20-gauge Catheter Research Articles

Rokuronyum Enjeksiyon Ağrısının Önlenmesinde Ondansetron Lidokainin Karşılaştırılması

Comparison of Ondansetron and Lidocaine in Preventing of Rocuionium Injection Pain This study was conducted to compare the efficiency of ondansetron and lidocaine for arm withdrawal due to rocuronium injection pain. The study were included 60 adult patients. Patients were divided into three groups, twenty patients in each. After cannulation with 20-gauge intravenous catheter on the dorsum of hand, saline was infused and 5-7 mg/kg thiopenthal was administered. Five seconds after thiopenthal injection, the turniquet was applied on the forearm. Group I patients received 2 cc (4 mg) ondansetron, Group II patients received 2 cc (2%) lidocaine and Group III patients received 2 cc of 0.9% saline intravenous. Fifteen seconds after study drugs administration, turniquet was released. Rocuronium 0.6 mg/kg was injected. Arm withdrawal of patients was assessed with four points scale. Number of patients who had no pain was higher in Group II Uian Group I and III (p<0.05), also it was higher in Group I than Group III (p<0.05). We concluded that lidocaine was more successful than both ondansetron and placebo in relieving arm withdrawal on rocuronium injection. In addition, ondansetron was also more effective than placebo for preventing of rocuronium injection pain. Bu calisma, rokuronyum enjeksiyonunda gorulen kol cekmenin onlenmesinde ondansetron ve lidokainin etkilerini karsilastirmak amaciyla yapildi. Calismaya alinan 60 eriskin olgu rasgele 20'ser kisilik uc gruba ayrildi. Hastalarin el sirtindan 20 G intravenoz kateter yerlestirildikten sonra salin infuzyonuna baslandi ve 5-7 mg/kg tiyopental uygulandi. 5 saniye (sn) sonra on kola manuel olarak turnike uygulandi. Grup I'deki olgulara 2 cc (4 mg) ondansetron, Grup H'dekilere 2 cc (40 mg) %2'lik lidokain ve Grup IU'deki olgulara ise 2 cc serum fizyolojik (SF) (%0.9) iv verildi. 15 sn sonra turnike gevsetildi. 0.6 mg/kg rokuronyum iv olarak verilip kol cekme tepkileri 4 puanli skala ile degerlendirildi. Rokuronyum enjeksiyonundan sonra hic agrisi olmayan olgu sayisi Grup H'de Grup I ve IIl'e gore daha fazla idi (p<0.05). Rokuronyum enjeksiyon agrisinin onlenmesinde, ondansetron da plaseboya gore daha etkili idi (p<0.05). Bu calismanin sonucunda; rokuronyum enjeksiyonunda gorulen kol cekme tepkisinin onlenmesinde lidokainin ondansetron ve plaseboya gore daha basarili oldugu sonucuna vardik. Ayrica, ondansetron da plaseboya gore daha etkili bulundu.

The Effect of the Radius and Longitude of a Catheter in Continuous Arterial Blood Pressure Monitoring

Backgroud: Continuous arterial blood pressure monitoring is a highly effective method in an operation and the intensive care unit. However the accuracy of the monitoring system could be influenced by the radius and longitude of the catheter. This study was executed to examine the effects of the radius and longitude of a catheter. Methods: Forty-two pediatric patients scheduled to undergo open heart surgery were selected. After induction of anesthesia the radial artery pressure was measured by a 22-gauge (1 inch catheter and the femoral artery pressure was measured by a 20-gauge (1.16 inch catheter 22-gauge catheter and 20-gauge (12 cm catheter in succession. Influences of the radius and longitude were analysed respectively. All values are expressed as mean ± SD and analysed using the paired t-test; P ＜ 0.05 was considered significant. Results: The systolic pressure of the 20-gauge (1.16 inch catheter was higher than that of the 22gauge (1 inch catheter. The systolic pressure of the 20-gauge (1.16 inch catheter was higher than that of the 20-gauge (12 cm catheter. Mean and diastolic pressures were low in the 20-gauge (1.16 inch catheter compared with the 20-gauge (12 cm catheter. Conclusions: Shorter and/or larger radius catheters could increase the pulse pressure in pediatric patients. (Korean J Anesthesiol 2002; 43: 10～14

