VEL TECH MULTI TECH Dr.RANGARAJAN Dr.

SAKUNTHALA ENGINEERING COLLEGE

(Approved by AICTE, New Delhi & Affiliated to Anna University, Chennai) No.60,Avadi Vel Tech Road, Chennai 600 062.

BM2356- HOSPITAL TRAINING LAB

NAME : ROLL NO. : REGISTER NO.: BRANCH : BIOMEDICAL ENGINEERING YEAR : IV year

VEL TECH MULTI TECH Dr. RANGARAJAN Dr. SAKUNTHALA ENGINEERING COLLEGE
(Approved by AICTE, New Delhi & Affiliated to Anna University,Chennai) No.60, Avadi Vel Tech Road, Chennai 600 062.

Name Year IV Semester VII Branch Biomedical engineering College Roll No University Reg. No.

Certified that this is the bonafide record of work done by the above student in the Hospital Training Lab(BM) during the academic year 2012-2013

..

Signature of HOD Signature of Lab Incharge ________________________________________________________________ Submitted for the University Practical Exam held on at VEL
TECH MULTI TECH Dr.RANGARAJAN Dr.SAKUNTHALA ENGINEERING COLLEGE,#60,AVADI VEL TECH ROAD,CHENNAI 62.

Signature of Examiners Internal: . Date: External: .

ACKNOWLEDGMENT

I praise almighty GOD for his grace abundance blessings he has showered upon me to complete this work.

I express my immense gratitude to respected chairman MR. KISHORE for support to complete this record.

I express my immense gratitude to Principal MR.HEMATHKUMAR for his support in providing permission for training sessions.

I express my sincere thanks to HOD DR.C.CHELLARAM for the guidance in completing my record successfully.

I cordially thank my parents & friends for the external support & encouragement which they provided for me in preparing this record successfully.

LIST OF DEPARTMENTS VISITED

1. LABORATORIES Biochemistry Histopathology & Cytology Hematology Immuno serology Medical Genetics Mycobacteriology Culture area 2. ICU (Intensive Care Unit) 3. DIALYSIS 4. BLOOD BANK 6. NEONATAL/LABOR WARD 7. EMERGENCY WARD 8. OT (Operation Theatre) 9. PHYSIOTHERAPY

LABORATRIES

BIOCHEMISTRY

INTRODUCTION: A biochemistry lab is a facility in which people can perform tasks related to the study of biochemistry. Biochemistry labs have equipment which can be used to explore various topics in biochemistry, along with space for storage of specimens, experiments, and other activities. Such labs can be found in colleges and universities with biochemistry departments, along with institutions which perform biochemistry research, and as standalone structures which perform research and analysis. Basic facilities for biochemistry can also be found in some criminal laboratories, as many topics in biochemistry are useful in the analysis and evaluation of evidence. Biochemistry is a science which involves the examination of various chemical processes as they are found in living organisms. These can range from the processes involved in cell division to the signals sent by neurons to coordinate the workings of the nervous system. Many tasks in biochemistry have to take place in a laboratory environment with special equipment, because there is no other way to study biochemical processes which take place on the cellular or even molecular level. A typical biochemistry lab includes workbenches for people to use, with equipment like spectrometers, microscopes, DNA sequencers, imagers, chromatographs, computers, and electrophoresis equipment, along with tools which can be used to manipulate samples. The lab also has protections such as fume hoods and isolation boxes to protect people from hazardous substances, along with storage space and specially equipped facilities like cold rooms and negative pressure rooms. The biochemistry lab may be attached to offices used by scientists affiliated with the lab. At colleges and universities, a biochemistry lab can be used for instruction, with students being obliged to spend time in the lab working on projects and developing hands-on experience. College labs can also be used for research by graduate students and advanced undergraduates. Scientific institutions maintain labs for research and analysis of samples, from suspect viruses involved in an epidemic to new species of plants. Some biochemistry labs focus on analysis of materials by request, handling materials such as samples from patients with medical problems, evidence from crime scenes, or DNA samples which need to be processed. These labs charge fees for handling such materials and generating reports. They may serve a large area, handling materials from a variety of sources, or they may only offer their services to specific companies and individuals. This type of biochemistry lab may have

additional concerns such as security of evidence and patient privacy which must be addressed with lab protocols.

INSTRUMENTS STUDIED IN THE LABORATORY: Centrifuge:

A centrifuge is a piece of equipment, generally driven by an electric motor (some older models were spun by hand), that puts an object in rotation around a fixed axis, applying a force perpendicular to the axis. The centrifuge works using the sedimentation principle, where the centripetal acceleration causes denser substances to separate out along the radial direction (the bottom of the tube). By the same token lighter objects will tend to move to the top (of the tube; in the rotating picture, move to the centre).

CENTRIFUGE APPARATUS

Applications:

Centrifuges with a batch weight of up to 2,200 kg per charge are used in the sugar industry to separate the sugar crystals from the mother liquor. Standalone centrifuges for drying (hand-washed) clothes usually with a water outlet.

Centrifuges are used in the attraction Mission: SPACE, located at Epcot in Walt Disney World, which propels riders using a combination of a centrifuge and a motion simulator to simulate the feeling of going into space. In soil mechanics, centrifuges utilize centrifugal acceleration to match soil stresses in a scale model to those found in reality. Large industrial centrifuges are commonly used in water and wastewater treatment to dry sludges. The resulting dry product is often termed cake, and the water leaving a centrifuge after most of the solids have been removed is called centrate. Large industrial centrifuges are also used in the oil industry to remove solids from the drilling fluid. Disc-stack centrifuges used by some companies in Oil Sands industry to separate small amounts of water and solids from bitumen.

Auto analyzer:
AutoAnalyzer is an automated analyzer using a special flow technique named "continuous flow analysis (CFA)" first made by the Technicon Corporation. The instrument was invented 1957 by Leonard Skeggs, PhD and commercialized by Jack Whitehead's Technicon Corporation. The first applications were for clinical analysis, but methods for industrial analysis soon followed.

The AutoAnalyzer profoundly changed the character of the chemical testing laboratory by allowing significant increases in the numbers of samples that could be processed. The novel design based on separating a continuously flowing stream with air bubbles all but eliminated slow, clumsy, and error prone manual methods of analysis. This instrument single handedly changed the concept of days per sample to a mindset that hundreds, or even thousands, of tests are possible per day.

Technicon sold its business to Revlon in 1980 [1] who later sold the company to separate clinical (Bayer) and industrial (Bran+Luebbe - now SEAL Analytical) buyers in 1987. At the time, industrial applications accounted for about 20% of CFA machines sold. In 1974 Ruzicka and Hansen carried out in Denmark and in Brasil initial experiments on a competitive technique, that they termed Flow Injection Analysis (FIA). Since then the technique found world wide use in research and routine applications, and was further modified through micro miniaturization and by replacing continuous flow with computer controlled programmable flow (see Sequential Injection and Lab-on-valve technology).

Clinical Analysis:
AutoAnalyzers were used mainly for routine repetitive medical laboratory analyses, but they had been replaced during the last years more and more by discrete working systems which allow lower reagent consumption. These instruments typically determine levels of albumin, alkaline phosphatase, aspartate transaminase (AST), blood urea nitrogen, bilirubin, calcium, cholesterol, creatinine, glucose, inorganic phosphorus, proteins, and uric acid in blood serum or other bodily samples. AutoAnalyzers automate repetitive sample analysis steps which would otherwise be done manually by a technician, for such medical tests as the ones mentioned previously. This way, an AutoAnalyzer can analyze hundreds of samples every day with one operating technician. Early AutoAnalyzer instruments each tested multiple samples sequentially for individual analytes. Later model AutoAnalyzers such as the SMAC tested for multiple analytes simultaneously in the samples. In 1959 a competitive system of analysis was introduced by Hans Baruch of Research Specialties Company. That system became known as Discrete Sample Analysis and was represented by an instrument known as the "Robot Chemist." Over the years the Discrete Sample Analysis method slowly replaced the Continuous Flow system in the clinical laboratory.

Uses:
AutoAnalyzers are still used for a few clinical applications such as neonatal screening or Anti-D, but the majority of instruments are now used for industrial and environmental work. Standardized methods published by the ASTM (ASTM International), the US Environmental Protection Agency (EPA) as well as the International Organization for Standardization (ISO) for environmental analytes such as nitrite,nitrate, ammonia, cyanide, and phenol. Autoanalyzers are

also commonly used in soil testing laboratories, fertilizer analysis, process control, seawater analysis, air contaminants, and tobacco leaf analysis. Autoanalyzers are used because they decrease costs, save time, conserve reagents and materials, minimize errors, and improve productivity. A laboratory should consider using an autoanalyzer if there is a significant backlog of samples, a lot of overtime just to get things done on time, or continuous repeating of mistakes due to human error. Not all laboratories should consider continuous flow. If the sample load is less than 20 samples per week, other options should be considered. Before adding an autoanalyzer, management needs to seriously consider that the operators need to understand the basic concepts of flow analysis. Instrument manufacturers, eager to make a sale, will tout simplicity, rapid start up and shut down, and flat learning curves. While these things may be possible when running standards, the laboratory runs real samples that have an effect on the reagents used. In the real world, methods may need to be modified and slight modifications can have significant impacts on the basic operation of the chemical system. Once an operator understands flow analysis the incredible capabilities of the instrument can be realized, allowing methods to be added, improved, enhanced, and developed.

SETUP FOR RADIOIMMUNOASSAY OR RIA:

Previously it was widely used to detect various things in bold fluids like proteins (natural, infective, those produced by the body in reaction to disease, cancer related), tumor markers, hormones, viruses(hepatitis, HIV, etc.), etc.

URINE ANALYZER:
Automated urine analyser having 3 modes of operation: general, one by one and quick mode. It provide complete urine profile analysis (leucocyctes, nitrite, urobiinogen, protein, pH, blood specific gravity, ketones, bilirubin, glucose and ascorbic acid). Throughput is nearly of 300 test/hr (max. of 8oo test/hr). It is based on reflectance photometry priniciple and 2000 sample memory.

It have external keyboard to input patient ID(14 digits), optional barcode reader andRS232 data connectivity facility.

HISTOLOGY AND CYTOLOGY

Introduction:
The histology and cytology lab is equipped to prepare tissue for microscopic analysis. Animal and human hard tissues (bone, ligament, cartilage, tendon) are processed routinely. Contract work on orthopedic, neurologic,and selected forensic samples is frequently carried out. Here is a partial listing of the equipment available in this lab:
1.

Tissue-Tek VIP Tissue Processor Stores up to ten processing programs Memory capabilities include: station time periods, chamber temperature, vacuum/pressure needs and delay operations All decalcified tissues are processed through fourteen stations from formalin to final paraffin infiltration Tissue Embedding Console System is attached, providing efficient embedding of tissue specimens in paraffin; contains Dispensing, Thermal, and Cryo Consoles

2. ISOMET

Low-Speed Bone Saw

Cuts un-decalcified bone, some having biomaterial implants within Designed to perform high-precision, low deformation materials sectioning Samples are held in suitable chuck and introduced through gravity of a known weight to a rotating diamond wafering blade

3.

Vibratome Semi-automatic Sectioning System

Cuts flesh or fixed specimens without embedding or freezing by means of a vibrating blade Amplitude of vibration, speed of blade advance, and section thickness are operation selectable Used for tissue; ganglia, spinal cord, preservation of enzymatic activity, etc.

