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Each renal pyramid has a base situated at the boundary between the cortex and the medulla. The tip of the renal pyramid extends toward the middle of the kidney and is surrounded by a calyx. Calyces are extensions of the renal pelvis, which is the expanded finish of the ureter inside the renal sinus. The elements of a nephron are the renal corpuscle, the proximal convoluted tubule, the loop of Henle, and the distal convoluted tubule. The filtration membrane is fashioned by the glomerular capillaries, the basement membrane, and the podocytes of the Bowman capsule. The kidneys management blood quantity and blood pressure by regulating the amount of urine produced. The kidneys participate, with the pores and skin and liver, in regulating vitamin D synthesis. Efferent arterioles carry blood from the glomeruli to the peritubular capillaries. Each kidney is behind the peritoneum and surrounded by a renal capsule and adipose tissue. The renal filtrate passes from the glomerulus into the Bowman capsule and contains no blood cells and few blood proteins. Increased sympathetic activity decreases blood flow to the kidney, decreases filtrate formation, and reduces urine production. Water and the ions dissolved within the water are distributed within the intracellular and extracellular fluid compartments. Approximately one-third of the entire physique water is found exterior cells, mainly in interstitial fluid, blood plasma, and lymph. About 65% of the filtrate volume is reabsorbed within the proximal convoluted tubule, 15% is reabsorbed within the descending limb of the loop of Henle, and another 19% is reabsorbed in the distal convoluted tubule and accumulating duct. Exchange Between Body Fluid Compartments Water strikes continuously between compartments in response to hydrostatic strain variations and osmotic differences between the compartments. Tubular Secretion Hydrogen ions, some by-products of metabolism, and a few drugs are actively secreted into the nephron. Thirst Regulation the feeling of thirst will increase if extracellular fluid becomes more concentrated or if blood strain decreases. Atrial natriuretic hormone, secreted from the best atrium in response to increases in blood strain, acts on the kidney to enhance Na+ and water loss in the urine. Increased blood levels of K+ stimulate, and decreased blood levels of K+ inhibit, aldosterone secretion. Parathyroid hormone secreted from the parathyroid glands will increase extracellular Ca2+ ranges by causing bone resorption and increased Ca2+ uptake in the kidney. The ureters and urinary bladder are lined with transitional epithelium and have smooth muscle of their walls. Three principal classes of buffers in the body fluids resist changes within the pH: proteins, the phosphate buffer system, and the bicarbonate buffer system. Increased volume within the urinary bladder stretches its wall and activates the micturition reflex. Reduced somatic motor action potentials cause the exterior urinary sphincter to relax. Stretching of the urinary bladder stimulates sensory neurons that carry impulses to the brain and inform the mind of the necessity to urinate. Kidneys the kidneys excrete H+ in response to a lowering blood pH, and so they reabsorb H+ in response to an increasing blood pH. Describe the relationships of the renal pyramids, calyces, renal pelvis, and ureter. How do modifications in blood pressure within the glomerulus have an result on the volume of filtrate produced Where is atrial natriuretic hormone produced, and what effect does it have on urine manufacturing Explain how the respiratory system and the kidneys reply to modifications in the pH of physique fluids.