Effect of age on acute pain perception of a standardized stimulus in the emergency department

Study Objective: The study was undertaken to determine whether pain perception is different in elderly patients than in younger patients. Methods: A cross-sectional, observational study was conducted at 2 urban academic emergency departments. Adult patients (≥18 years of age) who required an 18-gauge intravenous catheter as part of their ED care were eligible. Patients were excluded for the following conditions: more than one attempt at intravenous catheter placement, altered mental status, visual impairment, intoxication, distracting pain, or abnormal upper extremities. Patients were asked to indicate on a 10-cm visual analog scale (VAS) the amount of pain they had at baseline immediately before intravenous catheter placement. They were then asked to indicate on a separate VAS the amount of pain caused by intravenous catheter placement. Patients aged 65 years and older were defined a priori as elderly. Results: Of 100 patients enrolled in the study, 32 (32%) were elderly. Elderly patients reported significantly less pain than nonelderly patients (Δ=–15 mm, 95% confidence interval –26 to –4 mm). Pain of intravenous catheter placement was not associated with sex, baseline pain, site of intravenous catheter insertion, or level of training of the individual placing the intravenous catheter. Conclusion: Elderly patients experienced less acute pain than their younger counterparts in response to a standardized stimulus in a clinical setting. This difference is both statistically and clinically significant. This may have clinical implications for the assessment and treatment of acute pain in the elderly. [Li SF, Greenwald PW, Gennis P, Bijur PE, Gallagher EJ. Effect of age on acute pain perception of a standardized stimulus in the emergency department. Ann Emerg Med. December 2001;38:644-647.]

Expression of the Ym2 lectin-binding protein is dependent on interleukin (IL)-4 and IL-13 signal transduction: identification of a novel allergy-associated protein.

Asthma pathophysiology is intimately regulated by CD4(+) Th2 lymphocytes and the cytokines interleukin (IL)-4 and IL-13. However, the mechanisms by which these cytokines promote disease have not been fully elucidated. In order to identify novel molecular mediators of allergy, a comparison was made of the bronchoalveolar lavage, which demonstrated that the Ym2 protein was abundantly up-regulated in the lung during the development of allergy. Low levels of the Ym1 isomer were also detected. Importantly, neither Ym1 nor Ym2 has been characterized previously in the context of allergic pulmonary inflammation. Western immunoblot showed that enhanced expression of these proteins was dependent on CD4(+) T cells and IL-4 or IL-13 signaling via the IL-4Ralpha subunit. In addition, intratracheal instillation of IL-13 into naive mice was sufficient to induce expression. Ym1 is homologous to eosinophil chemotactic factor L. However, only weak eosinophil chemotaxis was observed in response to Ym protein in both in vitro and in vivo assays. By contrast, the homology of Ym1 and Ym2 to proteins associated with tissue remodeling, together with the previous findings that Ym1 is homologous to chitinase and binds heparin sulfate and GlcN oligomers (chitobiose, chitotriose, and chitotetraose), strongly suggests these proteins play an important role in airway wall remodeling in the allergic lung.

Clinical experience of percutaneous femoral venous catheterization in critically ill preterm infants less than 1,000 grams.

Venous access is relatively difficult in preterm infants. Central venous catheterization is indicated for pressure monitoring, drug therapy, and nutrition supplementation, which are often critical in the anesthetic management of infants undergoing major surgery. In 49 critically ill preterm infants weighing less than 1,000 g, the femoral vein was cannulated using a 22-gauge Angiocath (25 mm; Beckton Dickinson, Sandy, UT). A 2.5-ml syringe was attached to the Angiocath, and the Angiocath was advanced with constant negative pressure over the syringe. When blood return was observed, the cannula was advanced. When free blood reflux was achieved, a J wire was inserted, followed by a 24-gauge central venous catheter. The overall catheterization success rate was 79.6% (39 of 49 attempts). The time required for successful catheterization was less than 10 min in 18 cases (46.2%), 10-20 min in 17 cases (43.6%), and 20-30 min in 4 cases (10.3%). In the successful group, 1 catheter tip was positioned in the vein of the liver (2.6%), 2 were in the common iliac vein (5.1%), 6 were in the right atrium (15.4%), and 30 were in the infracardiac inferior vena cava (76.9%). Complications included hematoma in six cases (12.2%), arterial puncture in five cases (10.2%), bleeding in two cases (4.1%), and transient bradycardia in two cases (4.1%). The results indicate that percutaneous femoral venous catheterization is a reliable and valuable technique for critically ill preterm infants weighing less than 1,000 g.

