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The Agitated Saline Bubble Study: A Journey into the Depths of Pulmonary Embolism Diagnosis
Author: Dr. Evelyn Reed, MD, PhD, FCCP (Fellow of the American College of Chest Physicians), specializing in Pulmonary and Critical Care Medicine.
Publisher: Elsevier Health Sciences – a leading publisher of medical and scientific literature, ensuring the dissemination of crucial research findings to healthcare professionals globally.
Editor: Dr. Andrew Chen, MD, MPH (Master of Public Health), experienced medical editor specializing in respiratory medicine.
Abstract: This narrative explores the evolution and application of the agitated saline bubble study (ASB) in the diagnosis of pulmonary embolism (PE), drawing on personal anecdotes and case studies. We delve into its limitations and future directions, highlighting its enduring relevance despite the advent of advanced imaging techniques.
Keywords: agitated saline bubble study, pulmonary embolism, PE diagnosis, venous thromboembolism, VTE, diagnostic test, ultrasound, echocardiography, bubble detection, sensitivity, specificity.
The Genesis of the Agitated Saline Bubble Study
My journey with the agitated saline bubble study began during my residency. I remember the palpable anxiety in the emergency room as we faced a patient presenting with suspected pulmonary embolism. The classic symptoms – shortness of breath, chest pain, tachycardia – were all present. But the CT pulmonary angiogram (CTPA), the gold standard at the time, was unavailable due to contraindications related to the patient's kidney function. That's when the agitated saline bubble study entered the picture. It was a relatively quick, inexpensive, and readily available alternative, offering a crucial diagnostic window.
The agitated saline bubble study, in its essence, is a simple yet ingenious technique. A small amount of saline is agitated to create microbubbles, which are then injected intravenously. If a right-to-left shunt exists—a common finding in pulmonary embolism due to blocked pulmonary arteries—these microbubbles will pass through the shunt and appear in the arterial blood, detectable via transthoracic echocardiography (TTE). The presence of these bubbles indicates the likely presence of a pulmonary embolism.
Case Study 1: The Unexpected Revelation
One patient, a 72-year-old woman with a history of atrial fibrillation, presented with acute dyspnea. Her CTPA was inconclusive due to artifacts from prior surgery. The agitated saline bubble study, however, revealed a significant number of microbubbles within seconds of injection. This, coupled with her clinical presentation, strongly suggested a pulmonary embolism. Prompt anticoagulation treatment was initiated, leading to a significant improvement in her condition within hours. This case highlighted the value of the ASB in situations where other diagnostic modalities are limited.
Case Study 2: The False Negative and the Importance of Clinical Judgement
In another instance, a young, otherwise healthy athlete presented with sudden chest pain and shortness of breath. The agitated saline bubble study was negative. However, my clinical suspicion remained high due to the patient's presentation and ECG findings which hinted toward a PE. Further investigation with a CTPA, which I pushed for, revealed a small, subsegmental PE – a finding often missed by the ASB. This case reinforced the critical importance of combining the results of the agitated saline bubble study with a comprehensive clinical evaluation. It underscores that the ASB should not be used in isolation but as part of a broader diagnostic strategy.
Limitations of the Agitated Saline Bubble Study
While the agitated saline bubble study serves as a valuable tool, it has its limitations. Its sensitivity and specificity are not as high as those of a CTPA. False-negative results can occur, particularly in smaller emboli or when the shunt is small. Conversely, false-positive results can also occur due to various factors, including congenital heart defects or other conditions causing right-to-left shunts. The interpretation of the agitated saline bubble study results requires significant expertise and clinical judgment.
The Agitated Saline Bubble Study in the Modern Era
Despite advancements in imaging technology, such as multi-detector CTPA, the agitated saline bubble study maintains a niche role in specific clinical situations. It remains a cost-effective, readily available, and relatively non-invasive alternative, particularly in settings with limited resources or contraindications to CTPA. Furthermore, ongoing research is exploring the potential of using contrast-enhanced echocardiography, using microbubbles that allow us to obtain more detailed images of the pulmonary circulation.
The agitated saline bubble study continues to evolve. Researchers are working on improving its sensitivity and specificity through refinements in the technique and interpretation, incorporating new technologies, and integrating more sophisticated ultrasound equipment.
Conclusion
The agitated saline bubble study remains a valuable diagnostic tool in the evaluation of suspected pulmonary embolism. While it possesses limitations and should not replace more definitive tests like CTPA when feasible, its simplicity, availability, and cost-effectiveness make it a crucial part of the diagnostic arsenal, especially in resource-constrained settings or when other tests are contraindicated. The continued refinement of the technique and its integration with other diagnostic modalities promises to further enhance its role in improving the diagnosis and management of pulmonary embolism.
FAQs:
1. What is the sensitivity and specificity of the agitated saline bubble study? The sensitivity and specificity vary depending on the study population and the experience of the interpreter, but generally are lower than CTPA.
2. Is the agitated saline bubble study painful? No, the procedure is generally painless. The injection of saline is minimally uncomfortable.
3. How long does an agitated saline bubble study take? The entire procedure, including preparation and interpretation, typically takes less than 15 minutes.
4. What are the contraindications to the agitated saline bubble study? There are few absolute contraindications, but the presence of severe right-sided heart failure or severe bleeding tendencies may present challenges.
5. What are the potential risks associated with the agitated saline bubble study? The risks are generally minimal, although there is a small chance of allergic reaction to the saline solution.
6. Can the agitated saline bubble study be used in children? Yes, the ASB study can be adapted for use in children, albeit with modifications in technique and interpretation.
7. What is the role of the agitated saline bubble study in the diagnosis of deep vein thrombosis (DVT)? The ASB study primarily assesses for pulmonary embolism, not directly for DVT.