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Secondary care in Croatia is supplied by way of basic hospitals and university (clinical) hospitals. All scientific hospitals have vascular surgery divisions; major vascular injuries are transported and managed in medical hospitals. The system of hospital trauma care expects that the trauma surgeon (being obtainable 24 7 within the hospital) is the first on call when the injured affected person arrives. The vascular surgeon is all the time available on-call and if needed can assume administration of vascular damage. The management strategy typically requires pressing vascular reconstruction in the type of primary vessel repair or with using a conduit, ideally saphenous vein. Trauma surgical procedure coaching in Croatia consists of three months of vascular surgery education thus potentiating the trauma surgeon to manage vascular harm capably. The system of trauma care predicts that the trauma surgeon (being obtainable 24-7 within the hospital) is the primary to be contacted when the injured patient arrives. In this context, the trauma surgeon defines the primary management and diagnostic procedures. This vascular surgeon could simply consult on the case or may assume complete administration relying upon the complexity of the damage and the experience of the surgeon. In circumstances of concomitant injuries, a multidisciplinary team is assembled and is able to conduct simultaneous operations. The interaction and collaboration between vascular and trauma surgeons in Croatia is professional and is concentrated on the best plan of action for the injured patient. It is important to notice that in Croatia, endovascular therapy of vascular damage is very rarely indicated or carried out. Although a radiologist is on-call in the hospital 24 hours a day, this will not be an interventional radiologist. This research allows the trauma and vascular surgeons to examine the findings and to consult interventional radiology for additional imaging as essential. The difference between high-energy, wartime injuries and low-energy civilian wounds should also to be considered when selecting the kind of vascular restore and the kind of conduit. It is important to do not forget that, in some circumstances, ligation of the vessel and even main amputation is indicated as a fast harm control maneuver. In Croatia the problem of how best to improve the abilities of trainees in trauma surgical procedure can additionally be difficult by the declining number of open vascular reconstructions. Lackovic Z, Markeljevic J, Marusic M: Croatian drugs in 1991 war in opposition to Croatia: a preliminary report. Lovric Z, Wertheimer B, Candrlic K, et al: War accidents of major extremity vessels. Lovric Z, Wertheimer B, Candrlic K, et al: Reconstruction of the popliteal artery after struggle injury. Lovric Z, Lehner V, Wertheimer B, et al: Tourniquet occlusion technique for lower extremity artery reconstruction in warfare wound. Radoni V, Bari D, Petricevi A, et al: Military injuries to the popliteal vessels in Croatia. Strategies to Sustain and Train the Next Generation of Trauma Surgeons the training of surgeons in Croatia is currently being reformed. During the coaching, 2 years are spent in a "common trunk" of common surgery adopted by three years of training in one of a quantity of subspecialties, corresponding to trauma or orthopedic, belly, vascular, or cardiac. The common trunk training does involve 3 months of vascular surgical procedure schooling and thus potentiates the trauma surgeon, in addition to other surgical subspecialists, to be capable of diagnosing and managing vascular trauma. In addition, the laws in Croatia assist the trauma surgeon in performing an urgent vascular reconstruction. The solely limitations for these individuals in managing the spectrum of vascular trauma could additionally be these related to lack of present experience with this advanced injury sample. The first suture of an injured brachial artery was carried out by Halliwell as reported by Richard Lambert in a letter to William Hunter in 1759. The European Union has 28 member countries and has been a big organ for peace through the many years it has existed, however the historical past of Europe is that of strife, battle, and struggle. Cultural, religious, ethnic, political, and other differences have prevented any uniform tradition of medication from being accepted on the continent.

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When considering all patients who require cardiopulmonary bypass for repair of cardiac trauma these requiring its use within the delayed setting account for 85% to 90% of cases. Survival Survival after penetrating cardiac trauma depends on the mechanism of harm (stab versus gunshot), the number of signs of life on admission (cardiovascular and respiratory elements of trauma score), the placement of the thoracotomy (emergency department versus operating room), the cardiac rhythm at time of the pericardiotomy (rhythm versus asystole), the number of chambers injured, and the associated accidents. In this context, the terminology may include the ascending, transverse, and proximal descending aorta as properly as the innominate (brachicephalic), widespread carotid and the subclavian arteries. Because of their sizes and proximal places, the innominate and central jugular veins can also be included as great vessels of the chest. Table 9-6 provides the American Association for the Surgery of Trauma Thoracic Vascular Organ Injury Scale for vascular trauma on this region. Of patients who underwent emergent thoracotomy after