – The major source of heat loss in the infant is through the respiratory system • A 3kg infant with a MV of 500ml spends 3.5cal/min to raise the temperature of inspired gases • To saturate the gases with water vapor takes an additional 12cal/min • The total represents about 10-20% of the total oxygen consumption of an infant Temperature Regulation – The sweating mechanism is present in the neonate, but is less effective than in adults • Possibly because of the immaturity of the cholinergic receptors in the sweat glands • Full term infants display structurally well developed sweat glands, but these do not function appropriately • Sweating during the first day of life is actually confined mostly to the head Temperature Regulation • Heat Exchange Review – 1. Conduction: • The kinetic energy of the vibratory motion of the molecules at the surface of the skin or other exposed surfaces is transmitted to the molecules of the medium immediately adjacent to the skin – Rate of transfer is related to temperature difference between the skin & this medium – Use warm blankets, Bair huggers & warmed gel pads – 2. Convection: • Free movement of air over a surface – Air is warmed by exposure to the surface of the body then rises & is replaced by cooler air from the environment – Increase OR temp, radiant warmers, wrap in saran wrap, cover with blankets and/or OR drapes Temperature Regulation – 3. Radiation: • Radiation emitted from the body is in the infrared region of the electromagnetic spectrum – The quantity radiated is related to the temperature of the surrounding objects – Radiation is the major mechanism of heat loss under normal conditions (same techniques to prevent as used in Convection) – 4. Evaporation: • Under normal conditions ~20% of the total body heat loss is due to evaporation – This occurs both at the skin & lungs – Since the infant's skin is thinner & more permeable than the older child's or adult's evaporative heat loss from the skin is greater – In the anesthetized infant the MV (relative to body weight) is high thus increasing evaporative heat loss through the respiratory system Temperature Regulation • Summary – Decreased body temperature is initially compensated for by increased metabolism – If this fails & temperature continues to decrease, regional blood flow shifts, causing a metabolic acidosis & eventually apnea Pharmacological Differences with Inhalation Anesthetics • Review – Factors that determine uptake & distribution of inhaled agents • Factors that determine the rate of delivery of gas to the lungs – Inspired concentration – Alveolar ventilation – FRC • Factors that determine the rate of uptake of the anesthetic from the lung – CO – Solubility of the agent – Alveolar-to-venous partial pressure gradient Pharmacological Differences with Inhalation Anesthetics • In children there is a more rapid rise from inspired partial pressure to alveolar partial pressure than in adults – This is due to 4 differences between children & adults • 1. The ratio of alveolar ventilation to FRC – This a measure of the rate of "wash-in" of the anesthetic into the alveoli – In the neonate the ration is 5:1 compared to adults of 1.5:1 Pharmacological Differences with Inhalation Anesthetics • 2. There is a higher proportion of CO distributed to the VRG in the child – In adults an increase in CO slows the rate of rise in alveolar to inspired partial pressure, but in neonates it speeds the rate of induction because the CO is preferentially distributed to the VRG – The VRG constitutes 18% of the body weight of the neonate as opposed to only 6% in adults – Therefore, the partial pressure in the VRG (which includes the brain) equilibrates faster with the alveolar partial pressure Pharmacological Differences with Inhalation Anesthetics • 3. Neonates have a lower blood/gas solubility of inhaled anesthetics (the less soluble the greater the amount that remains in the alveolus – This allows a more rapid rise in the alveolar to inspired partial pressure • 4. Neonates have a lower tissue/blood solubility of inhaled anesthetics – Less agent is removed from the blood therefore the partial pressure of the agent in the blood returning to the lungs increases Pharmacological Differences with Inhalation Anesthetics •There are age related differences in MAC of inhalation agents Questions