HEMATOLOGY

Introduction:
Hematology, also spelled haematology, is the study of blood, the bloodforming organs, and blood diseases. Hematology includes the study of etiology, diagnosis, treatment, prognosis, and prevention of blood diseases that affect the production of blood and its components, such as blood cells, hemoglobin, blood proteins, and the mechanism of coagulation. The laboratory work that goes into the study of blood is frequently performed by a medical technologist. Hematologists physicians also very frequently do further study in oncology - the medical treatment of cancer. Physicians specialized in hematology are known as hematologists. Their routine work mainly includes the care and treatment of patients with hematological diseases, although some may also work at the hematology laboratory viewing blood films and bone marrow slides under the microscope, interpreting various hematological test results. In some institutions, hematologists also manage the hematology laboratory. Physicians who work in hematology laboratories, and most commonly manage them, are pathologists specialized in the diagnosis of hematological diseases, referred to as hematopathologists. Hematologists and hematopathologists generally work in conjunction to formulate a diagnosis and deliver the most appropriate therapy if needed. Hematology is a distinct subspecialty of internal medicine, separate from but overlapping with the subspecialty of medical oncology. Hematologists may specialize further or have special interests, for example in:

treating bleeding disorders such as hemophilia and idiopathic thrombocytopenic purpura treating hematological malignacies such as lymphoma and leukemia treating hemoglobinopathies in the science of blood transfusion and the work of a blood bank in bone marrow and stem cell transplantation

General Principle of Hematology:

Flow cytometry measures optical and fluorescence characteristics of single cells (or any other particle, including nuclei, microorganisms, chromosome preparations, and latex beads). Physical properties, such as size (represented by forward angle light scatter) and internal complexity (represented by right-angle scatter) can resolve certain cell populations. Fluorescent dyes may bind or

intercalate with different cellular components such as DNA or RNA. Additionally, antibodies conjugated to fluorescent dyes can bind specific proteins on cell membranes or inside cells. When labeled cells are passed by a light source, the fluorescent molecules are excited to a higher energy state. Upon returning to their resting states, the fluorochromes emit light energy at higher wavelengths. The use of multiple fluorochromes, each with similar excitation wavelengths and different emission wavelengths (or colors), allows several cell properties to be measured simultaneously. Commonly used dyes include propidium iodide, phycoerythrin, and fluorescein, although many other dyes are available. Tandem dyes with internal fluorescence resonance energy transfer can create even longer wavelengths and more colors.

Automated Hematology Instruments:

During the first half of the twentieth century, the complete blood count (CBC), one of the most commonly ordered laboratory tests, was performed using exclusively manual techniques:

Blood cell counts (red cells, white cells, platelets) were performed using appropriately diluted blood samples and a ruled counting chamber (hemocytometer). Hemoglobin concentration was analyzed colorimetrically by the cyanomethemoglobin method. The hematocrit (packed cell volume) was measured by high speed centrifugation of a column of blood, either in a specially designed tube (the Wintrobe tube) , or in sealed microcapillary tubes (ie, the "spun" hematocrit, often obtained by fingerstick blood collection). The white blood cell differential was obtained by examining and enumerating by class (eg, granulocytes, lymphocytes, monocytes) 100 to 200 individual white blood cells on a suitably stained blood smear.

In 1932, Wintrobe developed a set of calculated indices that estimated erythrocyte size and hemoglobin content based on the red blood cell count (RBC), hemoglobin concentration (HGB), and hematocrit (HCT). These indices included:

Mean corpuscular volume (MCV) the volume (in femtoliters, fL) of the average circulating red blood cell Mean corpuscular hemoglobin (MCH) the hemoglobin content (in picograms) of the average circulating red blood cell

Mean corpuscular hemoglobin concentration (MCHC) the hemoglobin concentration within circulating red blood cells (grams of hemoglobin 100mL of packed red blood cells)

AUTOMATED HEMATOLOGY INSTRUMENT

Methods and Materials:

Instrument evaluations were conducted at 3 laboratory sites in the OhioHealth group. The systems evaluated and the site at which they were evaluated were: Riverside Hospital: Coulter GenS, Sysmex SE9500 Grant Medical Center: Coulter HmX, Sysmex SF3000 Doctors North: Coulter AcT diff, Sysmex KX-21 Riverside Hospital, which has the largest daily volume of complete blood counts (CBCs) in the system, evaluated the Coulter GenS and Sysmex SE9500. These are the high-volume fully automated hematology systems with cutting-edge technology from their respective manufacturers. At Grant Medical Center, we evaluated the Coulter HmX and the Sysmex SF3000. These systems were designed for the midvolume laboratory and feature automated sampling with cap-pierce capability. They also include a 5-part white blood cell (WBC) differential and reticulocyte analysis. The AcT diff and KX-21 are systems well suited for the lowvolume laboratory. Both analyzers have cap piercing and a 3-part differential. Reagents used on all systems were those recommended and provided by the manufacturers. All systems were calibrated and controlled according to the

manufacturers recommendations. The manufacturers also provided calibration and control materials. Service representatives from each company set up the hematology instruments. The manufacturers provided training for the technologists designated to perform the instrument evaluations. These technologists at each site operated the instrument systems and analyzed all samples throughout the evaluation. During the actual evaluation period, no representatives from the participating companies were present in the laboratory. After all study data had been collected, other technologists in the laboratories had the opportunity to review and operate the evaluation instruments. These technologists received inservices and training from the manufacturers and were given time to run samples on each analyzer for several weeks. At the conclusion of the evaluation period, these technologists also completed surveys for each analyzer they used.

Applications in Hematology: Erythrocyte analysis:

The use of flow cytometry for the detection and quantification of fetal red cells in maternal blood has increased in recent years. Currently in the United States, rhesus D-negative women receive prophylactic Rh-immune globulin at 28 weeks and also within 72 h of delivery. The standard single dose is enough to prevent alloimmunization from 15 mL of fetal rhesus D+ red cells. If fetomaternal hemorrhage is suspected, the mothers blood is tested for the presence and quantity of fetal red cells, and an appropriate amount of Rh-immune globulin is administered. The quantitative test most frequently used in clinical laboratories is the Kleihauer-Betke acid-elution test. This test is fraught with interobserver and interlaboratory variability, and is tedious and time-consuming. The use of flow cytometry for the detection of fetal cells is much more objective, reproducible, and sensitive than the Kleihauer-Betke test. Fluorescently labeled antibodies to the rhesus (D) antigen can be used, or more recently, antibodies directed against hemoglobin F.This intracellular approach, which uses permeabilization of the red cell membrane and an antibody to the chain of human hemoglobin, is precise and sensitive This method has the ability to distinguish fetal cells from F-cells (adult red cells with small amounts of hemoglobin F).Histogram of a positive test for feto-maternal hemorrhage. Although the flow cytometry method is technically superior to the Kleihauer-Betke test, cost, instrument availability, and stat access may limit its practical utility.

Leukocyte analysis:

Immunologic monitoring of HIV-infected patients is a mainstay of the clinical flow cytometry laboratory. HIV infects helper/inducer T lymphocytes via the CD4 antigen. Infected lymphocytes may be lysed when new virions are released or may be removed by the cellular immune system. As HIV disease progresses, CD4-positive T lymphocytes decrease in total number. The absolute CD4 count provides a powerful laboratory measurement for predicting, staging, and monitoring disease progression and response to treatment in HIV-infected individuals. Quantitative viral load testing is a complementary test for clinical monitoring of disease and is correlated inversely to CD4 counts. However, CD4 counts directly assess the patients immune status and not just the amount of virus. It is likely that both CD4 T-cell enumeration and HIV viral load will continue to be used for diagnosis, prognosis, and therapeutic management of HIV-infected persons.

Platelets Analysis:
The analysis of platelets by flow cytometry is becoming more common in both research and clinical laboratories. Platelet-associated immunoglobulin assays by flow cytometry can be direct or indirect assays, similar to other plateletassociated immunoglobulin immunoassays. In autoimmune thrombocytopenic purpura, free serum antibodies are not found as frequently as platelet-bound antibodies .In contrast, in cases of alloantibody formation, serum antibodies may be detected without evidence of platelet-associated antibodies. Flow cytometry is an excellent method for direct analysis of platelet-bound antibodies, and it has also been shown to be of benefit in detection of free plasma membrane. The use of thiazole orange, a fluorescent dye that binds RNA, allows immature platelets (also referred to as reticulated platelets) to be quantified .The reticulated platelet count can be used to determine the rate of thrombopoiesis. This measurement can separate unexplained thrombocytopenias into those with increased destruction and those with defects in platelet production. The pathogenesis and molecular defects of many primary thrombocytopathies are well known and relate to defects in structural or functional glycoproteins, such as the abnormal expression of gpIIb/IIIa in Glanzmann thrombasthenia and gpIb in Bernard-Soulier disease .Flow cytometry is a rapid and useful method of obtaining a diagnosis. Until recently, functional analysis of platelet activation was used primarily in research. Many immunological markers of platelet activation have been described, and the commercial availability of antibodies permits flow cytometric determination of platelet activation. Platelet activation may be clinically important in stored blood components, after cardiopulmonary bypass and renal dialysis, and in the treatment of patients with myocardial infarction or thrombotic events.

IMMUNO SEROLOGY

Introduction:
Immunology is the study of the body's immune system and its functions and disorders. Serology is the study of blood serum (the clear fluid that separates when blood clots). Immunology and serology laboratories focus on the following:

Identifying antibodies (proteins made by a type of white blood cell in response to an antigen, a foreign protein, in the body) Investigating problems with the immune system such as autoimmune diseases (when the body's immune system turns on its own tissues) and immunodeficiency disorders (when a body's immune system is underactive) Determining organ compatibility for transplantation Common immunology and serology tests

Immunology Laboratory Equipment and Reagents: RNA Preanalytical Systems:

(a) Identification. RNA Preanalytical Systems are devices intended to collect, store, and transport patient specimens, and stabilize intracellular RNA from the specimens, for subsequent isolation and purification of the intracellular RNA for RTPCR used in vitro molecular diagnostic testing. (b) Classification. Class II (special controls). The special control is FDA's guidance document entitled Class II Special Controls Guidance Document: RNA Preanalytical Systems (RNA Collection, Stabilization and Purification System for RTPCR Used in Molecular Diagnostic Testing document. Complement reagent: (a) Identification. A complement reagent is a device that consists of complement, a naturally occurring serum protein from any warm-blooded animal such as guinea pigs, that may be included as a component part of serological test kits used in the diagnosis of disease.

Immunoelectrophoresis Equipment:
(a) Identification. Immunoelectrophoresis equipment for clinical use with its electrical power supply is a device used for separating protein molecules. Immunoelectrophoresis is a procedure in which a complex protein mixture is placed in an agar gel and the various proteins are separated on the basis of their relative mobilities under the influence of an electric current. The separated proteins are then permitted to diffuse through the agar toward a multispecific antiserum, allowing precipitation and visualization of the separate complexes.

Immunofluorometer Equipment:
(a) Identification. Immunofluorometer equipment for clinical use with its electrical power supply is a device used to measure the fluorescence of fluorochrome-labeled antigen-antibody complexes. The concentration of these complexes may be measured by means of reflected light. A beam of light is passed through a solution in which a fluorochrome has been selectively attached to serum protein antibody molecules in suspension. The amount of light emitted by the fluorochrome label is detected by a photodetector, which converts light energy into electrical energy. The amount of electrical energy registers on a readout system such as a digital voltmeter or a recording chart. This electrical readout is called the fluorescence value and is used to measure the concentration of antigen-antibody complexes.

Automated fluorescence in situ hybridization (FISH) enumeration systems:

(a) Identification. An automated FISH enumeration system is a device that consists of an automated scanning microscope, image analysis system, and customized software applications for FISH assays. This device is intended for in vitro diagnostic use with FISH assays as an aid in the detection, counting and classification of cells based on recognition of cellular color, size, and shape, and in the detection and enumeration of FISH signals in interphone nuclei of formalinfixed, paraffin-embedded human tissue specimens.

Radial Immunodiffusion Plate:

(a) Identification. A radial immunodiffusion plate for clinical use is a device that consists of a plastic plate to which agar gel containing antiserum is added. In radial immunodiffusion, antigens migrate through gel which originally contains specific antibodies. As the reagents come in contact with each other, they combine to form a precipitate that is trapped in the gel matrix and immobilized.
Rocket Immunoelectrophoresis Equipment:

(a) Identification. Rocket immunoelectrophoresis equipment for clinical use is a device used to perform a specific test on proteins by using a procedure called rocket immunoelectrophoresis. In this procedure, an electric current causes the protein in solution to migrate through agar gel containing specific antisera. The protein precipitates with the antisera in a rocket-shaped pattern, giving the name to the device. The height of the peak (or the area under the peak) is proportional to the concentration of the protein.