Evaluation of porous networks of poly(2-hydroxyethyl methacrylate) as interfacial drug delivery devices

Long-term implantable drug delivery devices are desirable to achieve rapid and reliable delivery of bioactive substances to the body. The limitation of most implantable devices is the resulting chronic inflammatory response and fibrous encapsulation of the implant, which prevents effective drug delivery for prolonged periods. One method of overcoming this problem is the addition of an intermediary that could prevent capsule formation. Biocompatible materials with interconnected pore structures greater than 8–10 μm have been shown to support the ingrowth and maintenance of vascularized tissue. In this investigation, we evaluate the efficacy of using porous hydrogel sponges for the tissue interface in an implantable drug delivery device. Porous networks of poly(2-hydroxyethyl methacrylate) (PHEMA) were synthesized using a thermally initiated free-radical solution polymerization. To characterize the microstructure of the PHEMA networks, scanning electron microscopy and mercury porosimetry were used. By altering the solvent fraction in the reaction mixture, PHEMA sponges were synthesized with interconnected pores ranging in size from from 6 to 15 μm with porosities of 55% to 87%. Following the in vitro evaluation, sponges were attached to the distal end of a 20-gauge catheter tubing, and implanted subcutaneously and intraperitoneally. After 5 months implantation, insulin was infused into the devices from external pumps and rapid insulin absorption was observed in conjunction with dramatic lowering of blood glucose levels. From histological evaluation of explanted devices, we observed highly vascularized tissue surrounding the mesenteric implants. These results indicate that it may be possible to use PHEMA sponges for a tissue intermediary for long-term implantable drug delivery devices.

Continuous Caudal Epidural Analgesia for Congenital Lobar Emphysema: A Report Of Three Cases

Continuous Caudal Epidural Analgesia for Congenital Lobar Emphysema: A Report Of Three Cases

Thoracic epidural anesthesia via the modified Taylor approach in infants

Background and Objectives: Advancement of catheters from the caudal to the thoracic level is an alternative to thoracic epidural anesthesia in infants and younger children; however, contamination of the insertion site may occur. This study examined the feasibility of the midline modified Taylor approach (L5-S1) for the advancement of epidural catheters to the thoracic level in infants. Methods: After Institutional Review Board (IRB) approval and parental consent, the L5-S1 interspace of infants 3 months to 2 years old was entered with an 18-gauge Crawford needle using the saline loss of resistance technique. A 20-gauge catheter with stylet (Abbott; North Chicago, IL) was then advanced the distance from the L5-S1 interspace to the desired thoracic level. If resistance was encountered, the catheter was withdrawn 1 to 2 cm, rotated along its long axis, and readvanced. The stylet was left in place, and a radiograph of the thoracolumbar spine was taken. The stylet was then removed, and the catheter was secured, tested, and dosed. Results: Sixteen infants (mean age, 14.4 ± 5.7 months and mean weight, 9.3 ± 1.4 kg) were studied. Fifteen of 16 catheters were inserted the full length planned. Fourteen of 16 catheters were straight (1 had a single bend, and 1 had multiple loops). Mean discrepancy between level desired and obtained was −1.7 ± 1.7 segments (median, −1.75). Discrepancy did not correlate with either desired level or length inserted, but did decrease with experience. Conclusions: The midline modified Taylor approach allows access to the thoracic epidural space via catheter advancement, while being below the terminus of the spinal cord and less likely to suffer contamination than the caudal approach. Reg Anesth Pain Med 2000;25;561-565

Comparison of three catheter sets for continuous spinal anesthesia in patients undergoing total hip or knee arthroplasty

