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I am a Sister working at the Royal Liverpool University Hospital Intensive Care Unit. which is a large ITU that admits around 485 patients per year. There is a very wide spectrum of pathology provided by the medical and surgical patients admitted from both within and outside the hospital.
In recent years the development of
arterial pulse contour cardiac output
and trans pulmonary thermodilution (PiCCO)
has meant there has been a decline in the use of pulmonary artery catheters, however it is still important to understand the principles of Swan Ganz Catheters.
The information on this site has been provided by:
Sr. Lorraine Burgess - Nurse Audit Lead, Joint Nurse Lead for the Cheshire and Merseyside Critical Care Network
Sr. Andrea Fazakerley - Critical Care Outreach Educator
Dr. Richard Wenstone - Consultant Intensivist
Contact Author (Please let me know your comments, is the page useful? What do you do in your hospital?)
|Down load this website Click Here
Back to Basics
What is a "Wedge"?
How ? Care of the patient
Why ? Shock – signs and symptoms
Cardiac Output Measurement using Thermodilution
When ? Titration of vaos active drugs, diagnostic.
Cardiac Output Studies - An Expanded Role
PiCCO Information
Looking after a patient with a pulmonary artery catheter (PA) is probably "the" most daunting experience for a nurse new to ITU. Yet those more experienced staff can do the job of caring for these patients easily and with little apparent stress, it becomes second nature a bit like driving a car. However there is never room for complacency complications are rare but they happen and they can be fatal so it is important to reinforce to both new and experienced staff the rationale for their actions so that hopefully at the end of this learning guide all staff will feel happier and more confident in caring for these patients.
We will be revisiting some old favorites like A&P, nursing care and do's and don'ts.
Back To Basics
Cardiac output is the rate which the heart pumps blood, often defined as: The volume of blood pumped out of the left ventricle into the aorta in one minute." This is calculated by multiplying the Stroke volume (the volume of blood pumped out with each contraction) by the heart rate.
Therefore Cardiac output (CO) = Stroke volume (SV) x heart rate (HR)
For example an adult at rest has a heart rate of about 72 beats/min and a stroke volume of 70mls therefore CO = 72 x 70 = 5 litres per minute.
At rest normal cardiac output is about 5 litres per minute.
This can increase to 25 litres/min during exercise or 35 litres for an athlete. When an increased cardiac output is needed to supply other organs e.g. the gut during digestion or muscles during exercise it is achieved by increasing the heart rate or the stroke volume.
The mechanisms by which the HR & SV can be altered.
A. Control of the Heart.
In the absence of nervous or hormonal control the sinoatrial node discharges spontaneously and rhythmically @ 100 beats per minute
Factors altering the heart rate: -
1. Nervous:
Most important is the influence of the autonomic nervous system. The heart is supplied by both the sympathetic and parasympathetic nerves.
Sympathetic nerves to the heart originate in the cardiovascular centre (group of neurones within the medulla) these affect the SA node, AV node and portions of the myocardium. Stimulation causes an increase in heart rate.
Parasympathetic nerves to the heart (vagus nerve) also originates in the medulla. This affects SA node And AV node. Stimulation causes decrease in the heart rate.
At rest HR is usually 60 to 80 / minute. This is rather less than the inherent rate of the discharge of the cardiac pacemaker (SA node) Therefore at rest the parasympathetic influence is dominant.
Primarily the heart rate is regulated by the slowing effects of the parasympathetic and the accelerating effects of the sympathetic.
2. Hormonal
Adrenaline (released from the adrenal medulla) causes increase in heart rate by stimulating the b receptors in the cardiac muscle conduction system.
3. Stretch
The stretching of the left atrium wall by increased venous return causes increase in heart rate by 10 to 15 % because stretch receptors in the atrial wall/superior vena cava and the inferior venacava send impulses that stimulate sympathetic output this is called the Bainbridge Reflex.
4. Temperature.
Rise in temperature causes increase in HR because it increases the rate of discharge from the SA node. Converse also applies.
5. Drugs.
To increase the HR - Isoprenaline / Adrenaline.
To reduce to HR - Beta-blockers e.g. propanolol.
The HR is also sensitive to plasma electrolyte concentrations and hormones other than adrenaline.
The heart rate is usually faster in females and declines with age.
B Control of Stroke Volume.
In the normal heart the most important factor that controls the amount of blood pumped from a ventricle with each heart beat (Stroke Volume) is the amount of blood in the ventricle immediately before contraction. This is called the ventricular end diastolic volume. V.E.D.V.
The more blood in the ventricles the greater the amount pumped -Starlings Law: The force of the muscle contraction is proportional to the initial muscle fibre length (i.e. Stretch).
1 Venous Return.
The force of contraction adjusts according to the volume of blood in the ventricles this is called auto regulation.
Blood volume: - reduced circulating volume e.g. Due to bleeding leads to reduced venous return.
The position of the person e.g. Trendelenburg, will increase venous return.
Intrathoracic pressures caused by I.P.P.V. Will reduce venous return.
2. Nervous.
Sympathetic nervous stimulation increases ventricular and atrial contractility.
Normally when the ventricles contract they do not empty completely. When contractility improves, the ventricles empty more completely therefore increasing SV.
Sympathetic stimulation not only causes a more forceful contraction but also a more rapid contraction. This is important when an increase in HR reduces the time available for diastolic filling of the ventricles; because if contraction can be made more rapid there will be a larger fraction of the cardiac cycle available for filling, and coronary blood flow during diastole.
Drugs affecting contractility.
Inotropic drugs.
Those increasing contractility are called positive e.g. dobutamine and adrenaline
Those decreasing contractility are called negative inotropes e.g. b blockers.
3 Hormonal Regulation: - Circulating catecholamines, adrenaline & noradrenaline produce changes in myocardial contraction (and hence in S.V.)
4 Arterial Blood Pressure: - An increase in the resistance to the ejection of blood from the ventricles can reduce the S.V. This is caused by the ability of the large arteries to expand and contract. This is called Afterload. Arterial blood pressure gives an indication of the degree of afterload.
If the B.P. is high and the force of contraction is constant then the ventricles will not empty as much and S.V. will be reduced.
In a normal heart changes in blood pressure do not affect the overall cardiac output as the heart can self adjust.
Drugs that can reduce afterload are nitrates like Isoket.
Summary: - A normal functioning heart will pump out all of the blood that is returned to it from the veins. Therefore venous return is the prime factor in determining cardiac output, and vice versa.
Basic principles of fluids, pressure, flow & resistance.
All fluids when in a confined space exert a pressure.
Hydrostatic pressure refers to the force that a fluids exerts against the walls of it's container.
The pressure that blood exerts in the vascular system is called: -
Blood Pressure
BP Is the result of blood flow and vascular resistance.
Blood Flow: - The circulation is a closed system therefore total flow leaving the heart must equal the total flow returning to the heart - This blood flow equals cardiac output.
Blood pressure = cardiac output X total peripheral resistance
B.P. Can be maintained or altered by manipulation of cardiac output and or total peripheral resistance.
Systolic pressure: - is determined by the amount of blood being forced into the aorta or arteries with each ventricular contraction i.e. The S.V. and the force of the contraction. Increase in either will raise systolic pressure and vice versa. Also increase in afterload caused by vascular disease will also raise systolic pressure. In old age the vascular tree is more rigid so systolic hypertension is common.
Diastolic pressure: - This reflects peripheral resistance.
If there is vasoconstriction the diastolic will rise.
If there is vasodilation the diastolic will fall.
Drugs to vasodilate e.g. hydralazine will lower diastolic pressure.
If the heart rate falls then the diastolic will fall as there is an increased time for the blood to flow out of the arteries (& vice versa)
The difference between the systolic and diastolic is called the Pulse Pressure.
Mean Arterial Pressure:- This represents the pressure driving blood through the systemic circulation. This is estimated by adding 1/3 of the pulse pressure to the diastolic pressure.
If BP = 120/70mmHg Then Pulse pressure = 50 mmHg
1/3 of 50 = 17
Add 17 to the diastolic of 70 = 87
Therefore M.A.P. = 87mmHg.
Afterload = The resistance of the ejection of blood offered by the systemic circulation
Cardiac Output = The amount of blood ejected by the left ventricle in one minute
Contractility = The ability of myocardial cells to contract (shorten) in response to an electrical impulse.