Rocket Immunoelectrophoresis Equipment

INTENSIVE CARE UNIT

INTRODUCTION:
An Intensive Care Unit (ICU), also known as a Critical Care Unit (CCU), Intensive Therapy Unit or Intensive Treatment Unit (ITU) is a special department of a hospital that provides intensive-care medicine. Intensive Care Units cater to patients with the most serious injuries and illnesses, most of which are life-threatening and need constant, close monitoring and support from specialist equipment and medication in order to maintain normal bodily functions. They are staffed by highly trained doctors and critical care nurses who specialise in caring for the most severely ill patients.[ Patients may be transferred to an Intensive Care Unit from a ward if they require constant monitoring, or immediately after surgery if the surgery is invasive or the patient is at risk of complications. Hospitals may have ICU's that cater to a specific medical speciality or patient, such as those listed below:

Neonatal Intensive Care Unit (NICU) Pediatric Intensive Care Unit (PICU) Psychiatric Intensive Care Unit (PICU) Coronary Care Unit (CCU) - Also known as Cardiac Intensive Care Unit (CICU) Post Anesthesia Care Unit (PACU) - Also known as the Post-Operative Recovery Unit, or Recovery Room, the PACU provides immediate post-op observation and stabilisation of patients following surgical operations and anesthesia. Patients are usually held in such facilities for a limited amount of time, and must meet a set physiological criteria before transfer back to a ward with a qualified nurse escort takes place. Due to high patient flow in Recovery Units, and owing to the bed management cycle, if a patient breaches a time frame and is too unstable to be transferred back to a ward, they are normally transferred to a High Dependency Unit (HDU) or Post-Operative Critical Care Unit (POCCU) for closer observation. High Dependency Unit (HDU) - Many hospitals have a transitional High Dependency Unit (HDU) for patients who require close observation, treatment and nursing care that cannot be provided on a general ward, but whose care is not at a critical enough level to warrant an ICU bed. These units are also called step-down, progressive and intensive recovery units and are utilised until a

patient's conditions stabilises enough to qualify them for discharge to a general ward. Common equipment in an ICU includes mechanical ventilators to assist breathing through anendotracheal tube or a tracheotomy; cardiac monitors including those with telemetry; external pacemakers; defibrillators; dialysis equipment for renal problems; equipment for the constant monitoring of bodily functions; a web of intravenous lines, feeding tubes,nasogastric tubes, suction pumps, drains, and catheters; and a wide array of drugs to treat the primary condition(s) of hospitalization. Medically induced comas, analgesics, andinduced sedation are common ICU tools needed and used to reduce pain and preventsecondary infections.

ICU SETUP EQUIPMENTS AVAILABLE IN ICU: BLOOD GAS ANALYSER:

An arterial blood gas (ABG) is a blood test that is performed using blood from an artery. It involves puncturing an artery with a thin needle and syringe and drawing a small volume of blood. The most common puncture site is the radial artery at the wrist, but sometimes the femoral artery in the groin or other sites are used. The blood can also be drawn from anarterial catheter. Pulse oximetry plus transcutaneous carbon dioxide measurement is an alternative method

of obtaining similar information as well. An ABG is a test that measures the arterial oxygen tension (PaO2), carbon dioxide tension (PaCO2), and acidity (pH). In addition, arterial oxyhemoglobin saturation (SaO2) can be determined. Such information is vital when caring for patients with critical illness or respiratory disease. As a result, the ABG is one of the most common tests performed on patients in intensive care units (ICUs). The test is used to determine the pH of the blood, the partial pressure of carbon dioxide and oxygen, and the bicarbonate level. Many blood gas analyzers will also report concentrations of lactate, hemoglobin, several electrolytes, oxyhemoglobin, carboxyhemoglobin andmethemoglobin. ABG testing is mainly used in pulmonology and critical care medicine to determine gas exchange which reflect gas exchange across the alveolar-capillary membrane. ABG testing also has a variety of applications in other areas of medicine. Combinations of disorders can be complex and difficult to interpret, so calculators, nomograms, and rules of thumb are commonly used.

BLOOD GAS ANALYZER

Sampling and analysis:

Arterial blood for blood gas analysis is usually drawn by a respiratory therapist and sometimes a phlebotomist, nurse or doctor. Blood is most commonly drawn from the radial artery because it is easily accessible, can be compressed to control bleeding, and has less risk for occlusion, the selection of which radial artery to draw from is based on the outcome of an Allen's test. The femoral artery (or less often, the brachial artery) is also used, especially during emergency situations or with children. Blood can also be taken from an arterial catheter already placed in one of these arteries. The syringe is pre-packaged and contains a small amount of heparin, to prevent coagulation or needs to be heparinised, by drawing up a small amount of heparin and squirting it out again. Once the sample is obtained, care is taken to eliminate visible gas bubbles, as these bubbles can dissolve into the sample and

cause inaccurate results. The sealed syringe is taken to a blood gas analyzer. If the sample cannot be analyzed within 1015 minutes, it must be placed on ice for valid results. Even when placed on ice, samples should still be analyzed within 1 hour. Standard blood tests can also be performed on arterial blood, such as measuring glucose, lactate, hemoglobins,dyshaemoglobins,bilirubin and electrolyte s.

MULTIPARAMETER MONITER:
Its monitor are used to monitor different body conditions of patients like heart beat, ECG, pulse oxygen saturation, noninvasive blood pressure and respiration. Further, these portable patient monitor are capable of working on both alterative current as well as direct current.

Application:

Able to measure in-phase 3-7-channel ECG, heart rate, respiration, animal temperature, pulse, blood oxygen saturation, non-invasive blood pressure and pulse conduction time. 12.1"TFT big-screen, real-color, wide-visual-angle and highbrightness display. In built with chargeable, maintenance-free and high-capacity batteries, thus able to work more than 2 hours without additional power supply. With the link formed by network, bed-side machines and central multiparameter monitor system, thus form a monitor network is formed. Able to display trend data, and manual printing and alarm trigger printing functions available.

MULTI PARAMETER MONITOR(TMX-7000A)

These TMX-7000a multiparameter monitor are equipped with following:

Color TFT display : 8.4 visual alarms with adjustable alarm ranges Networkable data management and storage capacity

ECG

Lead type:5-lead Input: RA; LA; RL; LL; V Sweep Speed: 2.5mm/s, 25mm/s, 50mm/s Accuracy:+-lbpm or +-1% which is greater Protection: withstand 4000ac/50hz voltage in isolation against elctro surgical and

Defibrillation

Have S-T detection and Arrhythmia analysis facility Have Alarm, audible and visual alarm, alarm events recallable facility

Standard Configuration

ECG NIBP Sp02

Optional:

RESP2-TEMP 2-IBP ET(02) Network Thermal Prinet Pacing Maker

PACEMAKER:
A pacemaker is a small device that's placed in the chest or abdomen to help control abnormal heart rhythms. This device uses electrical pulses to prompt the heart to beat at a normal rate. Pacemakers are used to treat arrhythmias (ah-RITH-me-ahs). Arrhythmias are problems with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm. A heartbeat that's too fast is called tachycardia (TAK-ih-KAR-de-ah). A heartbeat that's too slow is called bradycardia (bray-de-KAR-de-ah). During an arrhythmia, the heart may not be able to pump enough blood to the body. This can cause symptoms such as fatigue (tiredness), shortness of breath, or fainting. Severe arrhythmias can damage the body's vital organs and may even cause loss of consciousness or death. A pacemaker can relieve some arrhythmia symptoms, such as fatigue and fainting. A pacemaker also can help a person who has abnormal heart rhythms resume a more active lifestyle.

Understanding the Heart's Electrical System:

Your heart has its own internal electrical system that controls the rate and rhythm of your heartbeat. With each heartbeat, an electrical signal spreads from the top of your heart to the bottom. As the signal travels, it causes the heart to contract and pump blood.

Each electrical signal normally begins in a group of cells called the sinus node or sinoatrial (SA) node. As the signal spreads from the top of the heart to the bottom, it coordinates the timing of heart cell activity. First, the heart's two upper chambers, the atria (AY-tree-uh), contract. This contraction pumps blood into the heart's two lower chambers, the ventricles (VENtrih-kuls). The ventricles then contract and pump blood to the rest of the body. The combined contraction of the atria and ventricles is a heartbeat.

IMPLANTED PACEMAKER
Overview

Faulty electrical signaling in the heart causes arrhythmias. Pacemakers use low-energy electrical pulses to overcome this faulty electrical signaling. Pacemakers can:

Speed up a slow heart rhythm. Help control an abnormal or fast heart rhythm. Make sure the ventricles contract normally if the atria are quivering instead of beating with a normal rhythm (a condition called atrial fibrillation). Coordinate electrical signaling between the upper and lower chambers of the heart. Coordinate electrical signaling between the ventricles. Pacemakers that do this are called cardiac resynchronization therapy (CRT) devices. CRT devices are used to treat heart failure.

Prevent dangerous arrhythmias caused by a disorder called long QT syndrome.

Pacemakers also can monitor and record your heart's electrical activity and heart rhythm. Newer pacemakers can monitor your blood temperature, breathing rate, and other factors. They also can adjust your heart rate to changes in your activity. Pacemakers can be temporary or permanent. Temporary pacemakers are used to treat short-term heart problems, such as a slow heartbeat that's caused by a heart attack, heart surgery, or an overdose of medicine. Temporary pacemakers also are used during emergencies. They might be used until your doctor can implant a permanent pacemaker or until a temporary condition goes away. If you have a temporary pacemaker, you'll stay in a hospital as long as the device is in place. Permanent pacemakers are used to control long-term heart rhythm problems. This article mainly discusses permanent pacemakers, unless stated otherwise. Doctors also treat arrhythmias with another device called an implantable cardioverter defibrillator (ICD). An ICD is similar to a pacemaker. However, besides using low-energy electrical pulses, an ICD also can use high-energy pulses to treat life-threatening arrhythmias.

INTRA-AORTIC BALLOON PUMP (IABP):

The Intra-aortic balloon pump (IABP) is a mechanical device that increases myocardial oxygenperfusion while at the same time increasing cardiac output. Increasing cardiac output increases coronary blood flow and therefore myocardial oxygen delivery. It consists of a cylindrical polyethylene balloon that sits in the aorta, approximately 2 centimeters (0.79 in) from the left subclavian arteryand counterpulsates. That is, it actively deflates in systole, increasing forward blood flow by reducingafterload. It actively inflates in diastole, increasing blood flow to the coronary arteries. These actions combine to decrease myocardial oxygen demand and increase myocardial oxygen supply. A computer-controlled mechanism inflates the balloon with helium from a cylinder during diastole, usually linked to either an electrocardiogram (ECG) or a pressure transducer at the distal tip of thecatheter; some IABPs, such as the Datascope System 98XT, allow asynchronous counterpulsation at a set rate, though this setting is rarely used. Helium is used because its low viscosity allows it to

travel quickly through the long connecting tubes, and has a lower risk of causing an embolism should the balloon rupture.

INTRA-AORTIC BALLOON PUMP

The following situations may benefit from this device.

Cardiogenic shock when used alone as treatment for myocardial infarction. 922% survive the first year. Reversible intracardial mechanical defects complicating infarction, i.e. acute mitral regurgitation and septal perforation. Unstable angina pectoris benefits from counterpulsation. Post cardiothoracic surgerymost common and useful is counterpulsation in weaning patients from cardiopulmonary bypass after continued perioperative injury to myocardial tissue. Preoperative use is suggested for high-risk patients such as those with unstable angina with stenosis greater than 70% of main coronary artery, in ventricular dysfunction with an ejection fraction less than 35%. Percutaneous coronary angioplasty In high risk coronary artery bypass graft surgery where cardiopulmonary bypass time was shortened, as well as during intubation period and hospital stay. Thrombolytic therapy of acute myocardial infarction.