penetrating thoracic injury, lower than one third had nice vessel damage as the trigger of hemorrhage. Blunt Trauma Blunt injuries to the good vessels (exclusive of the descending thoracic aorta, which might be described in Chapter 10) are very unusual. When they do happen, these injuries virtually all the time contain the proximal innominate or subclavian artery. In an older series describing forty three patients with injury to the innominate artery from 1960-1992, a blunt mechanism was the cause in 17% of patients. Etiology Penetrating Trauma A gunshot wound to the chest has less than a 5% chance of injuring a thoracic great vessel. Stab wounds are additionally uncommon and are reported to injure a fantastic vessel in solely 2% of situations. Blunt Trauma Blunt accidents to the innominate and subclavian arteries mostly happen in individuals sporting shoulder-harness restraints in frontal motor-vehicle crashes. The proposed mechanism for this harm is direct compression to the upper sternum into the artery itself with partial or full avulsion off the aortic arch. This mechanism happens because the victim slides beneath the shoulder harness and should trigger stretching and avulsion of the innominate artery. Either mechanism could lead to disruption of the intima with or without damage to part or all the media and adventitia. Similar mechanisms are proposed to explain blunt harm to the carotid and vertebral arteries in latest years. Disruptive accidents to cervical vertebrae contribute to choose patterns of zone I vascular trauma as nicely. The etiology of blunt harm to both subclavian artery is slightly different and extra likely related to deceleration of the vessel in relation to the first rib and the supraclavicular area fixated underneath the shoulder-harness restraint itself. Shoulder harness notwithstanding, a sudden posterior movement of the shoulder from blunt trauma could trigger disruption of the intima and all or part of the media of this relatively fragile artery. Presentation Penetrating Trauma There are 3 different clinical situations with which sufferers with penetrating wounds to the thoracic outlet and superior mediastinum will present. Some patients will be asymptomatic with normal vital indicators and with a traditional chest x-ray. Secondly, some patients shall be asymptomatic with a normal blood stress but will have a contained hematoma within the suprasternal, mediastinal or supraclavicular area. The third group of sufferers will have proximity of penetrating wound to zone I constructions with onerous indicators of vascular trauma corresponding to external bleeding, increasing hematoma, or hemorrhagic shock. The aortogram demonstrated a through-and-through wound (arrow) of the descending thoracic aorta. However, measurement of blood pressure using both a stethoscope or the continuous wave Doppler machine has a fantastic sufficient sensitivity for the thorough clinician to determine this damage. The mark of a shoulder-harness restraint on the lateral side of the decrease neck could also be current as a physical examination discovering. If the victim was not sporting a restraint and there was no air-bag deployment, sternal contusions point out danger for blunt injury of the descending thoracic aorta. Patients with avulsion of the innominate artery from the aortic arch will current with hypotension, with diminished or absent pulses on the proper arm, and with a large hematoma within the superior mediastinum on a chest x-ray. Other less-severe accidents embody an intimal tear of the innominate or subclavian artery without thrombosis. Depending on the extent of the arterial-wall damage and the flow-limiting nature of the intimal abnormality there could additionally be a discovering of disparate blood pressures within the arms. As will be discussed in Chapter 10, widening of the superior mediastinum on chest x-ray is a marker for blunt damage to the descending thoracic aorta. As noted, the patient with blood pressure discrepancies between arms ought to be suspected of having a subclavian or axillary artery harm.

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Approximately 5% of the vascular accidents had been in the cervical region with a similarly small percentage within the abdomen (5%) and the thorax (3%). Surgical management of vascular harm in this retrospective collection consisted of main anastomosis (39%), graft reconstruction (21%), ligation (16%), and suture repair (12%). The major conduit used as vascular substitute was autologous vein, with artificial grafts utilized in only 5% of the reconstructions. The authors have noticed that endovascular stent-graft repair of blunt descending thoracic aortic accidents has significantly reduced the morbidity and mortality related to this pattern of vascular trauma. AbdominalVascularTrauma Injury to the abdominal aorta sometimes leads to the onset of retroperitoneal bleeding or sometimes free bleeding into the belly cavity. Unlike blunt injuries to the descending thoracic aorta, the authors choose an open strategy. Because of the propensity for giant resuscitation and harm to hole viscus or stable organs, ideas of harm management laparotomy are espoused by the authors. Like elsewhere on the planet, this method to abbreviated working focuses mostly on patient physiology and resuscitation whereas controlling hemorrhage and contamination with a willingness to return to the working room at a later time for more definitive restore. ExtremityVascularTrauma Penetrating harm to the extremities, leading to tissue destruction and vascular disruption, often requires a multidisciplinary