Oxygen consumption = The amount of oxygen used by the tissues in one minute.
Oxygen delivery = The amount of oxygen delivered to the tissues in one minute.
Preload = Ventricular end diastolic pressure
Pulmonary capillary wedge pressure = Reflects left ventricular end diastolic pressure
Stroke volume = Volume of blood ejected per ventricular contraction.
Systemic vascular resistance = MAP - CVP X 80 CO
A Bit of History
The pulmonary artery flotation catheter.
During the late 60's and early 70's Drs H.J.C. Swan and William Ganz developed a balloon tipped flotation catheter. The function of the catheter was to be able to continuously measure at the bedside certain intracardiac pressures. Before this the patient would have to have been transferred to a cardiac catheterization lab; and then only intermittent measurements would be obtained.
By floating a flexible catheter into the pulmonary artery and using a balloon to occlude it then indirect measurements can made of the pressure in the left ventricle.
Since the initial design there have been many modifications so that now we are able to continuously measure cardiac output and venous oxygen saturation, as well as infuse drugs and measure right sided heart pressure.
Incidentally the first Swan Ganz catheter to be inserted in this country was done in a Liverpool Hospital !!
What is a Wedge?
Pulmonary Artery Wedge Pressure:- When the tip of the Swan is properly positioned in the PA, a wedge pressure can be obtained. By inflating the balloon the tip will "float" into a smaller branch of the PA and occlude forward flow. When this occurs there is an unrestricted vascular chamber from the pulmonary artery through the pulmonary vascular system, the pulmonary vein, the left atrium, the open mitral valve and the left ventricle. therefore the theory is, the pressure in front of the occluded catheter tip is the same as the pressure in the left ventricle during diastole (because this is the time when all of the valves are open and the heart is filling with blood)
Nursing responsibilities during insertion of a Swan Ganz Catheter.
1. Ensure the comfort of the patient
2. Make sure the transducer is flushed and re zeroed and ready to read P.A.
3. Observe the monitor for signs of dysrhythmias
4. Observe the waveforms as the catheter passes through the different chambers of the heart
Nursing Care :-
Nursing care of the patient with a "Swan" is complex, the nurse must be able to interpret the data obtained as well as being able to alert medical staff of potential or actual complications.
1. Prevention of infection is paramount
2. The position of the tip may change forward migration will be indicated by a wedge trace with a deflated balloon spontaneous wedging, this may cause pulmonary infarction. Notify a doctor to reposition the catheter.
3. Over inflation of the balloon may cause the PA to rupture, prolonged inflation may result in pulmonary infarction and insertion of air into a ruptured balloon could cause an air embolus.
4. Inflation of the balloon should be done slowly while observing the pressure tracing on the monitor. When the pressure changes from PA to Wedge no more air should be inserted. There should be a slight resistance felt, if there is no resistance and a wedge trace can not be obtained then a balloon rupture should be suspected. The syringe should be therefore labeled as ruptured and medical staff informed.
5. After wedging the catheter always make sure the monitor returns to a PA trace.
The clinical information obtained from invasive pressure monitoring is truly beneficial in the care of the critically ill patient. The role of the nurse in the prevention and detection of complications is pivotal.
Nursing management of these patients does not begin and end with writing numbers on a chart the psychological care of the patient and their families is very important, they will ask questions want to know what you are doing and what all of the numbers mean .So you need to confident in your ability to explain to them what, why and when !!!! In a way they will understand.
Pressure (mmHg)
Right atrium Mean
Right Ventricle
End diastolic
Pulmonary artery
Pulmonary Artery Wedge
These are "Normal" Intra cardiac pressures for a spontaneously breathing patient (a bit rare in I.T.U.!!!)
Remember to add 5 mmHg plus PEEP for ventilated patients.
Troubleshooting guide !!!
Possible cause
Nursing actions
Damped pressure trace:
Shows as low amplitude tracing (low systolic/high diastolic pressure)
Clot occluding catheter
Catheter kinked touching the vessel wall, or malpositioned
Air in the system
Blood on the transducer
Equipment fault/error
Check patency by aspirating: continue until blood flows back easily then flush. If no blood can be aspirated do NOT flush.
Ask the patient to cough deflate the balloon and gently flush may need medical staff to reposition. Check X ray
Check flush bag and obturators for bubbles
Flush the system check the pressure bag
Check taps are open correctly and that settings on the monitor are correct
Risk of pulmonary emboli. All clots should be cleared. Risk is minimized by use of a constant flushing system and use of a heparinised solution. An occluded catheter should be removed.
Coughing and flushing may help displace the catheter
Air will distort readings
Blood on the transducer will distort readings
Methodical checking can be very revealing!
Wedge pressure unobtainable
Balloon over/under inflated
Balloon rupture
Catheter displaced
Monitor may be still set on Zero
Contact technician
Deflate balloon and reinflate
No resistance to inflation. Do NOT inject
Inform medical staff to reposition
Check settings
Over inflation may cause vessel damage or balloon rupture. Risk of air embolus
Risk of air embolus
Catheter may require repositioning or replacing
Sudden changes in pressures or configuration
Patient in pain or agitated.
Transducer not at correct level.
Catheter displaced spontaneous wedging
Ensure adequate sedation or analgesia reassure patient to ally anxiety
Re Zero
Inform medical staff to reposition
Pressures may rise in response to pain
Should be done regularly
Risk of pulmonary infarction
Most I.T.U. patients will probably have a P.A. catheter inserted at some point during their stay. The main reason being cardiovascular instability due to shock of one kind or another.
So what is Shock?
DEFINITION :- Inadequate delivery of oxygen to the tissues.
" A syndrome characterized by a reduction in blood flow and inadequate perfusion, leading to tissue hypoxia and failure of cell function"
There are five types of shock:-
Hypovolaemic Shock.
Caused by a reduction in circulating volume. The body can cope with a loss of 10 to 15 %.
Clinical Features
Hypotension :- Reduced venous return - reduced SV - reduced CO - Hypotension.
Tachycardia :- Reduced BP reduced stimulation of the carotid baroreceptors - increased sympathetic activity of the cardiovascular centre in the brain - increase in HR.
Sweating Cold and Clammy:- sympathetic stimulation leads to peripheral vaso constriction (stimulation of alpha receptors) also causes stimulation of sweat glands.
Oliguria:-Vasoconstriction reduced renal blood flow therefore reduced filtration and reduced urine output. Rennin is released ( Quick reminder of the renin angiotensin pathway-)
Renin - enzyme that splits angiotensinogen into angiotensin I Angiotensin I is converted into Angiotensin II under the influence of A.C.E. Angiotensin II causes the secretion of aldosterone from the adrenal gland allowing Na and water to be retained to increase circulating volume, further reducing urine output.
In response to stimulation of osmo and volume receptors A.D.H. is released this allows more water to be retained by increasing the permeability of the distal tubules.
Reduced L.O.C:- Confusion caused by cerebral hypoxia.
Tachypnoea :- Reduced oxygen to the cells - anaerobic metabolism- increase in lactic acid production - lactic acidosis. Central chemoreceptors sense the increase in hydrogen ions therefore stimulates the respiratory centre in the brain to increase the respiratory rate in order to "blow off" excess hydrogen H+ HCO3 ~ H2CO3 ~ H2O + CO2
Reduced oxygen level in the blood also stimulates the resp. Centre to increase rate.
Cyanosis:- Reduced peripheral oxygen. Increased amounts of reduced haemoglobin of more than 5g/dl = blue.
Hypothermia:- Anaerobic metabolism does not create much heat therefore leading to reduction of core body temperature.
Dysrhythmia Kidneys retain potassium to excrete hydrogen. Hyperkalaemia causes Dysrhythmia .Reduced coronary artery blood flow leads to ischaemia. Lactic acid is also cardiotoxic.
Thirst:-It is thought that osmoreceptors and A.D.H. production stimulates the "thirst " centre in the brain.
N&V:- Due to reduced blood flow to the G.I.T. Causing G.I.T.ischaemia, this could also lead to stress ulceration. Acidosis also makes one feel nauseous.
This list is not exhaustible and some of the reasons may be debatable.
In our ITU we tend to see three of the main causes of shock that require invasive haemodynamic monitoring, so we will look at these in a little more detail.
Management of Hypovolaemic shock:-
Oxygenation - Main problem is that of hypoxaemia therefore 100% oxygen is needed and early I.P.P.V. Should be considered. Although I.P.P.V. May worsen hypotension due to the increase in intrathoracic pressure causing a reduced venous return.
Fluids - circulating volume, replace lost fluids, good I.V. access is needed use of H.A.S. and
Blood. Stop further loss of fluid e.g. Go to theatre if A.A.A.
Monitoring - Arterial line, C.V.P. E.C.G. Urine output, pulse oxymeter blood gases, monitor L.O.C.