SYRINGE PUMP:
A syringe driver or syringe pump is a small infusion pump (some include infuse and withdraw capability), used to gradually administer small amounts of fluid (with or without medication) to a patient or for use in chemical and biomedical research. The most popular use of syringe drivers is in palliative care, to continuously administeranalgesics (painkillers), antiemetics (medication to suppress nausea and vomiting) and other drugs. This prevents periods during which medication levels in the blood are too high or too low, and avoids the use of multiple tablets (especially in people who have difficultyswallowing). As the medication is administered subcutaneously, the area for administration is practically limitless, although edema may interfere with the action of some drugs. Syringe drivers are also useful for delivering IV medications over several minutes. In the case of a medication which should be slowly pushed in over the course of several minutes, this device saves staff time and reduces errors. Syringe pumps are also useful in microfluidic applications, such as microreactor design and testing, and also in chemistry for slow incorporation of a fixed volume of fluid into a solution. In enzyme kinetics syringe drivers can be used to observe rapid kinetics as part of a stopped flow apparatus A syringe driver or syringe pump is a small infusion pump (some include infuse and withdraw capability), used to gradually administer small amounts of fluid (with or without medication) to a patient or for use in chemical and biomedical research. The most popular use of syringe drivers is in palliative care, to continuously administeranalgesics (painkillers), antiemetics (medication to suppress nausea and vomiting) and other drugs. This prevents periods during which medication levels in the blood are too high or too low, and avoids the use of multiple tablets (especially in people who have difficultyswallowing). As the medication is administered subcutaneously, the area for administration is practically limitless, although edema may interfere with the action of some drugs. Syringe drivers are also useful for delivering IV medications over several minutes. In the case of a medication which should be slowly pushed in over the course of several minutes, this device saves staff time and reduces errors. Syringe pumps are also useful in microfluidic applications, such as microreactor design and testing, and also in chemistry for slow incorporation of a fixed volume of fluid into a solution. In enzyme kinetics syringe drivers can be used to observe rapid kinetics as part of a stopped flow apparatus.

SUCTION APPARATUS:
A suctioning machine is an portable apparatus used in the medical field for aspirating fluids from a person's airways and mouth. There are many parts that go into the manufacturing of an electric suctioning machine. Several types of suctioning machines are on the market; some are portable, some are for home use and others are strictly for hospital use. There are several different varieties of suctioning machines. Some suctioning machines are battery-powered and portable, others are not. Electric suctioning machines are widely used in the medical field for their relative ease-of-use and accuracy. Portable tracheal suction machine are available for those who need them to remove mucus from their airways. Each type of suctioning machine has its advantages and disadvantages. The purpose of using any suctioning machine is to remove unwanted materials from the stomach, mouth or throat. Some suctioning machines are more sophisticated and offer more features than others. Tracheostomy suction machines remove mucus and secretions from the trachea that cannot be cleared by coughing. The main parts of an electronic suctioning machine are a vacuum pump, bacterial filter, vacuum gauge, moisture or debris trap, a reservoir for aspirated material and a suction catheter. Reservoirs are usually glass bottles with markings indicating volume. Tracheostomy suction machines are simple machines consisting of a suction catheter with a hard plastic end and a connecting tube. Many electric suctioning machines are available with high or low levels of suction. The levels relate to the rate of suction produced. High suction machines are usually employed for rapid aspiration of fluids or debris. Low suction machines are ideal for post-op drainage of wounds. Some suction machines have compact designs making them easy to store.

SUCTION APPARATUS

To avoid risk of injury and unnecessary wear, suctioning machines should only be used when needed and as recommended. Suctioning machines should be kept clean and free of bacteria to avoid the risk of infecting the user. There are quite a few portable suctioning machines designed for the home that are available to the public. Portable suction machines can be purchased for anywhere from one to several hundred dollars depending on the specifications of each model. If any servicing or replacement part is needed, a licensed professional should do the servicing.

PRESSURE BAG:
A pressure bag is a device that is used to pressurize a bag filled with intravenous fluid for the purpose of regulating how quickly the fluid is dispensed to the patient. Sometimes also called pressure pumps, pressure bags can be used in numerous clinical settings. Companies that manufacture pressure bags usually sell several different versions, including disposable ones designed for use with a single patient, which are thrown away after one use. This reduces the amount of time and energy spent on sterilization and storage. When a patient is set up with an intravenous line, the size of the intravenous catheter and the width of the line have an impact on how quickly fluids can be delivered. For a basic drip, a bag of fluids may be elevated on a pole above the patient, with gravity doing the work. Some fine tuning may be possible with clips. Using a pressure bag increases the rate of flow by pressurizing the bag and forcing the contents out more quickly. Pressure bags are inflatable cuffs that can be manually inflated to a desired level of pressure. The rate of the drip can be controlled by increasing or decreasing the pressure. Emergency release valves allow care providers to relieve pressure if there is a problem. Historically, people improvised pressure bags by putting bags under the patient and using the patient's weight as a source of pressure, or by inflating a blood pressure cuff around the IV bag. The pressure bag is a somewhat neater solution to the problem. The major complication that can arise when using a pressure bag is the risk that the bag of fluid will burst. This will not injure the patient, although it can be startling, and if the bag is filled with something like a blood product or a hazardous medication, it can present a safety risk to health care providers in the

room. Pressure relief valves are installed to limit the possibility of such events and care providers also use their judgment when inflating apressure bag. For very controlled delivery of intravenous fluids, a patient can be connected to an infusion pump. Infusion pumps can deliver very precise doses of medication over the period of time programmed into the device, which may be hours or days. They are especially useful when patients only need small amounts of a medication or when an intravenous drip needs to be tightly controlled to reduce the risk of giving the patient too much.

NEBULIZER:
Nebulizers are commonly used for the fibrosis, asthma, COPD and otherrespiratory diseases. treatment of cystic

Nebulizers use oxygen, compressed air or ultrasonic power to break up medical solutions and suspensions into small aerosol droplets that can be directly inhaled from the mouthpiece of the device. The definition of an aerosol is a "mixture of gas and liquid particles," and the best example of a naturally occurring aerosol is mist, formed when small vaporized water particles mixed with hot ambient air are cooled down and condense into a fine cloud of visible airborne water droplets. When using a nebulizer for inhalation therapywith medication to be administered directly to the lungs, it is important to note that inhaled aerosol droplets can only penetrate into the narrow branches of the lower airways if they have a small diameter of 15 micrometers. Otherwise they are only absorbed by the mouth cavity, where the effect is low. The most commonly used nebulizers are Jet nebulizers, which are also called "atomizers". Jet nebulizers are connected by tubing to a compressor, that causes compressed air or oxygen to flow at high velocity through a liquid medicine to turn it into an aerosol, which is then inhaled by the patient. Currently there seems to be a tendency among physicians to prefer prescription of a pressurized Metered Dose Inhaler (pMDI) for their patients, instead of a Jet nebulizer that generates a lot more noise (often 60dB during use) and is less portable due to a heavier weight. However Jet nebulizers are commonly used for patients in hospitals who have difficulty using inhalers, such as in serious cases of respiratory disease, or severe asthma attacks. The main advantage of the Jet nebulizer is related to its low operational cost. If the patient needs to inhale medicine on a daily basis the use of a pMDI can be rather expensive. Today several manufacturers have also managed to lower the weight of the Jet nebulizer down to 635 grams (22.4 oz), and thereby started to label it as a portable device. Compared to all the

competing inhalers and nebulizers, the noise and heavy weight is however still the biggest draw back of the Jet nebulizer.

NEBULIZER

Ultrasonic wave nebulizers were invented in 1964 as a new more portable nebulizer. The technology inside an ultrasonic wave nebulizer is to have an electronic oscillator generate a high frequency ultrasonic wave, which causes the mechanical vibration of apiezoelectric element. This vibrating element is in contact with a liquid reservoir and its high frequency vibration is sufficient to produce a vapor mist.[11] As they create aerosols from ultrasonic vibration instead of using a heavy air compressor, they only have a weight around 170 grams (6.0 oz). Another advantage is that the ultrasonic vibration is almost silent. Examples of these more modern type of nebulizers are: Omron NE-U17 and Beurer Nebulizer IH30.

Effectiveness:
Recent evidence show that nebulizers are no more effective than metereddose inhalers (MDIs) with spacers and that MDIs may offer advantages in children with acute asthma. Those findings refer specifically to the treatment of asthma and not to the efficacy of nebulisers generally, as for COPD for example. European Respiratory Society highlighted a risk relating to dosage reproducibility caused by selling nebulizer devices separately from nebulized solution. They found this practice could vary dosages 10-fold or more by changing from an inefficient nebulizer system to a highly efficient one. Two advantages attributed to nebulizers, compared to MDIs with spacers (inhalers), were their ability to deliver larger dosages at a faster rate, especially in acute asthma;

however, recent data suggests actual lung deposition rates are the same. In addition, another trial found that a MDI (with spacer) had a lower required dose for clinical result compared to a nebulizer (see Clark, et al. other references).

HUMIDIFIER:
A humidifier is a household appliance that increases humidity (moisture) in a single room or in the entire house. There are point-of-use humidifiers, which are commonly used to humidify a single room, and whole-house or furnace humidifiers, which connect to a home'sHVAC system to provide humidity to the entire house. Other types of humidifier include:

Vaporizer (or: steam humidifier, warm mist humidifier) boils water, releasing steam and moisture into the air. A medicated inhalant can also be added to the steam vapor to help reduce coughs. Vaporizers may be more healthful than cool mist types of humidifiers because steam is less likely to convey mineral impurities or microorganisms from the standing water in the reservoir.Boiling water requires significantly more energy than other techniques. The heat source in poorly-designed humidifiers can overheat, causing the product to melt, leak, and start fires. Impeller humidifier (cool mist humidifier) a rotating disc flings water at a diffuser, which breaks the water into fine droplets that float into the air. Ultrasonic humidifier a metal diaphragm vibrating at an ultrasonic frequency creates water droplets that silently exit the humidifier in the form of a cool fog. Ultrasonic humidifiers use a piezo-electric transducer to create a high frequency mechanical oscillation in a body of water. The water tries to follow the high frequency oscillation but cannot because of its comparative weight and mass inertia. Thus, a momentary vacuum is created on the negative oscillation, causing the water to cavitate into vapor. The transducer follows this with a positive oscillation that creates high pressure compression waves on the waters surface, releasing tiny vapor molecules of water into the air. This is an extremely fine mist, about one micrometre in diameter, that is quickly absorbed into the air flow. Unlike the humidifiers that boil water, these water

droplets contain any impurities that are in the reservoir, including minerals from hard water (which then forms a difficult to remove white dust on nearby objects and furniture), and pathogens growing in the stagnant tank. Ultrasonic Humidifiers should be cleaned regularly to avoid bacterial contamination which may be projected into the air.

Humidifier

DIALYSIS

INTRODUCTION:
Artificial kidney is often a synonym for hemodialysis, but may also, more generally, refer to renal replacement therapies (with exclusion of renal transplantation) that are in use and/or in development. This article deals with bioengineered kidneys/bioartificial kidneys that are grown from renal cell lines/renal tissue. Kidneys are paired vital organs located behind the abdominal cavity, at about the level of the bottom of the ribcage. They perform about a dozen physiologic functions, and are fairly easily damaged. Kidney failure results in the slow accumulation of nitrogenous wastes, salts, water, and disruption of the body's normal pH balance. Until the Second World War, kidney failure generally meant death for the patient. Several insights into renal function and acute renal failure were made during the war, not least of which would be Bywaters and Beall's descriptions of pigment-induced nephropathy drawn from their clinical experiences during the London Blitz.[1] Hemodialysis is a method for removing waste products such as creatinine and urea, as well as free water from the blood when the kidneys are in renal failure. The mechanical device used to clean the patients blood is called a dialyser, also known as an artificial kidney. Modern dialysers typically consist of a cylindrical rigid casing enclosing hollow fibers cast or extruded from a polymer or copolymer, which is usually a proprietary formulation. The combined area of the hollow fibers is typically between 1-2 square meters. Intensive research has been conducted by many groups to optimize blood and dialysate flows within the dialyser, in order to achieve efficient transfer of wastes from blood to dialysate.