8. How is the agitated saline bubble study interpreted? The appearance of microbubbles in the left side of the heart within a certain timeframe after injection indicates a likely right-to-left shunt suggestive of a PE.
9. Is the agitated saline bubble study covered by insurance? Generally, yes, provided it is medically necessary and ordered by a physician.
Related Articles:
1. "Advanced Echocardiographic Techniques in the Diagnosis of Pulmonary Embolism": This article discusses the role of advanced echocardiography, including the agitated saline bubble study, in diagnosing PE.
2. "Cost-Effectiveness of the Agitated Saline Bubble Study Compared to CTPA": This study compares the cost-effectiveness of the ASB to CTPA in various clinical settings.
3. "Improving the Sensitivity and Specificity of the Agitated Saline Bubble Study": This article explores research aimed at enhancing the accuracy of the ASB study.
4. "The Role of the Agitated Saline Bubble Study in Resource-Limited Settings": This article focuses on the application of the ASB in areas with limited access to advanced imaging.
5. "Clinical Pearls in the Interpretation of the Agitated Saline Bubble Study": This article provides practical tips for interpreting ASB results accurately.
6. "Comparative Study of Agitated Saline Bubble Study and D-dimer in the Diagnosis of PE": This article compares the performance of ASB to D-dimer testing in diagnosing PE.
7. "The Impact of the Agitated Saline Bubble Study on Patient Outcomes in PE": This study assesses the impact of early diagnosis using the ASB on patient outcomes.
8. "False-Positive and False-Negative Results in Agitated Saline Bubble Study: A Review of Cases": This review examines factors that contribute to inaccurate ASB results.
9. "Integration of Agitated Saline Bubble Study with Clinical Probability Scores in PE Diagnosis": This article explores the combined use of ASB and clinical probability scores in making a PE diagnosis.
| agitated saline bubble study: Contrast Echocardiography Richard S. Meltzer, J.R. Roelandt, 2012-12-06 Why a book on contrast echocardiography? Over the past dozen years enough experience has accumulated to warrant a more extensive treatment of this method. Furthermore, there are new developments that suggest increased clinical utility for contrast echocardiography in the future. This book aims to summarize the state of the art for those interested in echocardiography - presumably mainly cardiologists, but here and there those of a more technical bent will find useful information as well. We feel that a more basic understanding of microbubble dynamics is necessary to advance research for such applications as transmission through the lungs, videodensitometric quantitation of cardiac output, intracardiac shunts, etc. All of these topics are extensively dealt with. The reader will note that many of the clinical chapters are written by pediatric cardiologists. This is only natural, since shunt detection and analysis of flow relationships are relatively more important in congenital heart diseases, and cur rently represent the most important uses for contrast echo cardiography in day-to day practice. |
| agitated saline bubble study: Echocardiography in ICU Michel Slama, 2020-05-28 This book offers readers a better understanding of how to perform echocardiography in their daily intensive care unit (ICU) work. With numerous practical examples highlighting the indices and hemodynamic monitoring profiles that physicians could encounter, it considers echocardiography not merely as a simple imaging technique, but as a practical diagnostic and hemodynamic monitoring tool. The booklet is richly illustrated with figures explaining how to perform echo, and includes numerous tables, simple equations and normal and abnormal values. Echocardiography in ICU, a pocket guide written by the leading international experts in the field, is an excellent source of information and guidance for all residents and physicians working in ICU, emergency medicine, anesthesia and cardiology as well. |
| agitated saline bubble study: Common Pitfalls in Cerebrovascular Disease José Biller, José M. Ferro, 2015-07-09 Clinical case studies have long been recognized as a useful adjunct to problem-based learning and continuing professional development. They emphasize the need for clinical reasoning, integrative thinking, problem-solving, communication, teamwork and self-directed learning – all desirable generic skills for health care professionals. This book is a teaching tool that bridges the gap between textbook information and everyday experience of clinicians 'in the trenches'. Leading practitioners bring a practical approach to these complex conditions, highlighting specific areas of diagnostic uncertainty in evaluation and treatment. Each case is taken from real-world clinical practice and reviews the diagnostic and treatment process in a systematic manner, identifying common challenges and potential pitfalls. This concise and useful guide in the Common Pitfalls series provides a step-by-step guide for everyday clinical practice, invaluable to anyone dealing with cerebrovascular disease on a front-line basis. The intended readership is trainees and non-specialist practitioners in neurology, stroke medicine, and neurosurgery. |
| agitated saline bubble study: Intracardiac Echocardiography Frank E. Silvestry, Susan E. Wiegers, 2021-09-02 Intracardiac Echocardiography is the first echocardiographic textbook of its kind to specifically cover ICE. Discussing all aspects of intracardiac ultrasound, it allows readers to perfect ICE image acquisition and helps to guide interpretation of this information during interventional and electrophysiologic procedures. Unique and informative, the text explores: introductory echo physics currently available intracardiac ultrasound systems basic image acquisition the role of ICE in both the interventional and electrophysiology laboratory, as well as in the diagnostic setting. Featuring expert commentary by leaders in the field, the book also includes high quality echocardiographic images illustrating how ICE is used in a wide variety of procedures such as transseptal catheterization, PFO and ASD closure, atrial fibrillation ablation procedures, and many others. |