Once fluid level is optimum may need inotropes.
Treat underlying cause.
i. Renal failure:- acute tubular necrosis (A.T.N.)
ii. A.R.D.S.
iii. Heart failure / dysrhythmias due to ¯ cardiac output
iv. G.I.T. Ischaemia - stress ulceration
v. Liver failure ¯ detoxification and ¯ clotting
vi. D.I.C.
Cardiogenic Shock:- End stage of heart failure, Shock due to dysfunction of the heart and pump failure.
v M.I.
v Tamponade
v Myopathy
v Arrhythmia
v Following cardiac surgery e.g. Heart transplant
v Chest trauma
v Mitral and Aortic regurgitation
v Infection
Treatment:- prognosis is very poor. Mortality of 80 - 90%. Try to treat the underlying cause to prevent shock from occurring.
Swan Ganz Catheter:- To monitor the effect of inotropes and fluid therapy. Use of nitrates to ¯ afterload and hopefully increase cardiac output. Less resistance in the aorta allows for a bigger to S.V. To occur.
Intra Aortic Balloon Pump (I.A.B.P.):- Inflates at the start of diastole and forces blood into the coronary artery system. During systole it deflates and the sudden drop in pressure reduces afterload and allows for a larger stroke volume.
Surgery:- to remove the underlying cause e.g. Emergency C.A.B.G. Aneurysm repair etc.
In a previously fit and well person "septic" shock has a mortality rate of 50% which is even higher if there is a significant existing morbidity
Clinical features:- Septic shock occurs in two distinct but overlapping phases.
Warm Shock (hyperdynamic):- This is the first stage of septic shock and is characterised by a high cardiac output and a low vascular resistance. Vasodilation causes a relatively reduced circulating volume together with an increased capillary permeability, results in a rapid hypotension despite a high cardiac output. Fever and chills may develop as an immune system response and urine output may fall. However if compensating mechanisms are present then it may be difficult to first see the potential danger as the patient looks well perfused . An increase in circulating catecholamines causing blood pressure to be normalised.
Cold Shock (hypodynamic):- This is a late presentation and often irreversible phase of septic shock. It is characterised by vasoconstriction, hypotension, hypoperfusion decreased venous return and decreased cardiac output. The symptoms may include:-
A rapid thready pulse
Cold clammy skin
Subnormal or elevated temperature
Depressed level of consciousness
Eventually patients with cold shock develop multiple system failure e.g. A.R.D.S., D.I.C., liver and kidney failure.
A comprehensive description of the pathophysiology of septic shock is beyond the scope of this guide - as there is still debate, discussion and research being done in this complex field.
What we can say is that the events that lead from sepsis to full blown septic shock are probably initiated by the presence of a large number of bacteria , which have not been controlled by the immune response.
The problems are caused by endotoxins that are released when the bacteria are destroyed and the cell membranes are broken down
Endotoxins stimulate the release of various vaso active substances:- including histamine and prostaglandin. These potent vasodilators cause a decrease in peripheral vascular resistance and an increase in capillary permeability, allowing fluid to enter the interstitial spaces from the intravascular spaces resulting in volume depletion and relative hypovolaemia.
1. Identify and treat the underlying cause. The patient may need U.S.S., C.T., B.A.L. Blood cultures, surgery or a line change. In an ideal world antibiotics should not be started until a sensitivity is obtained. Practically cultures are sent than blind antibiotics are commenced
2. Oxygen therapy usually I.P.P.V. A.R.D.S. is a common complication of this condition patients have a high oxygen requirement and there are bilateral lung field infiltrates on the chest X Ray that look like pulmonary oedema however a normal P.A.O.P. indicates a non cardiogenic cause
3. Invasive monitoring using a Swan Ganz catheter.
4. Replace circulating volume using colloids other clotting factors and blood may be needed.
5. Inotropes to increase vascular resistance and blood pressure. These can be titrated according to cardiac output measurements.
6. Support of failed renal system with H.D./H.F.
7. Psychological care of the patient and family. The patient may be very anxious if he is not already sedated and families need a lot of reassurance and explanation of current treatment and progress or deterioration.
8. Good life insurance!!!!!!
We have established our "basics" now we will look at how the P.A. Catheter can help make accurate diagnosis' and enable the titration of vaso active drugs.
Cardiac Output Measurement Using The Thermodilution Method.
In the early 1950's , Fegler first described measuring cardiac output using the thermodilution method. It was not until the early 1970's that Drs Swan and Ganz demonstrated reliability of this technique with a special temperature sensing pulmonary artery catheter. Since that time the thermodilution method has become the standard for clinical practice.
The thermodilution method uses a known amount of solution (10 mls of 5% dextrose) at a known temperature (room air) which is then rapidly injected into the C.V.P. Lumen of the Swan. This cooler solution mixes with and cools the blood, and the temperature is measured downstream by a thermistor bead embedded in the tip of the catheter. The resultant change in temperature is then plotted on a time-temperature curve.
A normal curve will characteristically show a sharp upstroke from the rapid injection followed by a smooth downslope back to the baseline. The area under the curve is inversely proportional to the cardiac output. The computer in the monitor uses an equation to make the exact calculation. Usually several measurements are made and an average result taken.
There are conditions where the thermodilution method may produce unreliable results for example those that have a back flow of blood on the right side; tricuspid or pulmonary valve regurgitation and ventricular or atrial septal defects.
Direct Measurements:-
v Heart Rate
v Blood Pressure
v Pulmonary Artery Pressure
v Central Venous Pressure
v Cardiac Output
Derived Parameters:-
v Mean Arterial Pressure
v Cardiac Index
v Stroke Volume
v Systemic Vascular Resistance
v Pulmonary Vascular Resistance
v Stroke Work Index
Cardiac Index
Cardiac Output
205 – 4.2 L/min/m2
4 – 8 L/min
Heart Rate
70 – 120 beats/min
Mean Arterial Pressure
70 – 90 mmHg
Mean pulmonary artery pressure
< 30 mmHg
Right Atrial pressure (CVP)
12 – 20 mmHg
Pulmonary artery wedge pressure
12 – 20 mmHg
Systemic vascular resistance (SVR)
900 – 1600 dyne/sec/cm5
Pulmonary vascular resistance (PVR)
20 – 120 dyne/sec/cm5
70 – 75%
General Principles:-
i. Defence of blood pressure in critically ill patients forms the basis of haemodynamic resuscitation and organ perfusion.
ii. Hypovolaemia is the most common cause of hypotension and low cardiac output in critically ill patients and must be assiduously monitored and corrected.
iii. The main indication for inotropes is to increase myocardial contractility for a given preload or afterload. Unresponsive to fluid replacement therapy.
iv. MAP and CO should be interpreted within the context of the pre morbid state.
v. The use of inotropes in anything other than tiny doses require invasive monitoring with an arterial line and a PA catheter.
vi. Inotropes primarily increase cardiac output and MAP however all of these agents have variable effects on heart rate and vascular resistance which are neither predictable nor constant.
vii. No single drug or combination have been proved to be superior to another.
Mechanism of different Inotropes.
Digitalis Glycosides:- Inhibits Na+ and K= pump and causes impaired transport of Na+ and K+ out of the cardiac cell.
This leads to a rise in intracellular Na+
Na+ is exchanged for Ca++
Increases intracellular Ca++ leads to
Increased contractility.
Catecholamines:-( dopamine, noradrenaline, and adrenaline) Stimulate sympathetic receptors
(different doses of these drugs affect receptors in different ways however in low doses β effects dominate) Stimulation of β1 receptors results in Increased contractility.
Phosphodiesterase inhibitors:-( e.g. Enoximone) Phosphodiesterase is an enzyme that converts active cAMP into inactive cAMP. By inhibiting this reaction there is an Increase in intracellular active cAMP which allows for a greater influx of Ca++ . As we know increased intracellular Ca++ causes Increased contractility.
β1 effects:-
Increase contractility (inotropy)
Increase heart rate (chronotropy)
β2 effects:-
Increase inotropy
α1 effects:-
Increase inotropy
α2 effects
Increase inotropy
Infusion dose
β effects @ low doses
α effects @ high doses
6 mg in 100mls of 5% dextrose
ml/hr = mcg/min
Severe sepsis
Cardiogenic shock
Acute asthma
Maintenance of cerebral perfusion pressure
Medical pacing
α effects at high doses
6mg in 100ml of 5% dextrose
ml/hr = mcg/min
Vasodilated states e.g. septic shock
α & β effects
400mg in 100 mls of 0.9% Na+Cl or 5% dextrose
ml/hr = mcg/kg/min
No advantage over Adrenaline or noradrenaline "Renal dose" is no longer advocated
β effects mild α 2 effects
1 gram in 250 mls 0.9% Na+Cl or 5% dextrose
Primarily a vaso dilator with weak Inotropic action. Traditionally used in cardiogenic shock in low output high afterload states
100 mg diluted up to 50 mls with saline = 2 mg/ml
Cardiogenic shock due to Pump failure and high afterload
Vistors to this site since 23/06/2004