Need for a bioartificial kidney:

Over 300,000 Americans are dependent on hemodialysis as treatment for renal failure, but according to data from the 2005 USRDS 452,000 Americans have end-stage renal disease(ESRD).Intriguing investigations from groups in London, Ontario and Toronto, Ontario have suggested that dialysis treatments lasting two to three times as long as, and delivered more frequently than, conventional thrice weekly treatments may be associated with improved clinical outcomes[3] Implementing six-times weekly, all-night dialysis would overwhelm existing resources in most countries. This, as well as scarcity of donor organs for kidney transplantation has prompted research in developing alternative therapies, including the development of a wearable or implantable device. The main element in a dialyser is a semipermeable membrane through which small molecules can pass by diffusion. Dialysers are encountered in medical work

in renal dialysis where unwanted small molecules (e.g. urea) and water can be removed from the body. Dialysers may also be encountered in the clinical chemistry laboratory for purifying or modifying samples of fluid being analysed. Haemodialysers (sometimes called artificial kidneys) take blood from the body and pass it along one side of the dialysing membrane so that unwanted small molecules may diffuse into a special dialysing fluid passing along the other side. Small molecules which need not be removed are included in the dialysate so that there is equal diffusion of these molecules in each direction. Haemodialysers are constructed either as membranes wound into coils (not used now), membranes held between flat plates, or made into hollow fibres along the length of a special vessel. The peritoneum is a double membrane enveloping most of the organs in the abdomen, and renal dialysis may be achieved by pumping a special dialysing fluid into the cavity between the two membranes and allowing time for the diffusion to occur before withdrawing it. This technique is called peritoneal dialysis which may be a hospital procedure operated by sets of pumps, valves and timers, or may be used at the patient's home without special apparatus but using a collapsible bag from which the fluid is delivered and then returned after the process is complete. Both dialysis systems have their advantages.

DIALYSER

PRINCIPLE:
The principle of hemodialysis is the same as other methods of dialysis; it involvesdiffusion of solutes across a semipermeable membrane. Hemodialysis utilizes counter current flow, where the dialysate is flowing in the opposite direction to blood flow in theextracorporeal circuit. Counter-current flow maintains the concentration gradient across the membrane at a maximum and increases the efficiency of the dialysis. Fluid removal (ultrafiltration) is achieved by altering the hydrostatic pressure of the dialysate compartment, causing free water and some dissolved solutes to move across the membrane along a created pressure gradient. The dialysis solution that is used may be a sterilized solution of mineral ions or comply with British Pharmacopoeia. Urea and other waste products, potassium, and phosphatediffuse into the dialysis solution. However, concentrations of sodium and chloride are similar to those of normal plasma to prevent loss. Sodium bicarbonate is added in a higher concentration than plasma to correct blood acidity. A small amount of glucose is also commonly used. Note that this is a different process to the related technique of hemofiltration. A prescription for dialysis by a nephrologist (a medical kidney specialist) will specify various parameters for a dialysis treatment. These include frequency (how many treatments per week), length of each treatment, and the blood and dialysis solution flow rates, as well as the size of the dialyzer. The composition of the dialysis solution is also sometimes adjusted in terms of its sodium and potassium and bicarbonate levels. In general, the larger the body size of an individual, the more dialysis he/she will need. In North America and the UK, 3-4 hour treatments (sometimes up to 5 hours for larger patients) given 3 times a week are typical. Twice-a-week sessions are limited to patients who have a substantial residual kidney function. Four sessions per week are often prescribed for larger patients, as well as patients who have trouble with fluid overload. Finally, there is growing interest in short daily home hemodialysis, which is 1.5 - 4 hr sessions given 5-7 times per week, usually at home. There also is interest in nocturnal dialysis, which involves dialyzing a patient, usually at home, for 810 hours per night, 3-6 nights per week. Nocturnal in-center dialysis, 3-4 times per week, is also offered at a handful of dialysis units in the United States.

Access:
In hemodialysis, three primary methods are used to gain access to the blood: an intravenous catheter, an arteriovenous fistula (AV) or a synthetic graft. The type of access is influenced by factors such as the expected time course of a patient's

renal failure and the condition of his or her vasculature. Patients may have multiple accesses, usually because an AV fistula or graft is maturing and a catheter is still being used. The creation of all these three major types of vascular accesses requires surgery.

Catheter:
Catheter access, sometimes called a CVC (Central Venous Catheter), consists of a plastic catheter with two lumens (or occasionally two separate catheters) which is inserted into a large vein (usually the vena cava, via the internal jugular vein or the femoral vein) to allow large flows of blood to be withdrawn from one lumen, to enter the dialysis circuit, and to be returned via the other lumen. However, blood flow is almost always less than that of a well functioning fistula or graft. Catheters are usually found in two general varieties, tunnelled and nontunnelled. Non-tunnelled catheter access is for short-term access (up to about 10 days, but often for one dialysis session only), and the catheter emerges from the skin at the site of entry into the vein. Tunnelled catheter access involves a longer catheter, which is tunnelled under the skin from the point of insertion in the vein to an exit site some distance away. It is usually placed in the internal jugular vein in the neck and the exit site is usually on the chest wall. The tunnel acts as a barrier to invading microbes, and as such, tunnelled catheters are designed for short- to medium-term access (weeks to months only), because infection is still a frequent problem. Aside from infection, venous stenosis is another serious problem with catheter access. The catheter is a foreign body in the vein and often provokes an inflammatory reaction in the vein wall. This results in scarring and narrowing of the vein, often to the point of occlusion. This can cause problems with severe venous congestion in the area drained by the vein and may also render the vein, and the veins drained by it, useless for creating a fistula or graft at a later date. Patients on long-term hemodialysis can literally 'run out' of access, so this can be a fatal problem. Catheter access is usually used for rapid access for immediate dialysis, for tunnelled access in patients who are deemed likely to recover from acute renal failure, and for patients with end-stage renal failure who are either waiting for alternative access to mature or who are unable to have alternative access. Catheter access is often popular with patients, because attachment to the dialysis machine doesn't require needles. However, the serious risks of catheter access

noted above mean that such access should be contemplated only as a long-term solution in the most desperate access situation.

AV fistula:
AV (arteriovenous) fistulas are recognized as the preferred access method. To create afistula, a vascular surgeon joins an artery and a vein together through anastomosis. Since this bypasses the capillaries, blood flows rapidly through the fistula. One can feel this by placing one's finger over a mature fistula. This is called feeling for "thrill" and produces a distinct 'buzzing' feeling over the fistula. One can also listen through a stethoscope for the sound of the blood "whooshing" through the fistula, a sound called bruit. Fistulas are usually created in the nondominant arm and may be situated on the hand (the 'snuffbox' fistula'), the forearm (usually a radiocephalic fistula, or so-called Brescia-Cimino fistula, in which the radial artery is anastomosed to the cephalic vein), or the elbow (usually a brachiocephalic fistula, where the brachial artery is anastomosed to the cephalic vein). A fistula will take a number of weeks to mature, on average perhaps 46 weeks. During treatment, two needles are inserted into the fistula, one to draw blood and one to return it. The advantages of the AV fistula use are lower infection rates, because no foreign material is involved in their formation, higher blood flow rates (which translates to more effective dialysis), and a lower incidence of thrombosis. The complications are few, but if a fistula has a very high blood flow and the vasculature that supplies the rest of the limb is poor, a steal syndrome can occur, where blood entering the limb is drawn into the fistula and returned to the general circulation without entering the limb's capillaries. This results in cold extremities of that limb, cramping pains, and, if severe, tissue damage. One long-term complication of an AV fistula can be the development of an aneurysm, a bulging in the wall of the vein where it is weakened by the repeated insertion of needles over time. To a large extent the risk of developing an aneurysm can be reduced by carefully rotating needle sites over the entire fistula, or using the "buttonhole"(constant site) technique. Aneurysms may necessitate corrective surgery and may shorten the useful life of a fistula. To prevent damage to the fistula and aneurysm or pseudoaneurysm formation, it is recommended that the needle be inserted at different points in a rotating fashion. Another approach is to cannulate the fistula with a blunted needle, in exactly the same place. This is called a 'buttonhole' approach. Often two or three buttonhole places are available on a given fistula. This also can prolong fistula life and help prevent damage to the fistula.

AV graft:
AV (arteriovenous) grafts are much like fistulas in most respects, except that an artificial vessel is used to join the artery and vein. The graft usually is made of a synthetic material, often PTFE, but sometimes chemically treated, sterilized veins from animals are used. Grafts are inserted when the patient's native vasculature does not permit a fistula. They mature faster than fistulas, and may be ready for use several weeks after formation (some newer grafts may be used even sooner). However, AV grafts are at high risk to develop narrowing, especially in the vein just downstream from where the graft has been sown to the vein. Narrowing often leads to thrombosis (clotting). As foreign material, they are at greater risk for becoming infected. More options for sites to place a graft are available, because the graft can be made quite long. Thus a graft can be placed in the thigh or even the neck (the 'necklace graft').

Fistula First project:

AV fistulas have a much better access patency and survival than do venous catheters or grafts. They also produce better patient survival and have far fewer complications compared to grafts or venous catheters. For this reason, the Centers for Medicare & Medicaid (CMS) has set up a Fistula First Initiative, whose goal is to increase the use of AV fistulas in dialysis patients. There is ongoing research to make bio-engineered blood vessels, which may be of immense importance in creating AV fistulas for patients on hemodialysis, who do not have good blood vessels for creation of one. It involves growing cells which produce collagen and other proteins on a biodegradable micromesh tube followed by removal of those cells to make the 'blood vessels' storable in refrigerators.

Advantages:

Low mortality rate Better control of blood pressure and abdominal cramps Less diet restriction Better solute clearance effect for the daily hemodialysis: better tolerance and fewer complications with more frequent dialysis

Disadvantages:

Restricts independence, as people undergoing this procedure cannot travel around because of supplies availability Requires more supplies such as high water quality and electricity

Requires reliable technology like dialysis machines The procedure is complicated and requires that care givers have more knowledge Requires time to set up and clean dialysis machines, and expense with machines and associated staff.

BLOOD BANK

INTRODUCTION:
A blood bank is a cache or bank of blood or blood components, gathered as a result of blood donation, stored and preserved for later use in blood transfusion. The term "blood bank" typically refers to a division of a hospital laboratory where the storage of blood product occurs and where proper testing is performed to reduce the risk of transfusion related events. It is important for a blood bank [1] to pass all the eligibility guidelines as mandated by the National Health Service (NHS) in Britain and the Food and Drug Administration (FDA) in the United States. The safety and reliability should also be a consideration too. This includes compatibility testing for transfusion and may include blood donation processing, depending on the capabilities of the facility.

Transfusion:
Most hospital blood banks also perform testing to determine the blood type of patients and to identify compatible blood products forblood transfusions, along with a battery of tests (e.g. disease) and treatments (e.g. leukocyte filtration) to ensure and enhance quality. Some such procedures can be done "upstream" by the collecting agency, or a contracted laboratory. The increasingly recognized problem of inadequate efficacy of transfusion and post-transfusion complications raises the importance of quality testing and screening; U.S. hospitals spend more on dealing with the consequences of transfusion-related complications than on the combined costs of buying, testing/treating, and transfusing their blood. Donors are sometimes paid; in the U.S. and Europe, most blood for transfusion is collected from volunteers while plasma for manufacturing is from paid donors. In the U.S., certain standards are set for the collection and processing of each blood product. "Whole blood" (WB) is the proper name for one defined product, specifically unseparated venous blood with an approved preservative added. Most blood for transfusion is collected as whole blood. Autologous donations are sometimes transfused without further modification, however whole blood is typically separated (via centrifugation) into its components, with red blood cells (RBC) in solution being a commonly used product. Units of WB and RBC are both kept refrigerated at 33.8-42.8 F (1-6 C), with maximum permitted storage periods (shelf lives) of 35 and 42 days respectively. Red Blood Cell units can also be frozen when buffered with glycerol, but this is an expensive and time consuming process, and is rarely done. Frozen red cells are given an expiration date of up to 10 years and are stored at -85F (-65C).

The less-dense blood plasma is made into a variety of frozen components, and is labeled differently based on when it was frozen and what the intended use of the product is. If the plasma is frozen promptly and is intended for transfusion, it is typically labeled as fresh frozen plasma. If it is intended to be made into other products, it is typically labeled as recovered plasma or plasma for fractionation.Cryoprecipitate can be made from other plasma components. These components must be stored at -0F (-17.7C) or colder, but are typically stored at -22F (-30C). The layer between the red cells and the plasma is referred to as the buffy coat and is sometimes removed to make platelets for transfusion. Platelets are typically pooled before transfusion and have a shelf life of five days, or three days once the transfusion centre that collected them has completed their tests. Platelets are stored at room temperature (72F=22.2C) and must be rocked. Since they are stored at room temperature in nutritive solutions, they are at high risk for growing bacteria. Some blood banks also collect products by apheresis. The most common component collected is plasma via plasmapheresis, but red blood cells and platelets can be collected by similar methods. These products have the same shelf life and storage conditions as their manually produced counterparts. An ongoing study allows platelets collected by apheresis to be kept for seven days, but only with specific microbiological testing. The lack of a preservative solution makes a longer shelf life of little use.