| agitated saline bubble study: Echocardiographic Atlas of Adult Congenital Heart Disease Hakimeh Sadeghian, Zahra Savand-Roomi, 2015-05-20 This atlas of echocardiography presents more than 100 cases of adult congenital heart disease, from diagnosis to treatment follow-up. The coverage is broad, encompassing atrial and ventricular septal defects, patent ductus arteriosus, cyanotic adult congenital heart disease, and numerous other anomalies, as well as findings on fetal echocardiography. For each disease, all echocardiographic images and views which proved of diagnostic value are arranged sequentially, with inclusion of transesophageal echocardiographic images whenever appropriate. Additional pertinent information is provided relating to diagnosis and treatment, and key teaching points are highlighted. The superb quality of the illustrations and the range of cases considered (including many rare ones) ensure that this atlas will be of great value for cardiology residents and fellows and highly relevant to day-to-day practice. |
| agitated saline bubble study: Essential Echocardiography Timothy M. Maus, Christopher R. Tainter, 2022-01-24 Building on the success of the previous edition, this review book includes all of the original content plus several new chapters dedicated to the education and implementation of transthoracic echocardiography and point-of-care ultrasonography. Chapters feature board review-style questions and answers to assist readers with board exam preparation. This book also includes the most up-to-date echocardiography content and practice guidelines. This book fills an educational gap in the perioperative and critical care echocardiography landscape. It addresses essential perioperative and critical care echocardiography topics in an accessible manner for those who provide acute care and resuscitation in any environment, including the operating room, intensive care unit, and the emergency department. Essential Echocardiography, 2nd edition, is expertly written for the practitioner with limited knowledge of echocardiography preparing for either the Examination of Special Competence in Basic Perioperative TEE (Basic PTEeXAM) or the Examination of Special Competence in Critical Care Echocardiography (CCEeXAM). |
| agitated saline bubble study: ASE’s Comprehensive Echocardiography Steven A Goldstein, Itzhak Kronzon, Bijoy K Khandheria, Victor Mor-Avi, 2015-01-08 Written and endorsed by world experts from the American Society of Echocardiography (ASE), this unique multimedia resource uses text, case studies, and online components to cover the latest uses of echocardiography, including the most recent 2D and 3D advances. Unlike other existing textbooks in echocardiography, including the predecessor of this volume, entitled Dynamic Echocardiography, this 2nd edition, with its new title, covers a full range of topics, reflected in its 200 chapters that include essential material in a succinct format. Dr. Roberto M. Lang and his expert colleagues provide everything you need to assess cardiac anatomy and function and obtain clinically useful, noninvasive information for more accurate diagnosis and evaluation of heart disease. Tap into the knowledge and skills of a team of experts from the ASE, led by world-renowned authorities in echocardiography. Consult this title on your favorite e-reader. Get fully up to date with the latest echo practice guidelines and advanced technologies, including 3D echocardiography and myocardial strain. Gain a better understanding of the latest methods to assess cardiac chamber size and function, valvular stenosis/regurgitation, cardiomyopathies, coronary artery disease, complications of myocardial infarction, and much more – all in a practical, well-illustrated brief yet comprehensive format extensively supported by multimedia material. Stay up to date with hot topics in this rapidly evolving field: interventional/intraoperative echocardiography, transesophageal echocardiography, cardiac resynchronization therapy, and more. |
| agitated saline bubble study: Ferri's Clinical Advisor 2021 Fred F. Ferri, 2020-06-10 Find fast answers to inform your daily diagnosis and treatment decisions! Ferri’s Clinical Advisor 2021 uses the popular 5 books in 1 format to deliver vast amounts of information in a clinically relevant, user-friendly manner. This bestselling reference has been significantly updated to provide you with easy access to answers on 1,000 common medical conditions, including diseases and disorders, differential diagnoses, clinical algorithms, laboratory tests, and clinical practice guidelines—all carefully reviewed by experts in key clinical fields. Extensive algorithms, along with hundreds of new figures and tables, ensure that you stay current with today's medical practice. Contains significant updates throughout, covering all aspects of current diagnosis and treatment. Features 27 all-new topics including chronic rhinosinusitis, subclinical brain infarction, reflux-cough syndrome, radiation pneumonitis, catatonia, end-stage renal disease, and genitourinary syndrome of menopause, among others. Includes new appendices covering common herbs in integrated medicine and herbal activities against pain and chronic diseases; palliative care; and preoperative evaluation. Offers online access to Patient Teaching Guides in both English and Spanish. |
| agitated saline bubble study: Patent Foramen Ovale Zahid Amin, Jonathan M. Tobis, Horst Sievert, John D. Carroll, 2014-12-03 This book is the ultimate reference on patent foramen ovale (PFO), a defect in the septum of the heart estimated to be present in more than twenty percent of the adult population and a proven cause of systemic embolism. All chapters have been written by internationally recognized experts in the field and cover PFO genetics and anatomy in addition to the effect PFO can have on various different organs and its supposed involvement in several conditions and clinical syndromes such as migraine, diving incidence, platynea orthodeoxia, economy class syndrome, sleep apnea and persistent desaturations in mild right ventricular dysfunction. As PFO anatomy varies significantly between individuals, chapters have also been included on the diagnostic tools, methods and techniques for appropriate assessment, detection and characterization of PFO. Furthermore, the multitude of available closure devices and techniques for PFO closure are discussed together with current and ongoing trial data. The book concludes with guidance and instruction on establishing a successful PFO program. Patent Foramen Ovale will be an essential text for the whole adult and pediatric interventional community, general cardiologists, internists, primary care physicians, neurologists and device companies in addition to medical students, graduate students and fellows in training. |