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An Asian restaurant in Greenville has closed, just after a year in business.
The HuHot Mongolian Grill on Greenville Boulevard closed on June 19th, according to a sign posted on the door of the business. The chain's web site also says the location is closed.
The restaurant chain has locations in 17 states, but the Greenville restaurant was its only site in North Carolina. The location, which housed another restaurant, underwent extensive renovations before opening last April.
A sign posted on the door says that the restaurant had to close due to unforeseen circumstances. It told employees that they will get their final paycheck tomorrow.

subset: commoncrawl


text:
The Canadian Soul/R&B/Jazz band, jacksoul has to be one of my favourites of all time. I've wanted to make this post for a long time, as I still reminisce about the day I first came across their single off the Sleepless album, "Can't Stop". I must've been around the age of 12 years old when I flipped on Much Music and watched Haydain Neale sing me into a jazz-induced daydreaming frenzy. From that moment the band jacksoul and their soothing music has failed to lapse my memory. My memorable moments with jacksoul don't end there, I recall in grade school that we were forced, yes forced to perform gymnastics routines in gym class. The exact song, which I chose to perform my routine to, escapes me but it was one of "Can't Stop", "I Know What You Want", or "Let Me Call You Baby". If only this moment was caught on video and I could watch it, I would definitely conclude that I was an out of the closet 12 year old. It can be argued that I have changed since then, but it's definitely not a memory I try to forget.
On to the actual band headed by vocalist Haydain Neale the rest of the invaluable band members include Adam Leo, Davide Direnzo, Brent Setterington, John Kanakis, Dave Murray, Ron Lopata, and Roger Travassos, Justin Abedin. jacksoul has won number awards in recognition of their genre defining music and has released a total of 5 albums through the years 1996-2009. Unfortunately, on November 22, 2009 Haydain Neale passed away of lung cancer. The rest of the band members were able to release an album in memory of Haydain from work, which they had been working on while Neale was well. The album entitled SOULmate was released on December 1, 2009 and all profits from the album go to the Haydain Neale Family Trust. The album can be purchased here and the official jacksoul website can be visited here.
jacksoul – I Know What You Want
jacksoul – Let Me Call You Baby


text:
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UNDATED (CNN) -- Researchers at Alabama's Auburn University say they're training the ultimate bomb-sniffing dogs. They say these canines can figure out there's a bomb before cops even realize a package is suspicious.
Imagine if the Boston bombing suspects had left a trail, a trail of vapors in the air that smelled like a bomb; vapors that only a specially trained dog could detect.
Dogs like these are now being trained at auburn university. Researchers here call them vapor wake dogs.
The point of a Vapor Wake Dog is to detect vapor of bomb, if you will, before it's actually placed somewhere it might explode, to catch it before that. Dr. James Floyd with Auburn University says, "Exactly correct. Your standard bomb dog, your explosive detector dog, is primed on looking at an object, a backpack placed somewhere. A Vapor Wake Dog's ability is to detect the odor coming off of that backpack on the back of the person as they carry it, and to follow that plume of vapor."
Auburn University professor Jim Floyd says vapor wake dogs are the ultimate bomb sniffing dog. they can follow a plume- or bomb vapor- stretching several football fields. a skill so unique the university hopes to patent it.
Video from the university shows a vapor wake dog in action. Once he catches the odor in the air, he never lets up. In a crowded mall or on a city street, this technique is crucial. these dogs can potentially stop a would-be bomber before it's too late. Floyd says, "Had one of our dogs been in place on that corner with those two guys walking there with those backpacks, I think they would've alerted on them."
Their training starts early, even as early as these puppies, which are just about 3-weeks-old. At this time, they are held a lot and socialized, so by the time their formal training starts, when they're about a year old, they are used to people and loud noises, and they don't get spooked so easily.
Auburn has its own breeding program for bomb sniffing dogs. They rarely use shepherds and traditional breeds but lean more on Labradors and spaniels.
Paul Hammond, whose company iK9 is working with auburn to train and deploy vapor wake dogs, explains why. He says, "We need a dog that fits into the public profile that the public is just going to walk past and ignore as if it was a domestic pet."
Auburn's bomb dogs are being used in airports, on Amtrak trains and by police departments too. Hammond says, "Well the dogs olfactory system is 220 million sense cells compared to a human's 5 million sense cells, so that sort of gives you a real comparison. Where we might be able to smell a woman's perfume walking by, but the dog can smell not only the perfume, but the clothes, the material she's wearing, the shower gel she washed with that morning."
In addition to vapor wake training, these dogs are also able to detect explosives in the traditional way.
What may be a game to these dogs, could mean the difference between life and death for the rest of us.


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MC ID: 6859838Location: NorwayTwitter: @msandbuBlog: Sandbu-Blog
I was working part-time at a helpdesk when I began my path to certification. It was 2008 and I attended a Microsoft Vista client training course in Norway. After the course, the instructor asked if I wanted to give the certification a try, and I figured "why not?". I trained for a couple of weeks and aced the exam. As someone who doesn't have a college degree, it felt good knowing that I had achieved these skills.
After my first exam, I investigated other Microsoft certifications. After passing two more Windows Server exams, I got a new job as a system engineer working with infrastructure management.Currently, I have taken more than 30 certification exams with Microsoft, Citrix, Cisco, EXIN and Comptia and I know there are more to come.
I feel fortunate because certification has provided me with new opportunities. I've had the pleasure of working part-time at Microsoft as an infrastructure ranger. Currently, I work as a technical advisor and a Microsoft Trainer. My current work allows me to incorporate everything I've learned through certification, as well as my on-the-job experience. Nothing feels wasted. Why am I am going to continue with certification? Certification allows me to keep my knowledge up-to-date and I like playing around with technology. Why not take the exam and demonstrate my expertise with the technology?
Marius's Tips:
1) Find someone who has similar goals as you and become study partners. It's always easier to study for an exam if you have someone to discuss ideas with.
2) If you are studying for a particular exam, use the Microsoft study guides. Don't rely solely on hands-on experience to prepare you for your exam. Most of the Microsoft exams already have a study guide available. TrainSignal or CBT Nuggets also have good training books and videos.
3) Find a topic that interests you! If you don't, your training will take a lot more time because you won't be truly engaged. Microsoft has a wide range of resources to help you find the IT certification that suits your interests.
way to go, mr.sanbu!


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Preschool Information
We use a child-directed approach to learning in our program. Children will be given opportunities to explore and experience educational materials, participate in large and small groups, engage in activities that encourage creativity through music, art, children's literature and dramatic play. Play will be a central part of our program through which children will also learn pre-math and pre-reading skills, science, social studies, and develop social, language and motor skills.
Click on the link below to learn more about our preschool program.


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1 Park near Apple Valley, California
Hesperia, California 9.38 miles SW
Victorville, California 10.03 miles NW
Skyforest, California 15.74 miles S
Rimforest, California 17.53 miles S
Adelanto, California 18.63 miles NW
Apple Valley, California (map) | (760) 247-7878
Sites: 83 | Latest Rate: $37.00 | 3 Reviews
|Clean Restrooms:
|Clean Showers:
Jan 2013 - $37.00
This park has so many problems in should not be in business, the water supply has according to the bulletin handed out by the Manager coli form and is un-drinkable. The septic system collapsed and a motor home sunk into the ground causing $7,000. in damage to the motor home alone, and according to the work crew this is the third time this has happened! There are no pool or any thing else at this park and it is miles from any attractions. This seams to be a long term park for low income people. - lethia
Dec 2012 - $17.00
We stayed here for six weeks and enjoyed it very much. Very friendly and very clean. About 70% of spaces are permanent campers. It was very quiet. Propane available on site. Our monthly rate was $400. We aren't towing a vehicle and the only negative thing was that it's a two-mile walk to the grocery store. That said, we had plenty of offers for rides. - Maudeen
Jan 2012 - $30.00
We weren't sure what we were going to find when we decided to try this park. On previous trips through this area we had stayed at other parks, both private and county, and found them to be difficult to get to or way to noisy or run down. We were pleasantly surprised and very happy with our stay at the Lone Wolf Colony. We didn't have reservations but the office staff was very friendly and anxious to make our stay comfortable. We parked in the B section, which is mostly permanent residents, and the sites are large with easy access. The park is clean and well cared for and many of the permanent residents have their sites fixed up very nicely. There is also another area for short timers which was all dirt but with nice trees and lots of space and since it was nicely graded it appears that these sites are level. Although we camped here only 3 nights, we were given a vacant spot in the B section. One thing we learned is that the Lone Wolf Colony is a nonprofit organization which is owned and operated by retired telephone company employees and volunteers. In my opinion, one of the reasons this park is so well cared for is because these folks take great pride in their organization. Showers, bathrooms, laundry room and clubhouse were all very clean and in good condition. We had good Verizon broadband and cell service in this area. - HnHTravels