Short-term storage:
Routine blood storage is 42 days or 6 weeks for stored packed red blood cells or pRBC (the most common blood product), and involves refrigeration but usually not freezing. There has been increasing controversy about whether the age of blood is a factor in transfusion efficacy, specifically on whether older blood directly or indirectly increases risks of complications. Studies have not been consistent on answering this question, with some showing that older blood is indeed less effective but with others showing no such difference; nevertheless, as storage time remains the only available way to estimate quality status or loss, a first-in-first-out inventory management approach is standard presently. Insufficient transfusion efficacy can result from blood product units damaged by so-called storage lesion - a set of biochemical and biomechanical changes which occur during storage. With red cells, this can decrease viability and ability for tissue oxygenation.(Note that upon transfusion, cells have exhibited some degree of ability to reverse their storage lesion, albeit not entirely - and often too slowly to benefit urgent-care patients.) Without a clinically feasible and

reliable means to directly measure this phenomenon (during storage), many physicians have adopted a so-called "restrictive protocol" - whereby transfusions are simply being held to a minimum, as delayed recovery times and extended hospitals stays is viewed as the "lesser evil" compared to the harm and thus resulting cost of transfusing blood product of unknown quality.

Long-term storage:
Long-term storage is relatively uncommon, compared to short-term storage. Cryopreservation of red blood cells is done to store rare units for up to 10 years. The cells are incubated in a glycerol solution which acts as a cryoprotectant ("antifreeze") within the cells. The units are then placed in special sterile containers in a freezer at very cold temperatures. The exact temperature depends on the glycerol concentration.

NEONATAL / LABOR WARD

INTRODUCTION:

When a baby is relatively stable but still premature or requiring intravenous fluids or other special attention, he or she is cared for in an "incubator." The incubator keeps the baby warm with moistened air in a clean environment, and helps to protect the baby from noise, drafts, infection, and excess handling. Incubators were invented in France in the late 1800's and the earliest incubators were, in fact, modeled after poultry incubators -- hence their name. Incubators are sometimes called "isolettes," but "Isolette" is actually a brand name for a particular company's incubator product. You'll see many varieties of incubators in NICUs but whether they are flashy or plain, colorful or austere, they all do basically the same job.

A physiologic monitor, sometimes called a cardiorespiratory monitor, is attached to sensors on the baby and provides a constant read-out of the baby's heart rate and rhythm, breathing rate, arterial or central venous pressure, and other useful information. Alarms can be configured to provide an alert when any of the vital signs being monitored goes above or below a certain limit. Monitors come in a huge variety of shapes, sizes, configurations, and the most recent models contain embedded computer systems that are capable of filtering out false alarms, recording and reviewing data for extended periods, performing some degree of trend analysis, and many other sophisticated functions. The pulse oximeter, or "pulse ox," monitors the oxygen saturation of the baby's blood. It does this by shining light through the baby's skin and measuring the color of the light that is transmitted. Most of you are familiar with the concept that red blood is arterial and blue blood is venous; this is another way of saying that blood which is being pumped by the heart from the lungs to the body and has a lot of oxygen in it is red, whereas blood that is returning to the heart through the veins after oxygen has been removed by the body's tissues is blue. By measuring the transmitted light at certain colors very precisely, the pulse oximeter can provide an estimate of how much oxygen is in the blood. The pulse oximeter can be fooled, however, when the flow of blood to the hands and feet is poor, such as when the baby is cold, or when the baby's blood pressure is low.

Infant ventilators (respirators) breath for the baby when the baby is too sick or too weak to breath for itself. There are many different types and brands of ventilators in use in NICUs; the one shown here, the Sechrist 100B, was popular in the 1980's and is still in common use today.

Recent models of infant ventilators are heavily computerized and support diverse modes of operation, including "assist control." Some models can provide real-time data on the baby's pulmonary function.

IV pumps, or infusion pumps, are a crucial item of equipment in an NICU. Most sick babies have one or more intravenous (IV) or arterial lines, and the fluid that is delivered through those lines must be very carefully regulated, all the way down to the amount of 0.1 cc per hour (about 1/30 of a teaspoon per hour). There are many brands, sizes, and shapes of IV pumps; the pump shown here is called an IVAC.

Phototherapy lights, or "bili lights," are used when babies are jaundiced (yellow). Some degree of jaundice, which is caused by the presence of a molecule called bilirubin in the blood, is common and even normal in newborns. However, in sick infants, jaundice can result from a variety of problems, and when jaundice is extreme it can cause brain damage. During the 1970's, it was discovered that certain wavelengths of light (in the blue part of the spectrum) can cause a chemical reaction that converts bilirubin into a harmless form as blood passes through the skin. It's important to note that bili lights do not deliver any ultraviolet light, so the babies are not in any danger of sunburn or other toxic effects. However, as a safety measure, the babies' eyes are usually shielded with a cloth covering when they are under bili lights. A blood gas machine analyzes a sample of the baby's blood, usually obtained from an arterial catheter or from a "heelstick," and reports the pH and the level of oxygen and carbon dioxide. It also calculates values for the bicarbonate level, oxygen saturation, base deficit, and so on. These values are then used by the neonatologist, nurse practitioner, or respiratory therapist to adjust the setting of the ventilator and the oxygen blender. It was not practical to do blood gas tests on babies until the 1970's, when simple techniques for umbilical arterial catheterization were developed and blood gas machines appeared that could perform tests on "micro-samples." Today's blood gas machines can perform a complete analysis on less then 0.2 cc of blood (less than 1/10 of a teaspoon).

In the modern, digital era, films are read online and the images can be manipulated through software to aid interpretation -- the contrast and brightness can be manipulated, the image can be flipped or rotated, edges can be enhanced, areas of interest can be enlarged, old images can be retrieved from disk storage and compared with the new images, etc. Most importantly, an image can be viewed in more than one place at a time, the neonatologist does not need to wait for film to be "developed," and each image is stored and backed up electronically so it cannot be misplaced in the radiology file room or borrowed and lost. A transport incubator is used when a sick or premature baby is moved from one hospital to another -- for example, from a community hospital to a larger medical center that has a neonatal intensive care unit. In fact, a transport incubator is like a little selfcontained intensive care unit on wheels. It usually has a miniature ventilator (respirator), cardio-respiratory monitor, IV pump, pulse oximeter, and oxygen supply built right into its frame. A specially-trained physician, nurse, and respiratory therapist typically accompany the baby fhroughout the trip. A defibrillator is used to "shock" the heart from an abnormal rhythm pattern back into a normal rhythm. Every neonatal ICU has one of these devices, but they are rarely used there. Abnormal heart rhythms are quite unusual in babies, even those babies with several cardiac abnormalities -- arrhythmias are more typical of aged patients with damaged heart muscle or conduction pathways.

EMERGENCY WARD

INTRODUCTION:
An emergency department (ED), also known as accident & emergency (A&E), emergency room (ER), or casualty department is a medical treatment facility specialising in acute care of patients who present without prior appointment, either by their own means or by ambulance. The emergency department is usually found in a hospital or other primary care center. Due to the unplanned nature of patient attendance, the department must provide initial treatment for a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention. In some countries, emergency departments have become important entry points for those without other means of access to medical care. The emergency departments of most hospitals operate 24 hours a day, although staffing levels may be varied in an attempt to mirror patient volume. Today, a typical hospital has its emergency department in its own section of the first floor of the campus, with its own dedicated entrance. As patients can present at any time and with any complaint, a key part of the operation of an

emergency department is the prioritization of cases based on clinical need. This is usually achieved through the application of triage. Triage is normally the first stage the patient passes through, and consists of a brief assessment, a set of vital signs, and the assignment of a "chief complaint" (i.e. chest pain, abdominal pain, difficulty breathing, etc.). Most emergency departments have a dedicated area for this process to take place, and may have staff dedicated to performing nothing but a triage role. In most departments, this role is fulfilled by a nurse, although dependent on training levels in the country and area, other health care professionals may perform the triage sorting, including paramedics or physicians (DOs or MDs). Triage is typically conducted face-to-face when the patient presents, or a form of triage may be conducted via radio with an ambulance crew; in this method, the paramedics will call the hospital's triage center with a short update about an incoming patient, who will then be triaged to the appropriate level of care. Most patients will be initially assessed at triage and then passed to another area of the department, or another area of the hospital, with their waiting time determined by their clinical need. However, some patients may complete their treatment at the triage stage, for instance if the condition is very minor and can be treated quickly, if only advice is required, or if the emergency department is not a suitable point of care for the patient. Conversely, patients with evidently serious conditions, such as cardiac arrest, will bypass triage altogether and move straight to the appropriate part of the department.

EQUIPMENTS IN EMERGENCY WARD: DEFIBRILLATOR:

Defibrillation is a common treatment for life-threatening cardiac dysrhythmias, ventricular fibrillation, and pulseless ventricular tachycardia. Defibrillation consists of delivering a therapeutic dose of electrical energy to the affected heart with a device called adefibrillator. This depolarizes a critical mass of the heart muscle, terminates the dysrhythmia, and allows normal sinus rhythm to be reestablished by the body's natural pacemaker, in the sinoatrial node of the heart. Defibrillators can be external, transvenous, or implanted, depending on the type of device used or needed. Some external units, known asautomated external defibrillators (AEDs), automate the diagnosis of treatable rhythms, meaning that lay responders or bystanders are able to use them successfully with little, or in some cases no training at all.

Implantable devices:
A further development in defibrillation came with the invention of the implantable device, known as an implantable cardioverter-defibrillator (or ICD). This was pioneered at Sinai Hospital in Baltimore by a team that included Stephen Heilman, Alois Langer, Jack Lattuca,Morton Mower, Michel Mirowski, and Mir Imran, with the help of industrial collaborator Intec Systems of Pittsburgh. Mirowski teamed up with Mower and Staewen, and together they commenced their research in 1969 but it was 11 years before they treated their first patient. Similar developmental work was carried out by Schuder and colleagues at the University of Missouri. The work was commenced, despite doubts amongst leading experts in the field of arrhythmias and sudden death. There was doubt that their ideas would ever become a clinical reality. In 1962 Bernard Lown introduced the external DC defibrillator. This device applied a direct current from a discharging capacitor through the chest wall into the heart to stop heart fibrillation.[6] In 1972, Lown stated in the journal Circulation "The very rare patient who has frequent bouts of ventricular fibrillation is best treated in a coronary care unit and is better served by an effective antiarrhythmic program or surgical correction of inadequate coronary blood flow or ventricular malfunction. In fact, the implanted defibrillator system represents an imperfect solution in search of a plausible and practical application." The problems to be overcome were the design of a system which would allow detection of ventricular fibrillation or ventricular tachycardia. Despite the lack of financial backing and grants, they persisted and the first device was implanted in February 1980 atJohns Hopkins Hospital by Dr. Levi Watkins, Jr. Modern ICDs do not require a thoracotomy and possess pacing, cardioversion, and defibrillation capabilities. The invention of implantable units is invaluable to some regular sufferers of heart problems, although they are generally only given to those people who have already had a cardiac episode.

Interface with the patient:

The connection between the defibrillator and the patient consists of a pair of electrodes, each provided with electricity conductive gel in order to ensure a good connection and to minimize electrical resistance, also called chest impedance (despite the DC discharge) which would burn the patient. Gel may be either wet (similar in consistency to surgical lubricant) or solid (similar to gummi candy. Solid-gel is more convenient, because there is no need to clean the used gel off of

patient's skin after defibrilation (the solid gel is easily lifted off of the patient). However, the use of solid-gel presents a higher risk of burns during defibrillation, since wet-gel electrodes more evenly conduct electricity into the body. Paddle electrodes, which were the first type developed, come without gel, and must have the gel applied in a separate step. Self-adhesive electrodes come prefitted with gel. There is a general division of opinion over which type of electrode is superior in hospital settings; the American Heart Association favors neither, and all modern manual defibrillators used in hospitals allow for swift switching between selfadhesive pads and traditional paddles. Each type of electrode has its merits and demerits, as discussed below.