method that includes vascular, trauma, and orthopedic surgeons. Like other anatomic areas of vascular injury, the priorities in the extremities are to management hemorrhage and to restore perfusion. However, in contrast to other anatomic areas, consideration of fracture reduction and stabilization is often essential in extremity trauma. Following hemorrhage control, fracture reduction and alignment is usually accomplished. If fracture fixation (internal or external) is critical and predicted to take some size of time, the authors usually proceed with reestablishing perfusion to the limb first. This can be achieved with a proper vascular reconstruction or with the usage of temporary vascular shunts. Another essential consideration is enough soft-tissue coverage of the vascular restore. The intrathoracic phase of the subclavian artery is often approached using a high anterolateral thoracotomy with or without a separate supraclavicular exposure of the extra distal artery. Because of the challenges related to exposing and controlling the intrathoracic subclavian artery, the authors have found this injury location notably nicely suited to remedy using an endovascular lined stent. The more distal subclavian artery segments behind and distal to the primary rib can be uncovered with a supraclavicular incision typically combined with an infraclavicular method of the axillary artery. Like the intrathoracic phase, the authors have found endovascular repair of the extra distal subclavian and even proximal axillary artery favorable in some circumstances. ThoracicVascularTrauma Given the prevalence of car crashes in Brazil, expertise with blunt thoracic aortic accidents is considerable. Contrast angiography is usually reserved for the time of stent-graft restore of Regional Strategies to Sustain and Train the Next Generation of Trauma Surgeons Learning from our personal experiences and mindful of army experience and stories from around the globe, trauma facilities and methods in Brazil have been formed in two totally different manners. In the opposite group was a bigger assortment of hospitals, largely public, that had an extended experience in caring for trauma victims, but with fewer propensities for formal teachers or study within the subject of trauma surgical procedure. To turn into a common surgeon in Brazil, the doctor must all the time carry out a minimum of two years of basic surgery. By regulation in Brazil, with 2 years of basic surgery residency, one can be certified as a basic surgeon and apply acute care surgery. In an try to appropriate this drawback, some residency applications have divided the final surgery residency into two sections: basic basic surgical procedure for two years and superior basic surgical procedure for an additional 2 years. All different surgical specialties require 2 years of common surgery and 2 or three years of the specialty. Specialist surgeons in Brazil have two titles: basic surgeon and one other title that displays their specialty. In Brazil, there are 55 vacancies for medical residency programs in trauma surgical procedure, distributed in 9 states. These residency applications consist of 2 years of basic surgical procedure plus 1 yr of coaching in trauma. There remains to be a deficiency in the educating of trauma, due to the complexity of this specialty.

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Once the new food label has been permitted, producers should embrace the revisions on most packaged foods inside two years. After reading this part, you should be succesful of One serving of a food has 30 g of carbohydrate. The % Daily Values for vitamins related to vitality consumption are based on a 2000 kcal/day food plan. Describe the basic steps involved in using lipids and amino acids as power sources. P Catabolism Catabolism is the energyreleasing process by which bigger molecules are damaged down to smaller ones. It consists of catabolism (katabo-lizm), the energy-releasing course of by which large molecules are broken down into smaller ones, and anabolism (a-nabo-lizm), the energy-requiring course of by which small molecules are joined to type larger ones. Catabolism begins during the strategy of digestion and is concluded within particular person cells. Anabolism occurs in all cells of the body as they divide to type new cells, maintain their very own intracellular structure, and produce molecules such as hormones, neurotransmitters, or extracellular matrix molecules for export. Metabolism may be divided into the chemical reactions that occur during digestion and the chemical reactions that occur after the products of digestion are taken up by cells. The chemical reactions that occur inside cells are often referred to as cellular metabolism. The digestive products of carbohydrates, proteins, and lipids could be further broken down inside cells. Which pathways perform and the way a lot every pathway is used is decided by enzymes as a end result of each step within the pathway requires a specific enzyme (see chapter 2). Thus, the types and amounts of enzymes present in cells are underneath genetic control. The combination of a chemical signal, such as a neurotransmitter or hormone, with a membrane-bound or intracellular receptor can activate or inhibit enzyme exercise (see chapter 10). The finish product of a biochemical pathway can inhibit the enzyme answerable for the primary response in the pathway. This negative-feedback regulation prevents accumulation of the intermediate merchandise and the end product of the pathway (figure 17. Carbohydrate Metabolism Monosaccharides are the breakdown products of