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- All
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Growing in Christ, Serving in Ministry: An Interview with Sinclair Ferguson
Tabletalk: How did you become a Christian, and what brought you to the United States from your native Scotland? Sinclair Ferguson: I was brought up in a close family, with loving parents who tried to get me to keep the …Read More
When I Don't Feel Forgiven
The Christian life is a constant battle against the world, the flesh, and the devil. If these forces had their way, it would destroy every single one of God's blood-bought and dearly loved children. But our Lord Jesus assures us …Read More
How Should I Feel?
Human beings are emotional creatures. We love or hate, feel happy or sad, angry or joyful. And yet christians sometimes struggle with integrating emotion into their spiritual lives and end up falling victim to dangerous tendencies when it comes to …Read More
In Awe of God's Glory: An Interview with Joel Beeke
Tabletalk: At what age did you first hear God's call to ministry, and how did you receive confirmation of this call? Joel Beeke: God began to strive with my soul when I was age fourteen. I was brought to spiritual …Read More
Stop Asking Jesus into Your Heart
If there were a world record for the "number of times asking Jesus into your heart," I'm pretty sure I would hold it. I've probably "prayed the prayer" more than five thousand times. Every time was sincere, but I was …Read More
Faith and Assurance
A man and a woman stood hand in hand on the beach. For a time, the only sound was the crashing of waves. Then the man asked, "What are you scared about?" She answered: "I want to marry you more …Read More
Federally Backed Security
Nations are currently experiencing the most volatile economic period in a generation. Many investors have made moves to reduce their risk and put their treasure into securities backed by the U.S. federal government. The government gives us its word that …Read More
What Is Your Only Comfort?
Of all the Reformation-era catechisms, perhaps none is as well-loved as the Heidelberg Catechism. In the opening question and answer, the personal and distinctive tone of the catechism becomes evident. "What is your only comfort in life and in death?" …Read More
The Most Frightening Words
As Jesus draws His Sermon on the Mount to a close, He makes one of the most frightening statements to be found in Scripture. Martyn Lloyd-Jones calls His declaration the most solemn and solemnizing words ever uttered in this world. "Not …Read More
The Spirit of Promise
I don't know if this happens to everyone, but a deep sense of longing fills my soul when I listen to Celtic music. I get homesick. I dream of the day when I can go the land of my fathers …Read More


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Related Articles
- 'Sell' Crompton Greaves on weak outlook for FY14, target price Rs 75: UBS'Overweight' rating on Crompton Greaves, safe in tough macro climate: Morgan Stanley'Sell' Crompton Greaves shares on expensive valuations, target price of Rs 114Worst over for Crompton Greaves, upgrade to 'neutral': Nomura
Shares of electrical equipment maker Crompton Greaves today surged over 9 per cent after the company reported an 27.67 per cent rise in standalone net profit for the third quarter ended December 31.
At the NSE, the scrip ended 9.18 per cent higher at Rs 111.75. Crompton Greaves's scrip rose by 7.91 per cent to settle at Rs 110.45 on the BSE.
Crompton Greaves had yesterday reported an 27.67 per cent rise in its standalone net profit at Rs 135.54 crore for the third quarter ended December 31.
The company had posted a profit of Rs 106.16 crore in the same period of previous fiscal.
Its total income increased to Rs 1,867.65 crore in the October-December 2013 quarter compared to Rs 1,746.05 crore during the same period a year ago.
Meanwhile, the company's Board of Directors declared an interim dividend of 20 per cent i.e. Rs 0.40 per share.


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Oklahoma state basketball: Cowgirls get commitment from Roshunda Johnson
STILLWATER — Roshunda Johnson, one of the Arkansas high school basketball players late Oklahoma State coaches Kurt Budke and Miranda Serna were traveling to evaluate when they were killed in a plane crash last November, has committed to the Cowgirls, according to DFW Elite Basketball's website.
Johnson, a point guard from Little Rock Park View, is rated the No. 49 overall prospect in the nation by ESPN HoopGurlz. According to the website, Johnson was also considering Arkansas, Florida State, Kentucky, Texas and Tennessee.
Johnson is OSU's sixth commitment for the 2013 class, joining forward Kaetlyn Loecker (McPherson, Kan.), guard Lakota Beatty (Anadarko), center Marisha Wallace (Northern Oklahoma College-Enid), forward Diana Omozee (Pflugerville, Texas) and forward Brianne Coffman (Jarell, Texas).


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Home » inspiration, kids » Black Belt Weekend
Black Belt Weekend
|August 1, 2011
|Posted by Carrie under inspiration, kids
This past weekend, Dude earned his 2nd Degree Black Belt in Taekwondo.
The consensus on the new uniform –
a little ninja like – not so Taekwondo.
Not my choice – I'm not in charge.
(sorry for the sloppy photoshop privacy work, too)
When Dude was 4 years old, he started taking Taekwondo lessons. At the time we thought it'd help him with discipline and focus and that he would be able to stay active and have an outlet for physical activity.
I can't seem to find a picture of him in his
white belt, but wasn't he so cute? Little did
we know we'd still be doing this 4+ years later.
There were times that he didn't love going to Taekwondo. But, he usually got over it. About 2 months ago, he was thinking about quitting again, but agreed to stick it out through this test. Once he got started with the more intensive training for the test, he got really into it all again. Now he doesn't want to quit. He's actually willing to give up some hanging out with friends time in order to go to class tonight.
Back to the weekend. The Black Belt test is an all day thing. They've been training really hard and had essentially passed all the technical requirements. The day, however, started with an endurance portion.
We met at the studio at 7AM on Saturday. There were 5 candidates. Dude, two more kids (ages 8 and 11, who have been in this with us all along) and two adults. The group headed to the local park – there they ran laps of the park interspersed with 100 push ups, 100 sit ups and 100 mountain climbers. They also did sets of stairs and some step work on a curb. All in all, it was about an hour and a half of intensity. One of the adults wore her Garmin and it showed 4.89 miles for the morning. Oh – and they had to carry a 15 lb. kettlebell (as a team, it got passed around – although the adults did the lion's share of the work).
He's carrying the kettlebell here. Yes,
that's one of the adults next to him,
big size difference.
The group headed back to the studio for a break. The two adults went home to ice bath and fuel. The kids didn't do any such thing. They were running around, playing and mine had a donut.
The second portion of the test was drills – kicks, etc. After an hour of that, they put on their full sparring gear and did another hour of drills. This was probably the hardest part.
It was fascinating to see the difference between the adults and the kids. They were all working hard, but it was almost like the kids didn't notice. Maybe it was that the two adults started out injured.
After the second portion ended, they had another break. Again, the adults left to take care of their aching bodies. The kids ate lunch and did kid stuff at the studio. Seriously, they were climbing, running, playing tag… everything but resting.
At 4PM, they started the formal portion. They did their forms, self-defense moves and board breaking. Then they were presented with their new belts. Dude had such a big smile on his face (as you can see from the top picture).
In case you're wondering, Dancing Girl has a 1st degree Black Belt. Both kids earned them together last May. She wasn't loving Taekwondo so much at that point and had gotten back into dancing. She stopped Taekwondo back in November of last year. Read all about that decision here. It was great this past weekend that she put on her uniform and helped out. She was holding paddles for her brother and encouraging him when he got tired.
When my kids were testing for their 1st degree Black Belt last year is about when I started running. I saw how hard they were working and I wanted to keep up. They were such a huge inspiration. Watching them work so hard opened my eyes to tackling a physical goal.
I was so proud of Dude this weekend. The candidates have dog tags made that get hung on that kettlebell after they've passed the test. Dude chose a few sayings to have engraved on the back of his dog tag.
"Never Give Up"
"Try Hard"
"Good Luck"
"Have Fun".
How cool are the first two sayings? I love that he thought of those. He totally followed through.
Proud Mommy here.
3 Responses to Black Belt Weekend
Wow! Congrats to him on such a fabulous achievement. I did Tae Kwon Do as a teen and the discipline/self-confidence it instilled is awesome. How cool you started running to 'keep up' as your kids trained!
Wow! Congratulations! I love that the kids just kept being active during the "breaks." We need to follow that example.