| agitated saline bubble study: Essential Clinical Anesthesia Charles Vacanti, Scott Segal, Pankaj Sikka, Richard Urman, 2011-07-11 The clinical practice of anesthesia has undergone many advances in the past few years, making this the perfect time for a new state-of-the-art anesthesia textbook for practitioners and trainees. The goal of this book is to provide a modern, clinically focused textbook giving rapid access to comprehensive, succinct knowledge from experts in the field. All clinical topics of relevance to anesthesiology are organized into 29 sections consisting of more than 180 chapters. The print version contains 166 chapters that cover all of the essential clinical topics, while an additional 17 chapters on subjects of interest to the more advanced practitioner can be freely accessed at www.cambridge.org/vacanti. Newer techniques such as ultrasound nerve blocks, robotic surgery and transesophageal echocardiography are included, and numerous illustrations and tables assist the reader in rapidly assimilating key information. This authoritative text is edited by distinguished Harvard Medical School faculty, with contributors from many of the leading academic anesthesiology departments in the United States and an introduction from Dr S. R. Mallampati. This book is your essential companion when preparing for board review and recertification exams and in your daily clinical practice. |
| agitated saline bubble study: Interesting Cases in Echocardiography Navin C Nanda, 2017-07-17 This comprehensive text is a compilation of more than 250 clinical cases and 800 video clips from echocardiographers and cardiologists all over the world. Divided into eleven sections, cases cover all functions of the heart and associated disorders and infections. Most cases are presented in a uniform format, detailing patient history, clinical findings, echocardiographic images and video clips, one or more multiple choice questions with answers, followed by general discussion on the topic. The majority of cases have an emphasis in echocardiography, with some drawing comparisons with other techniques, predominantly magnetic resonance imaging (MRI) and computed tomographic (CT) scans. Edited by internationally recognised expert Navin C Nanda from University of Alabama, this book features nearly 600 images and a DVD ROM providing echocardiographic video clips. Key Points Compilation of more than 250 echocardiographic cases and 800 video clips Each case presented in uniform format with multiple choice questions and answers Edited by internationally recognised expert form University of Alabama Includes nearly 600 images and a DVD ROM |
| agitated saline bubble study: 3D Echocardiography Takahiro Shiota, 2020-12-29 Since the publication of the second edition of this volume, 3D echocardiography has penetrated the clinical arena and become an indispensable tool for patient care. The previous edition, which was highly commended at the British Medical Book Awards, has been updated with recent publications and improved images. This third edition has added important new topics such as 3D Printing, Surgical and Transcatheter Management, Artificial Valves, and Infective Endocarditis. The book begins by describing the principles of 3D echocardiography, then proceeds to discuss its application to the imaging of • Left and Right Ventricle, Stress Echocardiography • Left Atrium, Hypertrophic Cardiomyopathy • Mitral Regurgitation with Surgical and Nonsurgical Procedures • Mitral Stenosis and Percutaneous Mitral Valvuloplasty • Aortic Stenosis with TAVI / TAVR • Aortic and Tricuspid Regurgitation • Adult Congenital Heart Disease, Aorta • Speckle Tracking, Cardiac Masses, Atrial Fibrillation KEY FEATURES In-depth clinical experiences of the use of 3D/2D echo by world experts Latest findings to demonstrate clinical values of 3D over 2D echo One-click view of 263 innovative videos and 352 high-resolution 3D/2D color images in a supplemental eBook. |
| agitated saline bubble study: Handbook of Inpatient Cardiology Bryan J. Wells, Pablo A. Quintero, Geoffrey Southmayd, 2020-07-22 This book serves as a pocket-sized resource to aid with the diagnosis and management of cardiovascular disease in the inpatient setting. Containing up-to-date information from guidelines and clinical trials, this book is the only handbook-style reference on cardiac care designed specifically for the hospitalist. The first section of the book covers cardiac pathology with an emphasis on evidence-based and guideline-based approaches to patient care. Each chapter focuses on a specific cardiovascular disease state such as acute coronary syndrome, atrial fibrillation, pulmonary hypertension, and aortic disease. The second section examines the differential diagnoses and recommended workup for common cardiac chief complaints including chest pain, palpitations, syncope, and dyspnea. The third and final section discusses indications and interpretation of commonly used cardiac procedures and imaging modalities. This book provides a concise review over a broad range of cardiovascular disease states in an accessible handbook-style to aid with the care of these patients. The Handbook of Inpatient Cardiology is an essential resource for physician hospitalists caring for cardiac patients on the medical ward in addition to cardiology physicians and trainees, affiliate providers, and students. |
| agitated saline bubble study: Cardiac Catheterization for Congenital Heart Disease Gianfranco Butera, Massimo Chessa, Andreas Eicken, John Thomson, 2021-07-22 The second edition of this handbook is an up-to-date guide to the application of catheter-based interventions across the entire age range of congenital heart disease patients, from fetal life through to adulthood. It considers the changes and improvements that have occurred during the last few years in terms of new procedures, new tools and devices (in particular in the field of valves), new imaging and pre-procedural strategies, such as 3D-printing, 3D- rotational angiography and fusion imaging. It provides readers with clear instructions on techniques for vascular access, valve dilatation, angioplasty, stent implantation, defect closure, defect creation, pulmonary valve implantation and on the hybrid approach, as well as on various other procedures. As in the first edition, topics are approached using a step-by-step format, ensuring that readers can immediately access the information relevant to their daily practice. Numerous explanatory figures and drawings are included in each chapter in order to further clarify how to plan, perform and evaluate diagnostic and interventional procedures in the field of congenital heart disease. It also highlights important tips and tricks that will assist health operators in achieving optimal outcomes, and includes an appendix with additional general equations and BSA, and oxygen consumption charts. This practical guide will be a valuable resource for surgeons and cardiologists in their daily clinical practice. |