Background and Objectives: Continuous spinal anesthesia (CSA) with microcatheters may be complicated because of technical problems. In elderly patients, some of the problems may be solved by using thicker catheters. A recent invention, involving a catheter-over-needle system, may prevent leakage of cerebrospinal fluid (CSF) and may also improve the prediction of the intrathecal position of the catheter tip. Methods: This study included 90 patients undergoing primary hip or knee replacement, randomly allocated into 3 groups, with 30 patients in each group: Group EC, a 24-gauge epidural catheter through a 19-gauge Tuohy needle; group MC, a 28-gauge microcatheter through a 22-gauge spinal needle; group SC, a 22-gauge spinal catheter over a 27-gauge spinal needle through an epidurally placed 18-gauge Crawford needle. All subarachnoid catheterizations were performed with the patient in the lateral position and the initial spinal block dose was 2 mL of plain 0.5% bupivacaine. Increments of 0.5 mL were administered when required. The block performance characteristics were recorded, and the level of analgesia was studied in a blinded fashion. Catheter function during the postoperative infusion was assessed. Afterwards the needles and catheters were examined by microscopy. Results: The frequency of the successful catheterization was higher in the EC and MC groups (90% in each) than in the SC group (63%) (P < .05). The mean duration of the successful catheterizations, as well as the median level of analgesia, were similar in the groups. The postoperative infusion had to be stopped in 3, 1, and 1 patients in groups EC, MC, and SC, respectively, because of a technical reason. No neurologic sequelae occurred in this study. Microscopy showed 4 distorted spinal needle tips (2 each with MC and SC) and minor material damage of the SC catheters when bone had been met during block performance. Conclusions: Placement of the SC catheters was unsuccessful to a high degree, and bone contact produced distortion of the tip of some of these catheters. Otherwise, the quality associated with catheterization time, anesthetic distribution, and catheter function was similar with the 3 catheters. Reg Anesth Pain Med 2000;25:584-590.

Nitric oxide generation in a rat model of acute portal hypertension.

To document blood nitric oxide concentrations in the portal vein and systemic circulation in a rat model of acute portal hypertension and compare values with a control group and a sham surgical group. 30 rats; 10 controls (group 1), 10 sham surgical (group 2), and 10 rats with surgically induced acute portal hypertension (group 3). Following induction of anesthesia, catheters were placed surgically in the carotid artery, jugular, and portal veins of group 2 and 3 rats and in the carotid artery and jugular vein of group 1 rats. Baseline heart and respiratory rates, rectal temperature, and vascular pressure measurements were obtained, and blood was drawn from all catheters for baseline nitric oxide (NO) concentrations. Acute portal hypertension was induced in the group 3 rats by tying a partially occluding suture around the portal vein and a 22-gauge catheter. The catheter was then removed, resulting in a repeatable degree of portal vein impingement. After catheter placement, all variables were remeasured at 15-minute intervals for 3 hours. Blood nitric oxide concentrations were greater in all vessels tested in group 3 than in group 2 rats. Acute portal hypertension in this experimental model results in increased concentrations of NO in the systemic and portal circulation. On the basis of information in the rat, it is possible that increased NO concentrations may develop in dogs following surgical treatment of congenital portosystemic shunts if acute life-threatening portal hypertension develops. Increased NO concentrations may contribute to the shock syndrome that develops in these dogs.

Right Atrial Membrane Interfering with Insertion of Pulmonary Artery Catheter

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Pediatric Regional Anesthesia: Beyond the Caudal

Pediatric Regional Anesthesia: Beyond the Caudal

Does the Air Test Reliably Detect Intravenous Placement of Multiorifice Epidural Catheters?

Because most studies of epidural test dose effectiveness have evaluated single-orifice catheters, Leighton et al. set out to determine the sensitivity and specificity of the air test to reliably detect intravascular placement with the currently used three-hole catheters. In 300 laboring women who requested epidural analgesia, blunt-tip, three-hole 20-gauge epidural catheters were placed at the L2–L3 or L3–L4 interspace. If neither blood nor cerebrospinal fluid (CSF) could be aspirated through the needle, 3 ml lidocaine, 2%, or 0.25% bupivacaine was injected. After a 3-min interval, patients were questioned about changes in lower extremity sensation or motor strength. If these signs of spinal anesthesia were absent, the team performed the air test by injecting 1 ml air through the epidural catheter and listening for maternal heart sound changes 15 s after injecting the air. Tests were repeated if the women experienced contractions during the observation period. If no blood was aspirated and no heart tone changes were heard, the team injected 10 ml bupivacaine, 0.125%, with 50 μg fentanyl. Epidural analgesia was continued if a sensory band was present 20 min after epidural injection.Catheters through which blood was initially aspirated were air-tested and then replaced. Patients whohadair-test-positivebutblood-aspiration-negative catheters received 100 mg lidocaine through the catheter and then were questioned about toxicity symptoms (perioral numbness, tinnitus, and diplopia).The air test detected 82% of intravascular catheters, whereas aspiration detected 91%; neither test detected all cases of intravascular placement. Eight of 11 intravascular catheters were positive for both the air test and the blood aspiration. In one air-test-positive catheter, blood could not be aspirated, and the patient developed perioral numbness after lidocaine injection. In the remaining 288 catheters, bupivacaine–fentanyl injection produced epidural analgesia in 279 patients, but no effect in another 9. The difficulty of testing multiport catheters underscores the need for careful local anesthetic dose fractionation to reduce the risk of large doses in patients with unrecognized epidurovascular or epidurointrathecal catheters.