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Check out appoLearning.com, because your kids deserve the very best educational apps!
Ah Air Hockey. The game that everyone claims to be good at but so few people leave the table without bruised fingers. If you think back on your life, how many quarters have you spent on Air Hockey over the years? Well, to save your fingers and your piggy bank, you can always check out the Air Hockey app for the iPhone.
The Air Hockey app is a great concept but it fails to deliver on nearly every aspect. First off, the paddle moves way to slow. That means that you're going to be frantically swinging that around just to try and get it near the puck before you simply lose. The paddle is also much smaller than nearly anyones finger, so be prepared to not see it and overestimate just how much coverage you have with it.
Then theres the fact that it looks like it would be perfect for multiplayer action, but it doesn't support it. Who wants to play Air Hockey against a computer anyways? The margin of error on the computers side is much less than any one of your friends.
What seals the deal with Air Hockey is that it's a paid app. Even though it doesn't cost that much, it still isn't worth the money. So many apps have been coming out under $2.99 and most of them are junk. This one is definitely one of those games that belongs in that junk pile.


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SPCA of the Triad
Tues.-Fri.: 11am-6pm; Saturday: events/adoption fairs all day long
3163 Hines Chapel Rd.
Greensboro, NC 27405
Phone: 336-375-3222
Willow is a 10 month old Corgi mix.
Who says short dogs can't jump? Willow can!
She has lots of doggy friends at the SPCA but her favorite friend is sister, Meadow!
WFMY News 2/SPCA Of The Triad


text: Today i was BMX Racing with my friend at a ABA Track and it was raining some of the time. So it was my first time EVER bmx racing and after like 30 mins of praticiing it was all slippery and i fell once on the Big Wall like this big dirt thing and then i fell at the Finish line of the real 1st Race vsing 13 year olds HOW CHEAP and i was waving at my friend and did like a barspin and flew off and then in the Finals i got 2nd Place and got a SWEET TROPHY! Oh ya i was using my friends weird Brazilian Bmx Racing bike. It was really FUN!


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DAYS: Arianne's AdventuresBy Posted: Aug 18, 2008
When it comes to her DAYS OF OUR LIVES downtime, Arianne Zucker (Nicole) divides her time between supporting charities she strongly believes in and traveling and embarking on new adventures. Here, Zucker shares her passion for two causes near and dear to her heart and reveals the details of her latest adventure: a white-water rafting trip she took to Colorado during the show's last hiatus.
Soap Opera Weekly: What causes do you find yourself most eager to lend your name to?
Arianne Zucker: Anything to do with animals and abused women.
Weekly: Is there a particular pet charity you support?
Zucker: I did my first event for a group called Dogs in Danger. It was a doggie fashion show and a lot of fun. It's a newer charity for abused and abandoned dogs. There are so many out there, and they try to get the dogs adopted [and] find homes for them.
Weekly: What made you get involved with them?
Zucker: My dog, Bam Bam, is a rescue dog, so being part of something like this is really important to me. Anything that helps raise money to [save] even one dog, I'm proud to be a part of.
Weekly: You mentioned charities that support abused women, too. Is there one you strongly support?
Zucker: Yes. There's a very important one called The Shepherd's Door. I attended their event last summer. They asked me to host it this year, but unfortunately I was not available. It's really interesting. As much as I love animals, the woman who runs The Shepherd's Door told me there are actually more facilities for abused animals than there are for abused women.
Weekly: Isn't that sad?
Zucker: It is. In essence, women are just starting not to be afraid to say they are being abused or were abused, because it's a frightening fate to state; to even say it and recognize it. This organization helps women recognize the signs of abuse.
Weekly: And provides a safe haven for them, right?
Zucker: Exactly. Listen, we all make our own choices. But just to know that there's a place for someone to go to if they're in an abusive relationship is a great thing. If they're afraid for their lives or for their loved ones' lives, there are places that will help them.
Weekly: Aside from a safe place to go to, what else does The Shepherd's Door offer?
Zucker: They work with women one-on-one. They give them someone to confide in about their fears. It's a sensitive subject, and these women need to talk about it. That's the first step.
Weekly: Your charity work is definitely commendable, but hopefully you take a little time for yourself, too. What did you do on your last hiatus from DAYS?
Zucker: I went to Aspen for the first time. I went white-water rafting with a group of friends. It's the coolest sport. A lot of fun. It was phenomenal.
Weekly: Were you nervous?
Zucker: No. I only did a level three, which isn't super-high. It was amazing, actually. Level three is a three-hour rafting ride. The water is freezing, but the air is warm. It's such a cool experience, if you're an outdoor sort of person.
Weekly: What prompted you to try something like this?
Zucker: I got invited, and I always wanted to go white-water rafting. I'm such a tourist. If I go somewhere and there's something new to do, I grab my camera and go. I'm the one saying, "Let's go try this. Let's go do that." I like trying new things and being a tourist.
Weekly: Isn't this a tad dangerous?
Zucker: It can be, but the guides who are with you white-water raft twice a day. They don't take you down rapids you're not experienced enough to do. We were in Aspen. The rapids are lower there. Besides, we weren't doing a more extreme level, four or five. Those are the ones you have to wear helmets to do.
Weekly: Were there any scary moments?
Zucker: No, not at all.
Weekly: What about a highlight from the whole experience?
Zucker: The highlight was how gorgeous it was out there on the water. The highlight was getting in that raft, putting on your wetsuit, going out there and being in nature; living life. That was exciting. It's such a high to do those kinds of things in your life. Most people are stuck in their day-to-day life and never [embark] on any adventures.
Weekly: So what's next on your to-do list?
Zucker: I would like to go on a level four or five, work up to doing bigger rapids. They're bigger and steeper, and you get all soaked out there in your raft. That would be awesome.
Weekly: What about tackling something else, like skydiving or bungee-jumping?
Zucker: No. I'm not a jumping-out of-a-perfectly-good-airplane type of person. Anything on the ground is fine with me. As for midair adventures, I'm not interested.


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Present Continuous
Omer Fast uses complex narrative structures to explore the different ways stories are constructed. Blurring the boundaries between "reality" and "representation" and between document and artifice, his practice questions the status of the image. This exhibition, co-produced with Jeu de Paume, Paris and Kunsten Museum of Modern Art, Aalborg, will present new and recent work.
Jumana Emil Abboud works with drawing, installation, video and performance, exploring personal and collective memory, loss, longing and belonging. Inspired by the cultural landscape of her home, Abboud draws on the traditions of Palestinian folklore and myth-making by collecting stories and fairy tales. Investigating these story telling practices and oral histories, the artist provides new interpretations for the tales she has discovered.
The Cyphers
The Cyphers is Hajra Waheed's largest solo exhibition to date and expands upon Still Against the Sky, a recent presentation at Kunst-Werke, Berlin. The exhibition continues Waheed's ongoing research into what has been described as 'our current aerial occupation,' highlighting the ever increasing militarisation of the sky, where the circulation of military drones and surveillance technology extends over everyday life, often with lethal consequences.
Common Ground brings together work by four contemporary artists and four community groups living and working in South East Northumberland.
If you've been to see the current Hajra Waheed exhibition on the Ground Floor we want to hear what you thought. Please let us know about your experience of the exhibition by answering a few short survey questions.
Join BALTIC and Roseate Tern LIFE Project this half term to get creative with conservation! Explore "The Night Hide" straight from RSPB's Coquet Island and find out more about Puffins, Terns and BALTIC's very own Kittiwake Colony from our live Kittiwake-cam.
Join Durham Wildlife Trust and a member of BALTIC Crew for a Spotlight Tour of the kittiwake colony on BALTIC's north wall. Learn about these fascinating birds and the significance of the NewcastleGateshead Quayside Colony.
BALTIC 39 is a hub for contemporary art in the heart of Newcastle upon Tyne with the a project space gallery programmed by BALTIC with changing exhibitions and events. The building is also home to Northumbria University's Fine Art students, thirty two artists' studios and BALTIC Professor, Christine Borland.
Life's too short to have the same old stuff in the same old place all the time. We all like a refresh and as the season's change so does BALTIC Shop stock. So whether you need to re-decorate your walls with fresh art prints or grab a gift we've got it covered. Shop online with BALTIC SHOP.
Serving hot and cold drinks, speciality coffees, alcohol, sandwiches, pastries, mouthwatering cakes and a range of freshly made meals.
BALTIC's Learning space is transformed into a magical area for under 5's to explore art.
BALTIC is open 10.00-18.00 daily with last admission at 17.45.
BALTIC+ is the online home for videos, images, sounds and text celebrating BALTIC's complete exhibition history. Browse or search the site on your desktop, tablet or mobile and discover more.
Become a BALTIC Member and enjoy discounts, offers and events from just £20 a year. Be part of a very special group of people, supporting one of the UK's most exciting arts venues. Being a BALTIC member gives you unique access and great benefits.
These bitesize, introductory tours are suitable for everyone and help bring BALTIC's exhibitions to life.
Once you've signed up to BALTIC Love mailing list you will receive updates and information on BALTIC. Additionally, you can opt to receive further information on family activities, social events or food/drink.
BALTIC SHOP is one of the north east's best shops stocking killer designer homewares, artist products, exclusive commissions, unique jewellery and limited edition prints. Come visit this friendly and inspiring shop at BALTIC, Gateshead or shop online!