Paddle electrodes:
The most well-known type of electrode (widely depicted in films and television) is the traditional metal paddle with an insulated (usually plastic) handle. This type must be held in place on the patient's skin with approximately 25 lbs of force while a shock or a series of shocks is delivered. Paddles offer a few advantages over self-adhesive pads. Many hospitals in the United States continue the use of paddles, with disposable gel pads attached in most cases, due to the inherent speed with which these electrodes can be placed and used. This is critical during cardiac arrest, as each second of nonperfusion means tissue loss. Modern paddles allow for monitoring (electrocardiography), though in hospital situations, separate monitoring leads are often already in place.

DEFIBRILLATOR

Paddles are reuseable, being cleaned after use and stored for the next patient. Gel is therefore not preapplied, and must be added before these paddles are used on the patient. Paddles are generally only found on the manual external units. Paddles require approximately 25 lbs of force to be applied while the shock is delivered.

Self-adhesive electrodes:
Newer types of resuscitation electrodes are designed as an adhesive pad, which includes either solid or wet gel. These are peeled off their backing and applied to the patient's chest when deemed necessary, much the same as any other

sticker. The electrodes are then connected to a defibrillator, much as the paddles would be. If defibrillation is required, the machine is charged, and the shock is delivered, without any need to apply any additional gel or to retrieve and place any paddles. Most adhesive electrodes are designed to be used not only for defibrillation, but also for transcutaneous pacing and synchronized electrical cardioversion. These adhesive pads are found on most automated and semi-automated units and are replacing paddles entirely in non-hospital settings. In hospital, for cases where cardiac arrest is likely to occur (but has not yet), selfadhesive pads may be placed prophylactically. Pads also offer an advantage to the untrained user, and to medics working in the sub-optimal conditions of the field. Pads do not require extra leads to be attached for monitoring, and they do not require any force to be applied as the shock is delivered. Thus, adhesive electrodes minimize the risk of the operator coming into physical (and thus electrical) contact with the patient as the shock is delivered by allowing the operator to be up to several feet away. (The risk of electrical shock to others remains unchanged, as does that of shock due to operator misuse.) Self-adhesive electrodes are single-use only. They may be used for multiple shocks in a single course of treatment, but are replaced if (or in case) the patient recovers then reenters cardiac arrest.

Placement:
Resuscitation electrodes are placed according to one of two schemes. The anterior-posterior scheme is the preferred scheme for long-term electrode placement. One electrode is placed over the left precordium (the lower part of the chest, in front of the heart). The other electrode is placed on the back, behind the heart in the region between the scapulas. This placement is preferred because it is best for non-invasive pacing. The anterior-apex scheme can be used when the anterior-posterior scheme is inconvenient or unnecessary. In this scheme, the anterior electrode is placed on the right, below the clavicle. The apex electrode is applied to the left side of the patient, just below and to the left of the pectoral muscle. This scheme works well for defibrillation and cardioversion, as well as for monitoring an ECG.

PULSE OXIMETER:
Pulse oximetry is a non-invasive method allowing the monitoring of the saturation of a patient's hemoglobin. A sensor is placed on a thin part of the patient's body, usually a fingertip or earlobe, or in the case of an infant, across a foot. Light of two different wavelengths is passed through the patient to a photodetector. The

changing absorbance at each of the wavelengths is measured, allowing determination of the absorbances due to the pulsing arterial bloodalone, excluding venous blood, skin, bone, muscle, fat, and (in most cases) nail polish.With NIRS it is possible to measure both oxygenated and deoxygenated hemoglobin on a peripheral scale (possible on both brain and muscle). Reflectance pulse oximetry may be used as an alternative to transmissive pulse oximetery described above. This method does not require a thin section of the patient's body and is therefore well suited to more universal application such as the feet, forehead and chest, but it also has some limitations. Vasodilation and pooling of venous blood in the head due to compromised venous return to the heart, as occurs with congenital cyanotic heart disease patients, or in patients in the Trendelenburg position (Friedrich Trendelenburg, German physician 1844-1924), can cause a combination of arterial and venous pulsations in the forehead region and lead to spurious SpO2 results.

Function:
A blood-oxygen monitor displays the percentage of arterial hemoglobin in the oxyhemoglobin configuration. Acceptable normal ranges for patients without COPD with a hypoxic drive problem are from 95 to 99 percent, those with a hypoxic drive problem would expect values to be between 88 to 94 percent, values of 100 percent can indicate carbon monoxide poisoning. For a patient breathing room air, at not far above sea level, an estimate of arterial pO2 can be made from the blood-oxygen monitor SpO2 reading. Pulse oximetry is a particularly convenient noninvasive measurement method. Typically itutilizes a pair of small light-emitting diodes (LEDs) facing a photodiode through a translucent part of the patient's body, usually a fingertip or an earlobe. One LED is red, withwavelength of 660 nm, and the other is infrared, 905, 910, or 940 nm. Absorption at these wavelengths differs significantly between oxyhemoglobin and its deoxygenated form; therefore, the oxy/deoxyhemoglobin ratio can be calculated from the ratio of the absorption of the red and infrared light. The absorbance of oxyhemoglobin and deoxyhemoglobin is the same (isosbestic point) for the wavelengths of 590 and 805 nm; earlier equipment used these wavelengths for correction of hemoglobin concentration. The monitored signal fluctuates in time with the heart beat because the arterial blood vessels expand and contract with each heartbeat. By examining only the varying part of the absorption spectrum (essentially, subtracting minimum absorption from peak absorption), a monitor can ignore other tissues or nail polish, (though black nail polish tends to distort readings) and discern only the absorption

caused by arterial blood. Thus, detecting a pulse is essential to the operation of a pulse oximeter and it will not function if there is none.

Advantages:
A pulse oximeter is useful in any setting where a patient's oxygenation is unstable, including intensive care, operating, recovery, emergency and hospital ward settings, pilots in unpressurized aircraft, for assessment of any patient's oxygenation, and determining the effectiveness of or need for supplemental oxygen. Assessing a patient's need for oxygen is the most essential element to life; no human life thrives in the absence of oxygen (cellular or gross). Although a pulse oximeter is used to monitor oxygenation, it cannot determine the metabolism of oxygen, or the amount of oxygen being used by a patient. For this purpose, it is necessary to also measure carbon dioxide (CO2) levels. It is possible that it can also be used to detect abnormalities in ventilation. However, the use of a pulse oximeter to detect hypoventilation is impaired with the use of supplemental oxygen, as it is only when patients breathe room air that abnormalities in respiratory function can be detected reliably with its use. Therefore, the routine administration of supplemental oxygen may be unwarranted if the patient is able to maintain adequate oxygenation in room air, since it can result in hypoventilation going undetected. Because of their simplicity of use and the ability to provide continuous and immediate oxygen saturation values, pulse oximeters are of critical importance in emergency medicine and are also very useful for patients with respiratory or cardiac problems, especially COPD, or for diagnosis of some sleep disorders such as apnea and hypopnea.Portable battery-operated pulse oximeters are useful for pilots operating in a non-pressurized aircraft above 10,000 feet (12,500 feet in the U.S.) where supplemental oxygen is required. Portable pulse oximeters are also useful for mountain climbers and athletes whose oxygen levels may decrease at high altitudes or with exercise. Some portable pulse oximeters employ software that charts a patient's blood oxygen and pulse, serving as a reminder to check blood oxygen levels.

VENTILATOR:
Medical ventilator (or simply ventilator in context) is a machine designed to mechanically move breatheable air into and out of the lungs, to provide the mechanism of breathing for a patient who is physically unable to breathe, or breathing insufficiently.

Ventilators are chiefly used in intensive care medicine, home care, and emergency medicine(as standalone units) and in anesthesia (as a component of an anesthesia machine). Medical ventilators are sometimes coloquially called "respirators," a term which stems from commonly used devices in the 1950's (particularly the "Bird Respirator"). However, in modern hospital and medical terminology, these machines are never referred to as respirators, and use of "respirator" in this context is now a deprecated anachronism which signals technical unfamiliarity

Function:
In its simplest form, a modern positive pressure ventilator consists of a compressible air reservoir or turbine, air and oxygen supplies, a set of valves and tubes, and a disposable or reusable "patient circuit". The air reservoir is pneumatically compressed several times a minute to deliver room-air, or in most cases, an air/oxygen mixture to the patient. If a turbine is used, the turbine pushes air through the ventilator, with a flow valve adjusting pressure to meet patientspecific parameters. When overpressure is released, the patient will exhale passively due to the lungs' elasticity, the exhaled air being released usually through a one-way valve within the patient circuit called the patient manifold. The oxygen content of the inspired gas can be set from 21 percent (ambient air) to 100 percent (pure oxygen). Pressure and flow characteristics can be set mechanically or electronically. Ventilators may also be equipped with monitoring and alarm systems for patientrelated parameters (e.g. pressure, volume, and flow) and ventilator function (e.g. air leakage, power failure, mechanical failure), backup batteries, oxygen tanks, and remote control. The pneumatic system is nowadays often replaced by a computercontrolled turbopump. Modern ventilators are electronically controlled by a small embedded system to allow exact adaptation of pressure and flow characteristics to an individual patient's needs. Fine-tuned ventilator settings also serve to make ventilation more tolerable and comfortable for the patient. In Canada, and the United States, respiratory therapists are responsible for tuning these settings while biomedical technologists are responsible for the maintenance. The patient circuit usually consists of a set of three durable, yet lightweight plastic tubes, separated by function (e.g. inhaled air, patient pressure, exhaled air). Determined by the type of ventilation needed, the patient-end of the circuit may be either noninvasive or invasive.

VENTILATOR

Noninvasive methods, which are adequate for patients who require a ventilator only while sleeping and resting, mainly employ a nasal mask. Invasive methods require intubation, which for long-term ventilator dependence will normally be a tracheotomy cannula, as this is much more comfortable and practical for long-term care than is larynx or nasal intubation.

Life-critical system:
Because the failure of a mechanical ventilation system may result in death, it is classed as a life-critical system, and precautions must be taken to ensure that mechanical ventilation systems are highly reliable. This includes their powersupply provision. Mechanical ventilators are therefore carefully designed so that no single point of failure can endanger the patient. They may have manual backup mechanisms to enable hand-driven respiration in the absence of power (such as the mechanical ventilator integrated into an anaesthetic machine. They may also have safety valves, which open to atmosphere in the absence of power to act as an antisuffocation valve for the spontaneously breathing patient. Some systems are also equipped with compressed-gas tanks, air compressors, and/or backup batteries to provide ventilation in case of power failure or defective gas supplies, and methods to operate or call for help if their mechanisms or software fail.

PHYSIOTHERAPY

INTRODUCTION:
Physical therapy (or physiotherapy), often abbreviated PT, is a health care profession primarily concerned with the remediation of impairments and disabilities and the promotion of mobility, functional ability, quality of life and movement potential through examination, evaluation, diagnosis and physical intervention carried out by Physical Therapists (known as Physiotherapists in some countries) and Physical Therapist Assistants (known as Physical Rehabilitation Therapists in some countries). In addition to clinical practice, other activities encompassed in the physical therapy profession include research, education, consultation and administration. Definitions and licensing requirements in theUnited States vary among jurisdictions, as each state has enacted its own physical therapy practice act defining the profession within its jurisdiction, but the American Physical Therapy Association (APTA) has also drafted a model definition in order to limit this variation, and the APTA is also responsible for accrediting physical therapy educationcurricula throughout the United States of America. In many settings, physical therapy services may be provided alongside, or in conjunction with, other medical or rehabilitationservices. Physical therapy (or physiotherapy), often abbreviated PT, is a health care profession primarily concerned with the remediation of impairments and disabilities and the promotion of mobility, functional ability, quality of life and movement potential through examination, evaluation, diagnosis and physical intervention carried out by Physical Therapists (known as Physiotherapists in some countries) and Physical Therapist Assistants (known as Physical Rehabilitation Therapists in some countries). In addition to clinical practice, other activities encompassed in the physical therapy profession include research, education, consultation and administration. Definitions and licensing requirements in the United States vary among jurisdictions, as each state has enacted its own physical therapy practice act defining the profession within its jurisdiction, but the American Physical Therapy Association (APTA) has also drafted a model definition in order to limit this variation, and the APTA is also responsible for accrediting physical therapy educationcurricula throughout the United States of America. In many settings, physical therapy services may be provided alongside, or in conjunction with, other medical or rehabilitationservices.