carbohydrate digestion. Any excess glucose in the blood following a meal can be used to form Regulation of Metabolism the merchandise of digestion, such as glucose, fatty acids, and amino acids, are molecules containing vitality inside their chemical bonds. For example, in Tay-Sachs disease, the breakdown of lipids within lysosomes is impaired. Glycogen is a short-term energy-storage molecule that the physique can retailer only in restricted quantities, whereas lipids are long-term energy-storage molecules that the body can retailer in large amounts. Glycolysis Glycolysis (gli-kol i-sis) is a series of chemical reactions that happens in the fluid part of cytoplasm surrounding the organelles. It leads to the breakdown of glucose to two pyruvic (pi-roo vik) acid molecules (figure 17. Glucose consists of 6 carbon atoms, 12 hydrogen atoms, and 6 oxygen atoms covalently bonded collectively. During the breakdown of glucose, a hydrogen ion (H+) and two electrons (e-) are released and may connect to a provider molecule, which moves the H+ and electrons to different components of the cell. Lactic acid is released from the cells that produce it, and blood transports it to the liver. When O2 becomes available, the lactic acid in the liver can be transformed through a collection of chemical reactions into glucose. The six-carbon glucose molecule is damaged all the method down to form two molecules of pyruvic acid, each consisting of three carbon atoms. Each acetyl group combines with coenzyme A (CoA), derived from vitamin B2, to type acetyl-CoA. Each acetyl-CoA combines with a fourcarbon molecule to kind a six-carbon citric acid molecule, which enters the citric acid cycle. The citric acid cycle is a series of reactions whereby the six-carbon citric acid molecule is converted, in numerous steps, right into a four-carbon molecule (figure 17. The four-carbon molecule can then mix with one other acetyl-CoA molecule to form another citric acid molecule and reinitiate the cycle.

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Parathyroid hormone secretion increases to preserve blood calcium ranges if dietary Ca2+ and vitamin D ranges lower, as they usually do within the aged. Grace was treated with radioactive iodine (131i) atoms that have been actively transported into thyroid cells, where they destroyed a substantial portion of the thyroid gland. Predict 10 Endocrine Explain why removal of a half of the thyroid gland is an effective therapy for Graves disease. Weak contractions of muscle tissue of inspiration contribute to respiratory difficulties. We discovered that a tissue responds to hormones based on the presence of specific receptors. The four courses of chemical messengers are autocrine, paracrine, neurotransmitter, and endocrine. The endocrine system contains glands and specialized endocrine cells that secrete hormones into the bloodstream. Three types of stimuli end in hormone secretion: humoral, neural, and hormonal. Humoral stimulation is exhibited by hormones that are delicate to circulating blood levels of sure molecules, corresponding to glucose or calcium. Neural stimuli cause hormone secretion in direct response to action potentials in neurons, as happens throughout stress or exercise. Hormones from the hypothalamus that cause the release of different hormones are called releasing hormones. Hormonal stimulation of different hormone secretion is frequent in the endocrine system. Hormones from the anterior pituitary that stimulate hormones from different endocrine glands are called tropic hormones. Inhibition of Hormone Release Although the stimulus of hormone secretion is essential, inhibition is equally essential. Lipid-soluble hormones embody steroids, thyroid hormones, and a few fatty acid derivatives. However, some water-soluble hormones have chemical modifications, such because the addition of a carbohydrate group, which prolongs their lifespan. Regulation of Hormone Levels within the Blood Two processes regulate the overall blood levels of hormones: unfavorable feedback and positive suggestions. Negative suggestions prevents additional hormone secretion once a set point is achieved. Positive suggestions is a self-promoting system whereby the stimulation of hormone secretion increases over time. Lipid-soluble hormones bind to nuclear receptors situated contained in the nucleus of the target cell. Some lipid-soluble hormones have fast actions which would possibly be more than likely mediated via a membranebound receptor. Water-soluble hormones bind to membrane-bound receptors, that are integral membrane proteins. Glucocorticoids (cortisol) scale back inflammation and break down proteins and lipids, making them obtainable as energy sources to other tissues. Mineralocorticoids (aldosterone) help regulate blood Na+ and K+ ranges and water volume. These hormones cause blood vessels to constrict and enhance Na+ and water retention by the kidney. Adrenal androgens improve female sexual drive however normally have little impact in males. The pancreas secretes insulin in response to elevated levels of blood glucose and amino acids. Insulin will increase the rate at which many tissues, together with adipose tissue, the liver, and skeletal muscular tissues, take up glucose and amino acids. The pancreas secretes glucagon in response to lowered blood glucose and will increase the speed at which the liver releases glucose into the blood. Some membrane-bound receptors are associated with membrane proteins known as G proteins. Second-messenger techniques act rapidly as a end result of they act on already present enzymes and produce an amplification impact.