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Audio Precision ATS-2 Audio Analyzers
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Audio Precision ATS-2 Details
Audio Precision ATS-2
The Audio Precision ATS-2 is a newly designed audio measuring instrument recently introduced by Audio Precision. Different from their other portable instruments the Portable One and the ATS-1 the new ATS-2 is controlled from a separate computer like the larger and more comprehensive System One and System Two. Like its larger System One and Two big brothers the ATS-2 can be run from a desktop PC via either an ISA or PCI interface card or a PCMCIA card with a laptop PC. This unit comes with option AUX0025 Features and Benefits: * Multi-functioned sweeping audio analyzer with amplitude phase bandpass / bandreject 2-channel ratio crosstalk frequency frequency response THD+N IMD testing and more * Multitone analysis * Proprietary harmonic detail analyzer * On-screen results and graphing * Results values in tabular form exportable to data files * Graphs exportable in raster image (bitmap) and vector image formats * Balanced and unbalanced analog inputs and outputs * Balanced unbalanced and optical digital inputs and outputs * Trigger gating sync and monitor connections * General purpose logic input and output connections for device control
Option: AUX-0025 Switching Amplifier Measurement Filter
- Independent analog and digital signal generators
- Multitone analyzer with FFT for testing playback-only devices
- Converter-based analyzer brings high performance at a lower price
- Superior value and outstanding performance for demanding applications
- A wide range of analog and digital test signals
- Programmatic control for high-speed automation
- Optional digital interface testing capabilities
- A full complement of graphing and reporting options
- Auxiliary instruments are available for specialized testing
|Generated Waveforms
| Automation
Converter Based
The ATS-2 offers an excellent value in audio analyzers. Its converter-based architecture keeps the cost down while offering a wide range of features at high levels of performance. Converter-based audio analyzers generate and analyze signals in the digital domain and use analog-to-digital converters (ADCs) and digital-to-analog converters (DACs) for analog input and output.


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KU is running dollar days for ISU game. Its $1 to get in, free to park, and $1 for food.
Good deal. Come and cheer because I will be there to cheer for my lovely CYCLONES!
That sure says volumes about our team this year.
* didn't realize this was women.
Last edited by GeronimusClone; 02-23-2010 at 08:29 AM.
Originally Posted by MNCyGuy
The only answer to "who/what is GeronimusClone?" is in fact "GeronimousClone". You're like The Todd on Scrubs.
Originally Posted by Angie
This is why you're my favorite
Originally Posted by MoreCowbell
GC, he's obviously all man. And I don't think Ellen would go *****, even for GC...
Wow. So tempted. No work or school on Friday.
This is tempting. Very tempting.
Back in college State Farm bought 10,000 tickets to give away when we played at Nebraska. BF was asked if we'd ever consider a promotion like that and he said our fans care more about our program that we can get 10,000 fans to actually pay to see us so we don't need to put on some 1 time promotion like that to fill Hilton whenever a good team comes to town.
Go Cubs Go!
If this game weren't on a Thursday, I know SO many people who would go
Green hills for thy throne, and for crown a golden melody/Ringing in the hearts of all who bring thee love and loyalty/Dear Alma Mater, make our spirits great
True and valiant like the bells of I-O-WA STATE!
And thank you Stumpy for this:
Originally Posted by sodakjoe
If this game weren't on a Thursday, I know SO many people who would go
Yah, I wish this game was on Saturday as well. Past couple of years, the games were on Sundays.
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NEW YORK - From television's favourite psychiatrist to the owner of a French Riviera nightclub: Kelsey Grammer is set to star on Broadway in "La Cage aux Folles" next spring.
Producer Sonia Friedman says a revival of the 1983 Jerry Herman-Harvey Fierstein musical will open April 18 at the Longacre Theatre. It's based on the current hit London production and will feature that show's British star, Douglas Hodge. The director is Terry Johnson.
"La Cage" concerns the relationship between the club owner, portrayed by Grammer, and its drag star, the role played by Hodge.
Grammer, 54, played Dr. Frasier Crane on the NBC comedy series "Frasier" for 11 seasons.
Organizations: Longacre Theatre, NBC
Geographic location: Broadway, NEW YORK, LondonTop of page