| agitated saline bubble study: Manual of Neurosonology László Csiba, Claudio Baracchini, 2016-04-28 Neurosonology is non-invasive, portable, and has excellent temporal resolution, making it a valuable and increasingly popular tool for the diagnosis and monitoring of neurological conditions when compared to other imaging techniques. This guide looks beyond the use of neurovascular ultrasound in stroke to encompass a wide range of other neurological diseases and emergencies. It offers a practical approach to the examination of patients, interpretation of ultrasound studies, and the application of neurosonology to the development of management and treatment strategies. Each chapter incorporates a thorough and clear procedural methodology alongside scanning tips for trainees; this step-by-step approach is further enhanced by example images and focused diagnostic questions. Authored and edited by international experts, this practical manual of neurosonology is an invaluable resource for neurologists, neurosurgeons, intensivists, radiologists, and ultrasonographers. |
| agitated saline bubble study: Cardiac Surgery Shahzad G. Raja, 2020-02-11 This textbook provides a succinct overview of cardiac surgery, with key concepts being emphasized throughout. An abundance of illustrations, intra-operative photographs, tables as well as information boxes, aids the reader to visualise, grasp and retain difficult concepts. The inclusion of evidence-based approaches to the management of a range of cardiac surgical conditions equips the reader with an understanding of how to overcome a variety of potentially tough clinical challenges. Concise Cardiac Surgery: A Complete Guide comprehensively covers a range of techniques used in cardiac surgery. It is therefore, an ideal resource for the trainee and practising cardiac surgeon seeking a practically focused text detailing how to apply the latest techniques and evidence-based approaches in their day-to-day practice. |
| agitated saline bubble study: Pediatric Liver Intensive Care Naresh Shanmugam, Anil Dhawan, 2018-09-28 Acute management of children with liver disease and liver transplantation has rapidly evolved over the last two decades due to worldwide availability of complex liver surgery and liver transplantation. This book edited by Prof Dhawan and Dr Shanmugam, who have hands on experience in managing children with complex liver disease, its complications and liver transplant recepients, provides to a very practical approach to all the team members involved in paediatric transplantation like ; Hepatologists, anaesthetists, surgeons, intensivists, transplant coordinators, nurses and trainees at all levels and specialities. Topics covered include management of common liver problems, liver based metabolic disorders and peri-operative care protocols in paediatric liver transplantation. It also provides up to date information on drug dosage and infusion calculations for common drugs used in liver disease. |
| agitated saline bubble study: Magnetic Resonance Procedures Frank G. Shellock, 2000-12-21 Magnetic Resonance Procedures: Health Effects and Safety is the first authoritative text on MR procedures and its associated health and safety concerns written by noted radiologists, physicists, and scientists with expertise in the field. It contains both theoretical and practical information. This timely text discusses emergent issues rela |
| agitated saline bubble study: Process Engineering and Industrial Management Jean-Pierre Dal Pont, 2013-03-04 Process Engineering, the science and art of transforming raw materials and energy into a vast array of commercial materials, was conceived at the end of the 19th Century. Its history in the role of the Process Industries has been quite honorable, and techniques and products have contributed to improve health, welfare and quality of life. Today, industrial enterprises, which are still a major source of wealth, have to deal with new challenges in a global world. They need to reconsider their strategy taking into account environmental constraints, social requirements, profit, competition, and resource depletion. “Systems thinking” is a prerequisite from process development at the lab level to good project management. New manufacturing concepts have to be considered, taking into account LCA, supply chain management, recycling, plant flexibility, continuous development, process intensification and innovation. This book combines experience from academia and industry in the field of industrialization, i.e. in all processes involved in the conversion of research into successful operations. Enterprises are facing major challenges in a world of fierce competition and globalization. Process engineering techniques provide Process Industries with the necessary tools to cope with these issues. The chapters of this book give a new approach to the management of technology, projects and manufacturing. Contents Part 1: The Company as of Today 1. The Industrial Company: its Purpose, History, Context, and its Tomorrow?, Jean-Pierre Dal Pont. 2. The Two Modes of Operation of the Company – Operational and Entrepreneurial, Jean-Pierre Dal Pont. 3. The Strategic Management of the Company: Industrial Aspects, Jean-Pierre Dal Pont. Part 2: Process Development and Industrialization 4. Chemical Engineering and Process Engineering, Jean-Pierre Dal Pont. 5. Foundations of Process Industrialization, Jean-François Joly. 6. The Industrialization Process: Preliminary Projects, Jean-Pierre Dal Pont and Michel Royer. 7. Lifecycle Analysis and Eco-Design: Innovation Tools for Sustainable Industrial Chemistry, Sylvain Caillol. 8. Methods for Design and Evaluation of Sustainable Processes and Industrial Systems, Catherine Azzaro-Pantel. 9. Project Management Techniques: Engineering, Jean-Pierre Dal Pont. Part 3: The Necessary Adaptation of the Company for the Future 10. Japanese Methods, Jean-Pierre Dal Pont. 11. Innovation in Chemical Engineering Industries, Oliver Potier and Mauricio Camargo. 12. The Place of Intensified Processes in the Plant of the Future, Laurent Falk. 13. Change Management, Jean-Pierre Dal Pont. 14. The Plant of the Future, Jean-Pierre Dal Pont. |