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What are the major useful variations between the endocrine system and the nervous system List the main variations between intracellular and intercellular chemical indicators. Describe the mechanisms by which membrane-bound receptors produce responses in their goal tissues. Describe the mechanisms by which intracellular receptors produce responses in their goal tissues. What makes one tissue a target tissue for a hormone and one other not a goal tissue Describe how secretions of the anterior and posterior pituitary hormones are controlled. What are the features of the thyroid hormones, and the way is their secretion managed What occurs when too giant or too small an quantity of the thyroid hormones is secreted Explain how calcitonin, parathyroid hormone, and vitamin D are involved in maintaining blood Ca2+ ranges. List the hormones secreted from the adrenal gland, give their features, and evaluate the means by which the secretion price of each is managed. Based on these observations, describe the mechanism by which the membranebound receptor is most likely to produce a response to the hormone. Aldosterone and antidiuretic hormone play important roles in regulating blood volume and focus of blood. The response to one of these hormones is evident inside minutes, and the response to the other requires several hours. Biceps Benny figured that if a small quantity of a vitamin was good, a lot should be better, so he started to take supplements that included a great amount of vitamin D. Predict the effect of vitamin D on his blood Ca2+ ranges and on the secretion of hormones that regulate blood Ca2+ levels. Explain how the blood levels of glucocorticoids, epinephrine, insulin, and glucagon change after a person has gone without meals for 24 hours. However, over the last few days she had began experiencing vital stomach pain. Some societies contemplate blood the "essence of life" as a result of the uncontrolled lack of it can outcome in dying. Many cultures all over the world, each historical and modern, imagine blood has magical qualities. For example, folks of a noble bloodline are generally described as "blue bloods," whereas criminals are stated to have "dangerous" blood. People generally say that anger causes their blood to "boil," whereas concern makes it "curdle. Blood performs many functions important to life and might reveal a lot about our well being. The blood transports Module 9 Cardiovascular system ingested vitamins, ions, and water from the digestive tract to cells, and the blood transports the waste products of the cells to the kidneys for elimination. For example, the precursor to vitamin D is produced within the pores and skin (see chapter 5) and transported by the blood to the liver after which to the kidneys for processing into energetic vitamin D. Then the blood transports active vitamin D to the small gut, where it promotes the uptake of calcium. Another example is lactate produced by skeletal muscles during anaerobic respiration (see chapter 7). The blood carries lots of the hormones and enzymes that regulate body processes from one part of the physique to one other. The osmotic composition of blood can be critical for sustaining normal fluid and ion balance. Warm blood is transported from the inside of the body to the surface, the place warmth is released from the blood.

References

• Yucel S, Baskin LS: An anatomical description of the male and female urethral sphincter complex, J Urol 171(5):1890-1897, 2004.
• Asfar P, Meziani F, Hamel J-F, et al. High versus Low Blood- Pressure Target in Patients with Septic Shock. N Engl J Med. 2014;doi:10.
• Kote-Jarai Z, Leongamornlert D, Saunders E, et al: BRCA2 is a moderate penetrance gene contributing to young-onset prostate cancer: implications for genetic testing in prostate cancer patients, Br J Cancer 105:1230n1234, 2011.
• Nussbaum-Blask AR, Sanders RC, Rock JA: Obstructed uterovaginal anomalies: demonstration with sonography, Radiology 179:84n88, 1991.
• Smith I, Kranke P, Murat I, et al: Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology, Eur J Anaesthesiol 28(8):556-569, 2011.
• Van Aken H, Puchstein C, Schweppe ML, et al. Effect of labetalol on intracranial pressure in dogs with and without intracranial hypertension. Acta Anaesthesiol Scand 1982;26(6):615-19.