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Can You Have Caffeine after Gastric Bypass Surgery?
People hear a lot of different things about caffeine after gastric bypass surgery. Can you drink coffee after having a gastric bypass? What will happen if you do?
There are many reasons some people choose to avoid caffeine, whether or not they've had gastric bypass surgery:
- Caffeine can cause feelings of anxiousness or restlessness.
- Caffeine causes trouble sleeping, especially if consumed less than eight hours before bedtime.
- Caffeine gives some people diarrhea, especially in large amounts. It also exacerbates symptoms in many people with irritable bowel syndrome.
- Caffeine may increase blood pressure and/or heart rate in people with high blood pressure or heart conditions.
In addition to those reasons for avoiding caffeine, gastric bypass patients are often advised to avoid it for additional reasons:
- Many people, including some medical professionals, believe caffeine is a diuretic and that it increases the risk of dehydration. However, recent studies indicate that is not the case, unless one is unaccustomed to drinking caffeinated beverages and consumes a very large amount at one time.
- Caffeine might irritate a healing pouch in the first few weeks after surgery.
- Caffeine might irritate a developing ulcer and make it worse, although it won't cause an ulcer in a healthy pouch.
- Caffeine interferes with the absorption of certain minerals, including iron and calcium, though the effect is slight. For best results, don't take your iron or calcium supplements with a caffeinated drink, especially if you know your iron level is already low.
The bottom line:
For most gastric bypass folks, drinking caffeinated beverages in moderation should not pose a problem after the first few weeks, when your insides have healed. If you have high blood pressure, an anxiety disorder, trouble sleeping, an ulcer (or stomach pain that might be caused by an ulcer), irritable bowel syndrome, or certain other medical problems, it might be better to avoid caffeine, at least for the time being. Talk to your doctor about it.
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2007 Findings on the Worst Forms of Child Labor - Costa Rica
|United States Department of Labor
|Bureau of International Labor Affairs
|Publication Date
|27 August 2008
|Cite as
|United States Department of Labor, 2007 Findings on the Worst Forms of Child Labor - Costa Rica, 27 August 2008, available at: http://www.refworld.org/docid/48caa4695.html [accessed 31 May 2016]
|This is not a UNHCR publication. UNHCR is not responsible for, nor does it necessarily endorse, its content. Any views expressed are solely those of the author or publisher and do not necessarily reflect those of UNHCR, the United Nations or its Member States.
|Selected Statistics and Indicators on Child Labor893
|Working children, 12-14 years (%), 2004:
|Working boys, 12-14 years (%), 2004:
|Working girls, 12-14 years (%), 2004:
|Working children by sector, 12-14 years (%), 2004:
|– Agriculture
|– Manufacturing
|– Services
|– Other
|Minimum age for work:
|Compulsory education age:
|Free public education:
|Gross primary enrollment rate (%), 2005:
|Net primary enrollment rate (%):
|School attendance, children 5-14 years (%), 2004:
|Survival rate to grade 5 (%), 2004:
|ILO-IPEC participating country:
|* Must pay for miscellaneous school expenses.
Incidence and Nature of Child Labor
In Costa Rica, the rate of child work is higher in rural areas (91 percent) than in urban areas (9 percent). In rural areas, children work principally in agriculture, forestry, and service activities while in urban areas, children work mainly in trade and repair activities and construction.894
According to the National Institute for Children (PANI), commercial sexual exploitation of children is a problem in Costa Rica, with an unknown but significant number of children involved. Children in San José, Limón, and Puntarenas are at high risk. From January to March 2007, 34 sexual exploited minors were assisted.895 Children are trafficked within the country for sexual exploitation and forced labor. The Costa Rican Government identified child sex tourism as a serious problem, and girls are trafficked into the country from other countries for commercial sexual exploitation.896
Child Labor Laws and Enforcement
The law sets the minimum age for employment at 15 years. Minors under 18 years are prohibited from working at night; in mines, quarries, and other dangerous places; where alcohol is sold; and in activities where they are responsible for their own or other's safety. They are also not allowed to work with dangerous equipment, contaminated substances, or excessive noise.897 Employers of youth ages 15-17 must maintain a child labor registry. Violations of minimum age and child labor standards are punishable by fines.898
Costa Rican laws on work hours for children state that adolescents ages 15 to 17 are prohibited from working for more than 6 hours a day or 36 hours a week.899 Children may work longer hours in agriculture and ranching.900 When PANI determines that child labor is performed to meet the family's basic needs, economic assistance must be provided to the family.901
Slave labor is prohibited under the law.902 Costa Rica does not have armed forces, and the minimum age for recruitment to the police force is 18 years.903 The penalty for paid sexual relations with a minor under 13 years is 4 to 10 years in prison; if the victim is 13 to 15 years, it is 3 to 8 years imprisonment; and if the victim is 15 to 18 years, then it is 2 to 6 years incarceration.904 The penalty for profiting economically from the prostitution of a minor under 13 years is 4 to 10 years in prison, and 3 to 9 years if the victim is 13 to 18 years old.905 The production of pornographic materials with minors is punishable by 3 to 8 years in prison. The penalty for possession of pornography involving minors is 6 months to 2 years.906 The penalty for promoting, facilitating, or aiding the trafficking of minors for commercial sexual exploitation or slave labor is 4 to 10 years in prison.907
The Inspections Directorate of the Ministry of Labor is responsible for investigating child labor violations and enforcing child labor laws.908 According to USDOS, informal sector enforcement of child labor laws is limited by a lack of resources.909
PANI, the Special Prosecutor for Domestic Violence and Sexual Crimes, and various ministries are responsible for preventing and prosecuting crimes involving commercial sexual exploitation of children. PANI leads public awareness campaigns and provides assistance to minors involved in commercial sexual exploitation.910 Several investigations into commercial sexual exploitation of children have been started by various agencies, although there have been few successful prosecutions.911
Current Government Policies and Programs to Eliminate the Worst Forms of Child Labor
The National Agenda for Children and Adolescents 2000-2010 includes strategies to prevent and eliminate the worst forms of child labor.912 In addition, the Government of Costa Rica has launched the Second National Action Plan for the Prevention and Eradication of Child Labor and Special Protection of Adolescent Workers 2005-2010.913 It has also approved its third National Plan to Eradicate Commercial Sexual Exploitation of Children which aims to raise awareness; increase institutional capacity to address risk factors in target regions and populations; develop mechanisms to guarantee victims' access to psycho-social services; strengthen the judicial system to defend victims' rights; and create mechanisms to strengthen the National Commission against Commercial Sexual Exploitation of Children and Adolescents.914 In May 2007, the Costa Rican judicial system also implemented a database system for tracking cases of commercial sexual exploitation of children.915
Since 2006, the Costa Rican Government has been carrying out "Avancemos" (Let's Get Ahead), a conditional cash transfer program (CCT) that encourages low-income children to remain in school or return to school. In 2007, 94,621 children benefited from the program.
The Government of Costa Rica continues to participate in a USD 8.8 million regional project implemented by ILO-IPEC, which seeks to combat commercial sexual exploitation through a variety of activities including capacity building and legal reform. In addition, the project aims to withdraw 713 children and prevent 657 children from commercial sexual exploitation in the region.916 In coordination with the Government, CARE-USA is implementing a USD 5.5 million regional project funded by USDOL to combat exploitive child labor through the provision of quality basic education. The project aims to withdraw and prevent 2,984 children and adolescents from exploitive child labor in the region.917 The Government of Costa Rica also participates in a USD 1.2 million regional project funded by the Government of Canada and implemented by ILO-IPEC in support of the Timebound Program. In addition, it participates in a USD 0.5 million regional project funded by the Government of Canada to combat the worst forms of child labor through the strengthening of labor ministries and workers.918 The Government of Costa Rica participated in a Phase II USD 2.6 million regional project and a Phase III USD 3 million regional project to eradicate child labor in Latin America, funded by the Government of Spain and implemented by ILO-IPEC.919
893 For statistical data not cited here, see the Data Sources and Definitions section. For data on ratifications and ILO-IPEC membership, see the Executive Summary. For minimum age for admission to work, age to which education is compulsory, and free public education, see Government of Costa Rica, Código de la Niñez y la Adolescencia, (1998), article 78; available from http://www.asamblea.go.cr/ley/leyes/7000/7739.doc. See also U.S. Department of State, "Costa Rica," in Country Report on Human Rights Practices – 2007, Washington, DC, March 11, 2008, section 5; available from http://www.state.gov/g/drl/rls/hrrpt/2007/. See also Government of Costa Rica, Constitución Politica, (1949), article 78; available from http://www.cesdepu.com/nbdp/copol2.htm.
894 ILO-IPEC, In-depth analysis of child labour and education in Costa Rica, 2004, 21-26; available from http://white.oit.org.pe/ipec/documentos/cr_in_depth.pdf.
895 U.S. Department of State, "Country Reports – 2007: Costa Rica," section 5. See also Melissa A. Lépiz and Doris G. Mosquera, Persiste Impunidad ante Explotación Sexual de Nuestra Niñez, [online] May 17-23, 2007 [cited December 12, 2007]; available from http://www.primeraplana.or.cr/version2006/articulos_x_id.php?id_tipo_articulo=1&id_edicion=29&id_articulo=223 .
896 U.S. Department of State, "Costa Rica (Tier 2)," in Trafficking in Persons Report-2007, Washington, DC, June 12, 2007; available from http://www.state.gov/g/tip/rls/tiprpt/2007/82805.htm. See also U.S. Department of State, "Country Reports – 2007: Costa Rica," section 5.
897 Government of Costa Rica, Código de la Niñez y la Adolescencia, articles 2, 78, 92, 94, 95. See also, Government of Costa Rica, Código de Trabajo, Ley No. 2, (1943), articles 88 and 89; available from http://www.ministrabajo.go.cr/Codigo/Indice.htm.
898 Government of Costa Rica, Código de la Niñez y la Adolescencia, 1998, articles 98, 101.
899 Government of Costa Rica, Código de la Niñez y la Adolescencia, article 95.
900 Government of Costa Rica, Código de Trabajo, article 89.
901 Government of Costa Rica, Código de la Niñez y la Adolescencia, article 92.
902 Government of Costa Rica, Constitution, articles 20, 56.
903 Coalition to Stop the Use of Child Soldiers, "Costa Rica," in Child Soldiers Global Report 2004, London, 2004; available from http://www.child-soldiers.org/document_get.php?id=821.
904 Government of Costa Rica, La Reforma y Adición de Varios Artículos al Código Penal, 4573, (August 30, 2007), article 160; available from http://ministeriopublico.poder-judicial.go.cr/publicaciones/legislacion_dia/2007/02-2007.pdf.
905 Ibid., article 171.
906 Ibid., article 173.
907 Government of Costa Rica, Codigo Penal de Costa Rica, (1970), article 172; available from http://www.unifr.ch/ddp1/derechopenal/legislacion/cr/cpcr5.htm.
908 U.S. Department of State, "Country Reports – 2007: Costa Rica," section 6d. See also Ministerio de Trabajo y Seguridad Social, Poder Ejecutivo Directriz: Manual de Procedimientos de la Dirección Nacional de Inspección, San José, 2-3; available from http://www.ministrabajo.go.cr/Documentos/Inspeccion_manual.doc.
909 U.S. Department of State, "Country Reports – 2007: Costa Rica," section 6d.
910 Ibid., section 5.
911 Ibid.
912 Government of Costa Rica, Agenda Nacional para la Niñez y la Adolescencia: Metas y Compromisos, 2000-2010, San José, September 2000, 21.
913 Government of Costa Rica, Segundo Plan Nacional de Acción para la Prevención, Erradicación del Trabajo Infantil y Para la Protección Especial de las Personas Adolescentes Trabajadoras, Costa Rica, 2005-2010, San José, 2005; available from http://www.oit.org.pe/ipec/documentos/plan_eti_costa_rica.pdf.
914 Government of Costa Rica, Plan Nacional para la Erradicacion de la Explotacion Sexual Comercial de Ninos, Ninas, y Adolescentes 2008-2010, San José, 2007; available from http://white.oit.org.pe/ipec/documentos/plan_nac_esc_costa_rica.pdf.
915 ILO-IPEC, Stop the Exploitation: Contribution to the Prevention and Elimination of Commercial Sexual Exploitation of Children, Technical Progress Report, San José, September 30, 2007, 16.
916 ILO-IPEC, Contribution to the Prevention and Elimination of Commercial Sexual Exploitation of Children in Central America, Panama, and the Dominican Republic, Project Document, RLA/02/P51/USA, San José, 2005.
917 CARE USA, APRENDO Project. Combating Exploitive Child Labor Through Education in Central America (Costa Rica, El Salvador, Guatemala, Honduras and Nicaragua) and the Dominican Republic, Project Document, 2004.
918 ILO-IPEC Geneva official, E-mail communication to USDOL official, December 12, 2007.
919 ILO-IPEC official, E-mail communication to USDOL official, February 4, 2008.