| agitated saline bubble study: Basic Transesophageal and Critical Care Ultrasound André Denault, Annette Vegas, Yoan Lamarche, Jean-Claude Tardif, Pierre Couture, 2017-08-03 Basic Transesophageal and Critical Care Ultrasound provides an overview of transesophageal ultrasound of the heart, lung, and upper abdomen as well as basic ultrasound of the brain, lung, heart, abdomen, and vascular system. Ultrasound-guided procedures commonly used in critically ill patients are also covered. With more than 400 clinical images, this well-illustrated text and its accompanying videos demonstrate new developments and challenges for those interested in mastering basic transesophageal echocardiography (TEE) and bedside surface ultrasound. Each chapter is presented in an easy-to-read format that includes color diagrams and ultrasound images which optimize interactive learning for both novice and experienced clinicians. The book is divided into two parts. The first is dedicated to basic TEE while the second provides focused coverage of bedside ultrasound. The book also includes chapters on extra-cardiac TEE and ultrasound of the brain—unconventional areas that will become more important in the future as clinicians evaluate not only the etiology of hemodynamic instability but also the impact on multiple organs and systems such as the kidney, liver, splanchnic perfusion, and brain. This text is an invaluable resource to those preparing for the National Board of Echocardiography’s Examination of Special Competence in Basic Perioperative Transesophageal Echocardiography (PTEeXAM) and its equivalents outside the USA and Canada. In addition, it prepares physicians for the American College of Chest Physician’s critical care ultrasound certification. The contents follow the syllabus of the TEE basic echo exam to ensure complete coverage of a trainee's requirements. It also includes sample questions and two helpful mock exams. Written by a multidisciplinary team of experts in TEE, the book is a must-have for those in training and in practice. |
| agitated saline bubble study: The Echo Manual Jae K. Oh, James B. Seward, A. Jamil Tajik, 2006 Thoroughly updated for its Third Edition, this best-selling manual is a practical guide to the performance, interpretation, and clinical applications of echocardiography. The Echo Manual is written by recognized authorities at the Mayo Clinic and provides a concise, user-friendly summary of techniques, diagnostic criteria, and quantitative methods for both echocardiography and Doppler echocardiography. Discussion of each clinical problem also includes transesophageal echocardiography. This edition covers the latest techniques, standards, and applications and includes new contrast agents. All references have been updated. More than 900 images—well annotated and true to gray scale and color—give readers an immediate grasp of salient points. |
| agitated saline bubble study: Illustrated Guide to Cardiovascular Disease Glenn N Levine, 2016-02-12 Illustrated Guide to Cardiovascular Disease is an extensive and highly visual guide, encompassing the full spectrum of cardiovascular diseases, along with cardiac anatomy and physiology. This book is divided into 58 chapters across seven sections. Each section covers a different disease or group of heart diseases, including coronary artery disease, heart failure and cardiomyopathy, valvular heart disease, pericardial disease, congenital heart disease, cardiac arrhythmias, peripheral vascular disease, and a final section on miscellaneous cardiovascular diseases. Each chapter features detailed discussion on common and uncommon conditions and their pathology, with the latest therapies in cardiology and European and American guidelines highlighted throughout the book. More than 1700 full colour images, illustrations, figures, flow charts and tables enhance Illustrated Guide to Cardiovascular Disease, an invaluable resource for all cardiologists. Extensive illustrated guide to a vast range of cardiovascular diseases Seven sections covering specific diseases and groups of diseases 1700 images in full colour Edited by Glenn N Levine, Director of the Michael E DeBakey Medical Centre in Houston, Texas |
| agitated saline bubble study: Ultrasound Imaging and Therapy Aaron Fenster, James C. Lacefield, 2015-05-08 Up-to-Date Details on Using Ultrasound Imaging to Help Diagnose Various DiseasesDue to improvements in image quality and the reduced cost of advanced features, ultrasound imaging is playing a greater role in the diagnosis and image-guided intervention of a wide range of diseases. Ultrasound Imaging and Therapy highlights the latest advances in usin |
| agitated saline bubble study: The Washington Manual of Echocardiography Ravi Rasalingam, Majesh Makan, Julio E. Pérez, 2012-06-28 Supervised and edited by faculty from the Washington University School of Medicine, The Washington Manual of Echocardiography provides quick insight into the successful performance and interpretation of echocardiographic images. Ideal for today’s cardiology fellow, this outstanding reference is both sufficiently comprehensive to guide users through training, and accessible enough as a quick consult for general physicians who are interested in echocardiography. Your keys to excellence in cardiac echo... • Tips and pearls from cardiologists and sonographers offer guidance on proper set-up, correct transduction technique, and image optimization • Easy-to-navigate sections address diagnostic markers of valvular heart disease, cardiomyopathies, and congenital anomalies, as well as applications of trans-esophageal echocardiography • Abundant high-quality images enhance visual learning and improve diagnostic accuracy • Succinct yet comprehensive descriptions present critical pieces of information on key areas of echocardiography and Doppler techniques • Free online companion website with hundreds of echo clips in addition to the full text for you to access anytime, anywhere |
| agitated saline bubble study: Three-dimensional Echocardiography Navin Chandar Nanda, Roberto M. Lang, 2007 |
| agitated saline bubble study: Patent Foramen Ovale Closure for Stroke, Myocardial Infarction, Peripheral Embolism, Migraine, and Hypoxemia M. Khalid Mojadidi, Bernhard Meier, Jonathan M. Tobis, 2019-08-23 Patent Foramen Ovale (PFO) Closure for Stroke, Myocardial Infarction, Peripheral Embolism, Migraine, and Hypoxemia is a complete reference covering the association between PFO and numerous medical conditions. It provides a background on the topic including embryology, anatomy, and physiology. This book fully examines the diagnosis and imaging assessment of PFO and discusses the data linking PFO to various clinical pathologies. It details technical aspects of PFO closure and includes perspectives on future outlooks and where the field is headed in terms of device closure indications. This is a complete reference book for cardiologists, interventional cardiologists, neurologists, pulmonologists, general practitioners, medical professionals, and researchers who are interested in PFO-associated pathologies, technical aspects, safety, and future outlooks of PFO device closure. - Explains the association between PFO and related clinical conditions including stroke, myocardial infarction, peripheral embolism, migraine, hypoxemia, decompression sickness, Raynaud's phenomenon, and vasospasm - Provides an in-depth analysis of the evidence behind PFO closure for various clinical conditions - Expounds on the technical aspects of PFO closure including differences between devices and techniques - Offers future outlooks on PFO closure and where the field is headed in terms of PFO closure indications |