NEUROLOGICAL REHABILITATION:
A neurological rehabilitation period is begun with initial examinations by a doctor, a physiotherapist and a registered nurse. Individual physiotherapy (2 x 40 min) and occupational therapy (45 min) is included in neurological rehabilitation daily. In addition to exercise groups appropriate to the rehabilitee's general

condition and leisure activities, speech therapy may also be included according to the referral. The rehabilitee also receives a pedicure and an appointment with a social worker. At the end of the rehabilitation period, a doctor's examination is performed and the results of the physiotherapy and occupational therapy are evaluated. A professional team formulates a rehabilitation plan and follows its progress. Rehabilitative treatment is implemented round the clock at Kitinkannus. Rehabilitation is realised by the multi-professional cooperation of doctors, registered nurses, practical nurses, physiotherapists, occupational therapists, social workers and, if necessary, speech therapists and psychologists. With the help of operational therapeutic exercises, the objective of physiotherapy and occupational therapy is to restore the functional capacity of the rehabilitee to be fit for home care. The facilities and exercise equipment of Kitinkannus are well-suited for neurological rehabilitation. For example, we have a Lokomat walking simulation robot, an H/P Cosmos body-weight-supported walking exercise machine, aBalanceTrainer for balance and standing position training, basic physiotherapy equipment, modern gym machines, a sports hall and therapy pool, as well as diverse equipment and facilities for occupational therapy. Rehabilitees can take part in various structured leisure activities, lectures, exercise and discussion groups.

NEUROLOGICAL REHABILITATION

LIGHT THERAPY:
Light therapy or phototherapy (classically referred to as heliotherapy) consists of exposure to daylight or to specific wavelengths of light using lasers, light-emitting diodes,fluorescent lamps, dichroic lamps or very bright, full-spectrum light, usually controlled with various devices. The light is administered for a prescribed amount of time and, in some cases, at a specific time of day. Common use of the term is associated with the treatment of skin disorders (chieflypsoriasis), sleep disorder and some psychiatric disorders. Light therapy directed at the skin is also used to treat acne vulgaris, eczema and neonatal jaundice. Light therapy which strikes the retina of the eyes is used to treat circadian rhythm disorders such asdelayed sleep phase syndrome and can also be used to treat seasonal affective disorder, with some support for its use also with nonseasonal psychiatric disorders. Other medical applications of light therapy also include pain management, accelerated wound healing, hair growth, improvement in blood properties and blood circulation, and sinus-related diseases and disorders. Many of these use low level laser therapy and red light therapy in the 620660 nm range.

Skin conditions:
Two forms of phototherapy exist, non-targeted phototherapy (from sunlight, a tanning booth or a light box), and targeted-phototherapy, in which light is administered to a specific, localized area of the skin. Current targeted phototherapy is administered via excimer laser, elemental gas lamp, or via LED light. Current FDA cleared devices on the market include XTRAC excimer laser, BClear, Theralight, and Psoria-Light LED phototherapy. Targeted phototherapy is only administered to the affected skin, not the entire body, thus sparing healthy skin from UV rays which may lead to other health issues including skin cancer. With targeted phototherapy only being administered to the affected area of skin, more intense dosages of light can be administered, allowing skin conditions to be repaired in less time. As of early 2012, the only FDA-cleared device to offer both UVA and NB-UVB treatment within one device is the Psoria-Light.

Risks and complications:

Ultraviolet light causes progressive damage to human skin. This is mediated by genetic damage, collagen damage, as well as destruction of vitamin A and vitamin C in the skin and free radical generation. Ultraviolet light is also known to be a factor in formation ofcataracts. Researchers have questioned

whether limiting blue light exposure could reduce the risk of age-related macular degeneration. Modern phototherapy lamps used in the treatment of seasonal affective disorder and sleep disorders either filter out or do not emit ultraviolet light and are considered safe and effective for the intended purpose, as long as photosensitizing drugs are not being taken at the same time and in the absence of any existing eye conditions. Light therapy is a mood altering treatment, and just as with drug treatments, there is a possibility of triggering a manic state from a depressive state, causing anxiety and other side effects. While these side effects are usually controllable, it is recommended that patients undertake light therapy under the supervision of an experienced clinician, rather than attempting to self-medicate. It is reported that bright light therapy may activate the production of reproductive hormones, such as testosterone, luteinizing hormone,folliclestimulating hormone, and estradiol. There are few absolute contraindications to light therapy, although there are some circumstances in which caution is required. These include when a patient has a condition that might render his or her eyes more vulnerable to phototoxicity, has a tendency toward mania, has a photosensitive skin condition, or is taking a photosensitizing herb (such as St. John's wort) or medication. Patients withporphyria should avoid most forms of light therapy. Patients on certain drugs like methotrexate or chloroquine should use caution with light therapy as there is a chance that these drugs could cause porphyria.

OPERATION THEATRE

INTRODUCTION:
An operating theater (or theatre) was a non-sterile, tiered theater or amphitheater in which students and other spectators could watch surgeons perform surgery. Within the Commonwealth nations, the term is used synonymously with operating room (OR) operating suite, the modern facility within a hospital where surgical operations are carried out in a sterile environment. Operating theatres had a raised table or chair of some sort at the center for performing operations, and were surrounded by several rows of seats (operating theatres could be cramped or spacious) so students and other spectators could observe the case in progress. The surgeons wore street clothes with an apron to protect them from blood stains, and they operated bare-handed with unsterilized instruments and supplies (gut and silk sutures were sold as open strands with reusable, hand-threaded needles packing gauze was made of sweepings from the floors of cotton mills. In contrast to today's concept of surgery as a profession that emphasizes cleanliness and conscientiousness, at the beginning of the 20th century the mark of a busy and successful surgeon was the profusion of blood and fluids on his clothes.

Operating room equipment

The operating table in the center of the room can be raised, lowered, and tilted in any direction. The operating room lights are over the table to provide bright light, without shadows, during surgery. The anesthesia machine is at the head of the operating table. This machine has tubes that connect to the patient to assist him or her in breathing during surgery, and built-in monitors that help control the mixture of gases in the breathing circuit. The anesthesia cart is next to the anesthesia machine. It contains the medications, equipment, and other supplies that the anesthesiologist may need.

Sterile instruments to be used during surgery are arranged on a stainless steel table. An electronic monitor (which records the heart rate and respiratory rate by adhesive patches) are placed on patient's chest. The pulse oximeter machine attaches to the patient's finger with an elastic band aid. It measures the amount of oxygen contained in the blood. Automated blood pressure measuring machine that automatically inflates the blood pressure cuff on patient's arm. An electrocautery machine uses high frequency electrical signals to cauterize or seal off blood vessels and may also be used to cut through tissue with a minimal amount of bleeding. If surgery requires, a Heart-lung machine, or other specialized equipment, may be brought into the room.

Surgeon and assistants equipment:

People in the operating room wear surgical clothes to help prevent germs from infecting the surgical incision. The surgical clothing includes the following: a protective cap covering their hair masks over their lower face, covering their mouths and noses shades or glasses over their eyes vinyl gloves on their hands long gowns protective covers on their shoes The surgeon may also wear special glasses that help him/her to see more clearly.

ROBOTIC SURGERY:
Robotic surgery, computer-assisted surgery, and robotically-assisted surgery are terms for technological developments that use robotic systems to aid in surgical procedures. Robotically-assisted surgery was developed to overcome both the limitations of minimally invasive surgery or to enhance the capabilities of surgeons performing open surgery. In the case of robotically assisted minimally invasive surgery, instead of directly moving the instruments, the surgeon uses one of two methods to control the instruments ; either a direct telemanipulator or by computer control. A telemanipulator is a remote manipulator that allows the surgeon to perform the normal movements associated with the surgery whilst therobotic arms carry out those movements using end-effectors and manipulators to perform the actual surgery on the patient. In computer-controlled systems the surgeon uses a

computer to control the robotic arms and its end-effectors, though these systems can also still use telemanipulators for their input. One advantage of using the computerised method is that the surgeon does not have to be present, indeed the surgeon could be anywhere in the world, leading to the possibility for remote surgery. In the case of enhanced open surgery, autonomous instruments (in familiar configurations) replace traditional steel tools, performing certain actions (such as rib spreading) with much smoother, feedback-controlled motions than could ever be achieved by a human hand. The main object of such smart instruments is to reduce or eliminate the tissue trauma traditionally associated with open surgery without requiring more than a few minutes' training on the part of surgeons. This approach seeks to improve that lion's share of surgeries, particularly cardiothoracic, that minimally invasive techniques have so failed to supplant

Advantages and disadvantages:

Major advances aided by surgical robots have been remote surgery, minimally invasive surgery and unmanned surgery. Some major advantages of robotic surgery are precision, miniaturization, smaller incisions, decreased blood loss, less pain, and quicker healing time. Further advantages are articulation beyond normal manipulation and three-dimensional magnification, resulting in improved ergonomics. Robotic techniques are also associated with reduced duration of hospital stays, blood loss, transfusions, and use of pain medication. With the cost of the robot at $1,390,000 dollars and disposable supply costs of $1,500 per procedure, the cost of the procedure is higher.Additional surgical training is needed to operate the system. Numerous feasibility studies have been done to determine whether the purchase of such systems are worthwhile. As it stands, opinions differ dramatically. Surgeons report that, although the manufacturers of such systems provide training on this new technology, the learning phase is intensive and surgeons must operate on twelve to eighteen patients before they adapt. Moreover during the training phase, minimally invasive operations can take up to twice as long as traditional surgery, leading to operating room tie ups and surgical staffs keeping patients under anesthesia for longer periods. Patient surveys indicate they chose the procedure based on expectations of decreased morbidity, improved outcomes, reduced blood loss and less pain.Higher expectations may explain higher rates of dissatisfaction and regret. Advantages of this technique are that the incisions are small and patient recovery is quick. In traditional open-heart surgery, the surgeon makes a ten to twelve-inch incision, then gains access to the heart by splitting the sternum (breast bone) and spreading open the rib cage. The patient is then placed on a heart-lung

machine and the heart is stopped for a period of time during the operation. This approach can be associated with postoperative infection and pain, and prolonged time to complete recovery. Because patient recovery after robot-assisted heart surgery is quicker, the hospital stay is shorter. On average patients leave the hospital two to five days earlier than patients who have undergone traditional open-heart surgery and return to work and normal activity 50% more quickly. Reduced recovery times are not only better for the patient, they also reduce the number of staff needed during surgery, nursing care required after surgery, and, therefore, the overall cost of hospital stays. Compared with other minimally invasive surgery approaches, robot-assisted surgery gives the surgeon better control over the surgical instruments and a better view of the surgical site. In addition, surgeons no longer have to stand throughout the surgery and do not tire as quickly. Naturally occurring hand tremors are filtered out by the robots computer software. Finally, the surgical robot can continuously be used by rotating surgery teams. Critics of the system say there is a steep learning curve for surgeons who adopt use of the system and that there's a lack of studies that indicate long-term results are superior to results following traditional laparoscopic surgery.[ This is partly due to the difficulty that surgeons using robotic surgery face in getting their result published by mainstream medical journals. On the other hand, articles in the newly created Journal of Robotic Surgery tend to report on one surgeons experience. A Medicare study found that some procedures that have traditionally been performed with large incisions can be converted to "minimally invasive" endoscopic procedures with the use of the Da Vinci, shortening length-of-stay in the hospital and reducing recovery times. But because of the hefty cost of the robotic system it is not clear that it is cost-effective for hospitals and physicians despite any benefits to patients since there is no additional reimbursement paid by the government or insurance companies when the system is used.

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