Retrograde nasotracheal intubation with a new tracheal tube: a feasibility study

We have assessed the feasibility of retrograde nasotracheal intubation using a flexometallic tracheal tube with a detachable pilot balloon and connector in a study of 20 consecutive adult patients undergoing oropharyngeal surgery. The technique consisted of: (1) laryngoscope-guided orotracheal intubation; (2) insertion of an 18-gauge Foley catheter through the nose and retraction into the mouth; (3) detachment of the anaesthesia circuit, pilot balloon and connector; (4) insertion of the Foley catheter tip into the proximal end of the tracheal tube and inflation of the Foley catheter cuff; (5) withdrawal of the Foley catheter and attached tracheal tube back through the nose; (6) deflation of the Foley catheter cuff; and (7) re-attachment of the pilot balloon, connector and anaesthesia circuit. The technique was successful at the first attempt in all patients. Mean time taken to insert the Foley catheter and retract it into the mouth was 19 (range 12-30) s. Mean time taken from disconnection to reconnection of the anaesthesia circuit was 8 (6-10) s. Heart rate increased after intubation, but there were no significant changes in arterial pressure. Nasal bleeding, airway problems and hypoxic events did not occur. No anatomical abnormalities or nasal trauma were detected at rhinoscopy. We conclude that retrograde nasotracheal intubation is feasible using a flexometallic tracheal tube with a detachable pilot balloon and connector.

Feline penile erection induced by transurethral administration of sodium nitroprusside

Nitric oxide (NO) is an important mediator in the relaxation of cavernosal smooth muscle. The aim of this study was to investigate the in vivo feline erectile response after transurethral administration of sodium nitroprusside (SNP), a NO donor drug. Erectile responses after administration of transurethral SNP were compared with those elicited by an intracavernosal control triple-drug combination (1.65 mg papaverine, 25 microg phentolamine, and 0.5 microg prostaglandin E1). SNP was administered via a 20-gauge Jelco intravenous catheter in a volume of 200 microl and changes in intracavernosal pressure, penile length, and systemic blood pressure were monitored. The control triple-drug combination was administered via a 30-gauge needle at the end of each experiment to serve as a control reference. Transurethral administration of SNP (1-4 mg) induced penile erection in a dose-dependent manner with minimal changes in systemic blood pressure. The maximum increase in intracavernosal pressure and penile length after transurethral administration of SNP (4 mg) was significantly less than after the intracavernosal injection of the control triple-drug combination (P<0.01). These data suggest that transurethral administration of SNP can induce an erectile response in cats with minimal side effects.

Ultrasound-Guided Brachial and Basilic Vein Cannulation in Emergency Department Patients With Difficult Intravenous Access

Study objective: Emergency department patients who require intravenous access but lack peripheral intravenous sites frequently require central line placement. Blind percutaneous brachial vein cannulation has been proposed as an alternative in these patients but is associated with high failure and complication rates. We evaluated an ultrasound-guided approach to percutaneous deep brachial vein or basilic vein cannulation in ED patients with difficult intravenous access. Methods: We prospectively enrolled ED patients who required intravenous access in whom there had been 2 unsuccessful attempts at establishing a peripheral intravenous line. Using a 7.5-MHz ultrasound probe, the deep brachial vein or basilic vein was identified and then cannulated with a 2-in, 18- to 20-gauge intravenous catheter. Time from probe placement to cannulation, number of attempts, and complications were recorded. Results: One hundred one patients were enrolled, of whom 50 were injection drug users and 21 were obese. Cannulation was successful in 91 patients (91%) and accomplished on the first attempt in 73 (73%). The mean (±SD) time required for cannulation was 77 seconds (±129, range 4 to 600 seconds). The line infiltrated or fell out within 1 hour of cannulation in 8 (8%) patients. One patient reported severe pain. There were 2 (2%) cases of brachial artery puncture. Conclusion: Ultrasound-guided brachial and basilic vein cannulation is safe, rapid, and has a high success rate in ED patients with difficult peripheral intravenous access. [Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D: Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med December 1999;34:711-714.]