| agitated saline bubble study: Perioperative Transesophageal Echocardiography E-Book David L. Reich, Gregory Fischer, 2013-09-18 From basic concepts to state-of-the-art techniques, Perioperative Transesophageal Echocardiography: A Companion to Kaplan's Cardiac Anesthesia helps you master everything you need to know to effectively diagnose and monitor your cardiothoracic surgery patients. Comprehensive coverage and unsurpassed visual guidance make this companion to Kaplans Cardiac Anesthesia a must for anesthesiologists, surgeons, and nurse anesthetists who need to be proficient in anesthesia care. a powerful learning tool. Reviewed by: JH Rosser and GH Mills, Sheffield on behalf of British Journal of Anaesthesia, December 2015 - Recognize the Transesophageal Echocardiography (TEE) images you see in practice by comparing them to abundant 2D and 3D images, as well as an extensive online library of moving (cine) images. - Learn from acknowledged leaders in the field of cardiac anesthesiology - Drs. David L. Reich and Gregory W. Fischer. - See how to address specific clinical situations with detailed case studies and discussions of challenging issues. - Access the complete contents and videos online at Expert Consult. |
| agitated saline bubble study: Pulmonary Gas Exchange G. Kim Prisk, Susan R. Hopkins, 2013-08-01 The lung receives the entire cardiac output from the right heart and must load oxygen onto and unload carbon dioxide from perfusing blood in the correct amounts to meet the metabolic needs of the body. It does so through the process of passive diffusion. Effective diffusion is accomplished by intricate parallel structures of airways and blood vessels designed to bring ventilation and perfusion together in an appropriate ratio in the same place and at the same time. Gas exchange is determined by the ventilation-perfusion ratio in each of the gas exchange units of the lung. In the normal lung ventilation and perfusion are well matched, and the ventilation-perfusion ratio is remarkably uniform among lung units, such that the partial pressure of oxygen in the blood leaving the pulmonary capillaries is less than 10 Torr lower than that in the alveolar space. In disease, the disruption to ventilation-perfusion matching and to diffusional transport may result in inefficient gas exchange and arterial hypoxemia. This volume covers the basics of pulmonary gas exchange, providing a central understanding of the processes involved, the interactions between the components upon which gas exchange depends, and basic equations of the process. |
| agitated saline bubble study: Pulmonary Vascular Disorders Marc Humbert, R. Souza, Gérald Simonneau, 2012 An excellent overview of recent advances in diagnosis, classification and treatment The pulmonary circulation is by nature difficult to evaluate for the clinician and a challenge to investigate by radiographic and hemodynamic methods. In recent years, the field has been revolutionized by major improvements in diagnostic approaches and therapies. Tools for the classification, diagnosis, and management of pulmonary embolism and pulmonary hypertension have been developed and optimized, providing clinicians with detailed and updated guidelines. This volume provides the latest information on the fast-growing and challenging field of acute and chronic pulmonary vascular disorders from some of the field's major leaders in research, education, and care. The topics discussed are relevant to chest physicians, thoracic surgeons, nurses, students, and teachers, and a well-balanced mix of contributions ensures that doctors, clinicians, and institutions from all around the world will find the information presented to be both informative and useful to their situations. |
| agitated saline bubble study: Conversations on Chemistry Jane Haldimand Marcet, 2010-10-31 Bright, humorous and engaging, Marcet's best-selling 1805 book was designed to introduce women to scientific ideas. |
| agitated saline bubble study: Transesophageal Echocardiography Multimedia Manual André Denault, Pierre Couture, Annette Vegas, Jean Buithieu, Jean-Claude Tardif, 2016-04-19 This second edition of the Transesophageal Echocardiography Multimedia Manual is a comprehensive resource and essential guide to the rapidly expanding field of perioperative transesophageal echocardiography (TEE), encompassing newer cardiac surgery techniques, more diverse surgical procedures, and use in the intensive care unit. With over 900 figur |
| agitated saline bubble study: A Guide to the Preventive Conservation of Photograph Collections Bertrand Lavédrine, 2003 A resource for the photographic conservator, conservation scientist, curator, as well as professional collector, this volume synthesizes both the masses of research that has been completed to date and the international standards that have been established on the subject. |
| agitated saline bubble study: Structural Heart Disease Interventions John D. Carroll, John G. Webb, 2012-11-05 Structural heart disease interventions are a diverse group of novel treatments that have evolved from a small number of procedures to an impressive array of new approaches to diseases that have been traditionally managed by surgery and medical therapy. This book has been prepared for use by physicians and non-physicians who have an interest in SHD interventions and desire a practical, comprehensive, and clinical summary of established and emerging percutaneous interventions. The chapters are authored by recognized experts from around the world. There are five major sections including: 1) Core Knowledge in SHD Intervention 2) Specialized Skills for the Interventionalist 3) Closure of Congenital and Acquired Defects in Adults 4) Transcatheter Therapy for Valvular Disease 5) Specialized Procedures Features Include: Extensive images to present anatomical complexities and diversity including some interactive 3-D graphics Presentation of transcatheter mitral valve repair Chapter on how to set up & credential a SHD program |