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Josh Xantus - Love Games
Artist: Josh Xantus
Featuring: Jadakiss
Producer: Omen
Album: Everybody Hates Josh X
Avg Rating: 2.0 ( 6 votes )
Update: The streaming of "Love Games" has been temporarily removed.
Few things are as frustrating as trying to make love work when your partner can't seem to take the relationship seriously. Josh Xantus knows what I'm talking about; on the latest single off his forthcoming mixtape, the singer issues his girl an ultimatum: quit the Love Games, or watch him walk out the door. Joining Xantus over Omen's hip-hop-infused production, Let's Ride collaborator Jadakiss contributes guest bars. Everybody Hates Josh X is scheduled to hit the 'net April 30, and fans can look forward to an official video accompaniment to Xantus' hit single,Take 2, in mid-April.
Josh Xantus Jadakiss DownloadsR&B/Pop
Written by richard on 03/30/12
Submit your Rating
M USA Entertainment
First DJ Booth Appearance:
"Let's Ride ft. Jadakiss" (2008)
Total DJ Booth Features:
9 Songs
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Jesse James Accused of Cheating on Sandra Bullock with Michelle McGee in "Bombshell" Scandalby Free Britney at . Comments
Tens of millions saw Sandra Bullock thank her husband, Jesse James, as she accepted her best actress Oscar for The Blind Side this month. Little did we know ...
She might have chosen different words had she known about his torrid 11-month affair with tattoo model Michelle McGee, which In Touch Weekly alleges today.
The worst part of the scandal, if you buy it, is that McGee, who goes by the nickname "Bombshell," says James told her he and Sandra were no longer together.
"I would never have hooked up with him if I thought he was a married man," Michelle said. "He gave me the impression they were separated." The impression?
Whatever impression he made, it was lasting. With Sandra in Atlanta shooting The Blind Side, Michelle says she had sex at least once a week with James.
Is Sandra Bullock's husband guilty of the ultimate betrayal?
Far from a one-night stand, the Monster Garage star's relationship with Michelle was McGee "intimate and highly charged." We're talking prolonged boinkage people.
Michelle even says she called Jesse, who apparently does not wear underwear or condoms, by a special pet name, the Vanilla Gorilla, as he's "so well-endowed."
Okay, we really hope this story is made up for Sandra's sake and for our own. We may need to poach the In Touch writer who came up with that for a job at THG.
As for how they met, McGee said she "sent West Coast Choppers a friend request" because she hoped to snag a modeling gig there. Jesse James personally replied.
From the start, it was never about business."He started saying, 'Do you want to hang out?'" A week after he got in touch, Michelle drove two hours from her San Diego home to West Coast Choppers in L.A.
After taking Michelle on a tour, "We ended up on the couch," she says. "He wanted to watch movies, but I asked him, 'So what's going on with you and Sandra?'"
"He said, 'She doesn't live here. She has a house in Austin. She is filming, I can't talk about it.'" Assuming he and Sandra were separated, Michelle did her thing!
"We had intimate relations two or three times," she said, and began what she calls a serious relationship, meeting up for sex at least twice a week for five weeks.
James has previously made headlines for his turbulent relationship with ex-wife and porn star Janine Lindemulder, but that was nothing compared to this. Man.
If this report is true, all we can say is this:
Bad Vanilla Gorilla. Bad.
Well at least this will get all of these busy bodies off of Tiger's back. They were an odd couple to begin with. I guess Jesse was tired of being Mr. Sandra Bullock, and rebelled the only way that he could. This tattooed chic was probably a real temptress and really performed in bed. Sandra has some miles on her and was too busy with her career.
It truly must be a missing link in the brains of these men who cheat on woman that the average(unknown)man dream and fantasize about.Judhead looks plain and simple, but yet there was something that Sandra B saw in him and fell in love with.To be married to a respectable woman of Sandra's status, and take the risk of being with Tattoo Tilly is beyond comprehension.
OMG y wuld cheat on sandra.??????????????????? Sandra if ur reading this u desever better
The first thing Sandra needs to do it take a long bath to wash his nastiness off. Then she need to be tested for every STD known to man because of the skank he was doing. What a fool.
May that love cheat & dirty rat Jesse James reap all the disdain and hate that the decent women of American now have for him. How dare that tattoo-ed BAD BOY break the heart of Sandy Bullock-America's sweetheart! I hope the STD-SEX he had with that skanky stripper Michelle McGee was worth the dismantling of his marriage and good name. Men are such idiots-and Jesse James is a first rate example of that! Burn in Hell with Tiger (playa) Woods! Sandy: go back to Ryan Gosling-who looks like he might BE ABLE to keep his junk zipped up!
This guy is an absolute fool. He blew it. Sandra Bullock is the rare woman who is cute AND doesn't have the bitch attitude most women have these days.
You marry a bad boy, that's what you get. You can't change people like him. He will realize how much of a mistake he made, and will have to live with it for a long time... what a looser! I wish Sandra the best and to let it go... it's not worth it. She can do much better.
I just found out a few minutes ago when I read a headline that "Sandra Bullock" has left her home. I am so sorry for her and yes the love she showed for this man was real and the kind that only comes around once or twice in a life time, if your lucky enough. If this is true, I hope he just leaves her alone, she has given so much to him, his children and even his ex-wife. What a creep....if it's too good to be true it usually is. I am so sorry Sandy for the hurt you must be feeling. Take care of yourself....
OMG...He SUCKS! I feel SOOO Bad for Sandra! As the old sayings go, you can't tame a wild animal, the tiger cannot change its stripes, the leopard cannot change its spots. It's in his nature to do what he has always done. I hope she picks herself up, dusts herself off, and NEVER EVER Looks back! YOU GO GIRL!!!!
JJ is such a LOOSER


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Report: Markham arena deal could be dead in September
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Doug Marrone
It's late July and Doug Marrone already can't stand the media in Buffalo
It's safe to say Bills head coach Doug Marrone won't be answering any more questions ..... training camp, the local media asked Marrone about Mario Williams' sore foot ..... media didn't like the answer Marrone gave, so naturally they asked again
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logistics are very difficult," Bills coach Doug Marrone said. "Everyone did a good job ..... t have to take that trip," Marrone said. "From that standpoint ..... questionable for Monday's game, but Marrone said he expects him to play. Defensive
Bills make most of trip to Detroit, rout Jets 38-3
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We arrived at Brindisi at around 8.30 after a bit if a hot night on the boat. The ferry was OK but the AC in the cabin was poor, though a man said it could have been changed; maybe.... The cabin itself was good and the crossing smooth but it was bit a short hot night. Getting off the boat was also slow, not helped but unbelievably stupid lot who managed to have an accident on the boat deck due to impatience.... ...


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McDuffie clarified the situation on his boards later that day. "It was my own doing," posted McDuffie. "I was fired when [rumor column] "Lying in the Gutters" ran a compilation of two years or so of my answers to fans' questions on the DC Comics discussion boards. I'm told my removal had nothing to with either the quality of my work or the level of sales, rather with my revelation of behind-the-scenes creative discussions."
Back to the Latest News page.


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