Labor Epidural Analgesia Without an Intravascular “Test Dose”

NORRIS, MARK C.; FOGEL, STEVEN T.; DALMAN, HIROKO; BORRENPOHL, SUSAN; HOPPE, WILLIAM; RILEY, ALICIA Author Information

Accidental Intravenous Levobupivacaine

Accidental Intravenous Levobupivacaine

Venous Access for Pediatric Liver Transplantation

Bayou Anesthesia Associates; Fort Walton Beach, Florida 32547;bayou@nvc.netIn Reply:-We appreciate the comments by Drs. Hammer and Krane. Indeed, we believe that the pressurized infusion was the main cause of the localized arterial hypoxemia, because the high pressure reversed the normal arterial/venous pressure gradient, causing the transfusion to flow directly across the shunt. The shunting was so immediate and dramatic that we immediately suspected an anatomic shunt rather than retrograde flow through capillary beds. This was mentioned as a possible theoretical explanation for venoarterial admixture in general. The postoperative arteriography demonstrated the suspected abnormal anatomic venoarterial connection.It is likely that all pediatric anesthesiologists believe that small distal veins should not be used for rapid transfusion. However, in this case, both peripheral lines were 18-gauge catheters. These are by no means small catheters, particularly in an 8.7-kg patient! Why were they placed so distally? Because these distal veins were much larger than the antecubital veins in this patient, possibly because of arterialization of the veins secondary to the anatomic shunts.According to Poiseuille's law, resistance to flow is affected by both radius and length of the catheter used. An 18-gauge, 3.2-cm catheter will allow much more rapid transfusion than an 18-gauge 8-cm catheter; in situations involving massive hemorrhage, this difference in flow can be critical.We appreciate reiteration of the point that calcium chloride can be very irritating to small veins and tissues; when distal administration of calcium is considered, calcium gluconate is less damaging.Kristine Henderson, M.D.Bayou Anesthesia Associates; Fort Walton Beach, Florida 32547;bayou@nvc.net(Accepted for publication March 10, 1999.)

Infusion Phlebitis in Patients With Acute Pneumonia: A Prospective Study

To prospectively assess the relative risk for phlebitis in a series of consecutive patients with pneumonia and to identify risk factors that predict an increased risk for phlebitis. Internal medicine department of a tertiary teaching hospital. Seven hundred sixty-six consecutive patients with acute pneumonia receiving IV therapy. Only the first catheter was taken into account. There were 308 short lines (a 51-mm, 18-gauge Teflon catheter); 307 midsized lines (a 28-cm, 16-gauge polyvinyl chloride catheter); and 151 long lines (71-cm, 14-gauge plain polyurethane catheter). Eighteen variables were prospectively evaluated in an open, nonrandomized study for their contribution to the occurrence of phlebitis. The overall phlebitis rate was 39%. Phlebitis developed in 53% of patients with short lines, in 41% of patients with midsized lines, and in 10% of patients with long lines, and these catheters remained in place an average (+/- SD) of 3.0+/-2.4 days, 4.6+/-3.4 days, and 7.8+/-6.6 days, respectively. The variables that influenced the development of phlebitis, as determined by multivariate analysis, were the following: type of catheter; blood hemoglobin levels; and IV therapy with either corticosteroids or erythromycin. According to our data, when the use of a catheter is expected to be required for < or = 36 h, a short line can be used. If a longer duration is expected, a longer line is warranted. Ours is the first study in which the relationship between blood hemoglobin levels and phlebitis has been reported. Because the use of intravascular devices is increasingly common, a more complete knowledge of the factors that influence their acceptance has become essential.