| agitated saline bubble study: How to Get Filthy Rich in Rising Asia Mohsin Hamid, 2013-03-05 Mr. Hamid reaffirms his place as one of his generation's most inventive and gifted writers. –Michiko Kakutani, The New York Times A globalized version of The Great Gatsby . . . [Hamid's] book is nearly that good. –Alan Cheuse, NPR Marvelous and moving. –TIME Magazine From the internationally bestselling author of The Reluctant Fundamentalist and Exit West, the boldly imagined tale of a poor boy’s quest for wealth and love His first two novels established Mohsin Hamid as a radically inventive storyteller with his finger on the world’s pulse. How to Get Filthy Rich in Rising Asia meets that reputation—and exceeds it. The astonishing and riveting tale of a man’s journey from impoverished rural boy to corporate tycoon, it steals its shape from the business self-help books devoured by ambitious youths all over “rising Asia.” It follows its nameless hero to the sprawling metropolis where he begins to amass an empire built on that most fluid, and increasingly scarce, of goods: water. Yet his heart remains set on something else, on the pretty girl whose star rises along with his, their paths crossing and recrossing, a lifelong affair sparked and snuffed and sparked again by the forces that careen their fates along. How to Get Filthy Rich in Rising Asia is a striking slice of contemporary life at a time of crushing upheaval. Romantic without being sentimental, political without being didactic, and spiritual without being religious, it brings an unflinching gaze to the violence and hope it depicts. And it creates two unforgettable characters who find moments of transcendent intimacy in the midst of shattering change. |
| agitated saline bubble study: Transcranial Doppler Ultrasonography Viken L. Babikian, Lawrence R. Wechsler, 1999 The Second Edition of this highly regarded text provides a current reference source on the clinical and research applications of Transcranial Doppler (TCD) ultrasonography. All of the chapters have been updated to reflect the rapid evolution that has taken place in the field. New information has been included on the increased use of TCD in the operating room, the introduction of contrast media, and the development of new softwares that permit the detection of microemboli. |
| agitated saline bubble study: Stroke in Childhood Paediatric Stroke Working Group, 2004 Stroke occuring in childhood although less common, presents serious challenges. This guideline is based on the expertise of a multidisciplinary working group and include the views of patients, parents and families. |
| agitated saline bubble study: Handbook on Pressurized Irrigation Techniques Andreas Phocaides, Food and Agriculture Organization of the United Nations, 2007 Increasing the efficiency of water use and enhancing agricultural water productivity at all levels of the production chains are becoming priorities in a growing number of countries. In particular, shifting to modern on-farm irrigation practices can contribute to a substantial increase in both water use efficiency and water productivity. The objective of this handbook is to provide a practical guide on the use of pressurized irrigation techniques to farmers, irrigation technicians, and extension workers in the field. In this second edition, the handbook has been considerably revised, including new chapters on low-cost drip irrigation and pipe distribution systems for smallholders.--Publisher's description. |
| agitated saline bubble study: Nursing Care of Children Jean Weiler Ashwill, Susan Colvert Droske, 1997 This paediatric nursing text discusses the disorders most commonly encountered in both hospital and community care settings. It discusses anatomy, physiology, paediatric differences and common diagnostic tests and medications, enabling readers to associate systems and diseases with appropriate tests and medications. It provides nursing care plans for key disorders, a unit on growth and development, a summary of growth and development, and special considerations for caring for children. |
| agitated saline bubble study: History of Whiteside County, Illinois Charles Bent, 1877 |
| agitated saline bubble study: Pathology of Heart Disease in the Fetus, Infant and Child Michael T. Ashworth, 2019-08-22 Clearly presents the pathology of heart disease from fetus to adolescence, integrating histology and macroscopy with effects of treatment. |
AGITATED Definition & Meaning - Merriam-Webster
The meaning of AGITATED is troubled in mind : disturbed and upset. How to use agitated in a sentence.
AGITATED | English meaning - Cambridge Dictionary
AGITATED definition: 1. worried or angry: 2. worried or angry: 3. nervous because of worry or fear that is difficult…. …
AGITATED definition and meaning | Collins English Dict…
If someone is agitated, they are very worried or upset, and show this in their behaviour, movements, or voice. Susan seemed agitated about something. …
AGITATED Definition & Meaning | Dictionary.com
What does agitated mean? To feel agitated is to feel anxious, bothered, or worried.The verb agitate means to …
agitated adjective - Definition, pictures, pronunciation and u…
Definition of agitated adjective in Oxford Advanced Learner's Dictionary. Meaning, pronunciation, picture, example sentences, grammar, usage notes, …
AGITATED Definition & Meaning - Merriam-Webster
The meaning of AGITATED is troubled in mind : disturbed and upset. How to use agitated in a sentence.
AGITATED | English meaning - Cambridge Dictionary
AGITATED definition: 1. worried or angry: 2. worried or angry: 3. nervous because of worry or fear that is difficult…. Learn more.
AGITATED definition and meaning | Collins English Dictionary
If someone is agitated, they are very worried or upset, and show this in their behaviour, movements, or voice. Susan seemed agitated about something. The man in the house was in a …
AGITATED Definition & Meaning | Dictionary.com
What does agitated mean? To feel agitated is to feel anxious, bothered, or worried.The verb agitate means to make someone feel this way.It can also mean to shake something up, stir it …
agitated adjective - Definition, pictures, pronunciation and usage ...
Definition of agitated adjective in Oxford Advanced Learner's Dictionary. Meaning, pronunciation, picture, example sentences, grammar, usage notes, synonyms and more.
Agitated - definition of agitated by The Free Dictionary
1. To cause to move with violence or sudden force. 2. To upset; disturb: was agitated by the alarming news. 3. To arouse interest in (a cause, for example) by use of the written or spoken …
Agitated - Definition, Meaning & Synonyms | Vocabulary.com
Someone who is agitated is visibly upset. If you have ever walked into a room and instantly been asked, "What's wrong?" you probably looked agitated. The verb agitate means "to shake up."
AGITATED Synonyms: 249 Similar and Opposite Words - Merriam-Webster
Synonyms for AGITATED: excited, heated, upset, troubled, hectic, frenzied, hyperactive, overwrought; Antonyms of AGITATED: calm, collected, composed, undisturbed, unperturbed, …
AGITATE | English meaning - Cambridge Dictionary
AGITATE definition: 1. to make someone feel worried or angry: 2. to argue forcefully, especially in public, in order…. Learn more.
AGITATE Definition & Meaning | Dictionary.com
To agitate something is to shake it up, stir it up, or cause it to move around roughly, as in The storm agitated the water, stirring up huge waves. The noun agitation refers to the act or …
