Extension Tube Research Articles

An Alternative Airway Intervention to Preserve the Surgical Field in Oral and Maxillofacial Surgery.

Background/need. Office-based sedation has become increasingly commonplace in dental offices in recent years, allowing for practitioners to provide broader scope of care for their patients. Maintaining high standards of safety is of utmost importance when sedation is utilized in the office-based setting, especially for patients deemed at a higher-risk for intraoperative airway obstruction. This demographic includes but is not limited to individuals with a medical history significant for obstructive sleep apnea, chronic obstructive pulmonary disease, and morbid obesity. Presently, a wide variety of airway devices exist for use in the event of airway obstruction. However, in the context of oral and maxillofacial surgery, placement of these devices can encroach upon the surgical field, extending the perioperative period and putting the patient at greater long-term risk for maintaining adequate oxygenation. Methodology. The authors describe a preliminary technique trialed in our offices which utilizes a size 5.0 endotracheal tube (5OET) as an adjunct supraglottic airway to help mitigate the issue of oxygen saturation maintenance, as well as unimpeded access to the oral cavity. Implementation of the device requires identifying appropriate candidates during preoperative screening and placing the device through the nare and securing it above the glottis. Device Description. The 'tube kit' is comprised of a standard size straight 5.0 cuffed oral ETT, a 5-mL syringe for inflation of the cuff post insertion, lubricant, flex extension tubing, end tidal sampling line for capnography, tape for securement of the 5OET, and an anesthesia breathing circuit. Optional equipment pieces include an elbow connecter and a foam piece for comfort. Results/Current Status. Preliminary results have demonstrated oxygen saturations maintained above 98% when the 5OET is placed preoperatively. Continued use of the trial device will inform the development of a tube by our clinicians, and its efficacy will be studied in our offices. The next steps will be to start developing a pilot cuff that will be submitted for patent approval after its use in IRB-approved clinical studies.

Effect of closed extension tube on preventing airway leakage during artificial airway clearance

Objective: To explore the role of closed extension tube in preventing airway leakage during artificial airway clearance. Methods: The test lung was connected with a ventilator for mechanical ventilation. The pressure parameters were set as 16/5, 20/6, 24/7, 28/8, 32/9 and 36/10 cmH2O(1 cmH2O=0.098 kPa), respectively. The circuit was connected with an open extension tube or a closed extension tube. The ventilator was set with different pressure parameters to observe the changes of airway pressure and tidal volume during airway clearance. Results: (1) The pressure parameters were set as 16/5, 20/6, 24/7, 28/8, 32/9 and 36/10 cmH2O, and the airway pressures (in cmH2O) of circuit connected with open extension tube were (15.94±0.27)/(4.81±0.04), (20.09±0.23)/(6.05±0.16), (23.89±0.41)/(6.94±0.06), (27.90±0.22)/(7.71±0.18), (31.92±0.13)/(8.74±0.12)and(35.65±0.31)/(9.72±0.07), respectively.Under the same ventilator pressure parameters, the airway pressures (in cmH2O) of circuit connected with close extension tube were (16.36±0.06)/(4.85±0.04), (20.54±0.26)/(6.44±0.12), (24.36±0.24)/(7.01±0.33), (28.69±0.25)/(8.07±0.08), (32.97±0.33)/(8.93±0.09), (37.34±0.29)/(9.75±0.08), respectively. The airway pressure of circuit connected with open extension tube was lower than that connected with closed extension tube(P<0.05);with the increase of the pressure setting of the ventilator, the difference of the airway pressure between the two extended tubes gradually increased. When the maximum inspiratory pressure of the ventilator was set 36 cmH2O, the difference reached 1.69 cmH2O. (2) The airway pressures (in cmH2O) dropped from (15.94±0.27)/(4.81±0.04), (20.09±0.23)/(6.05±0.16), (23.89±0.41)/(6.94±0.06), (27.90±0.22)/(7.71±0.18), (31.92±0.13)/(8.74±0.12), (35.65±0.31)/(9.72±0.07) to (13.42±0.4)/(3.15±0.14), (16.81±0.6)/(4.30±0.14), (20.22±0.5)/(5.48±0.45), (23.73±1.4)/(6.25±0.22), (24.78±0.7)/(7.13±0.21), (20.83±0.4)/(6.61±0.19)when the suction port of the open extension tube was opened (P<0.05);and the tidal volume (in L) also decreased from 0.328±0.004, 0.580±0.012, 0.621±0.003, 0.626±0.003, 0.615±0.003, 0.603±0.002 to 0.272±0.008, 0.416±0.051, 0.487±0.047, 0.396±0.116, 0.507±0.022, 0.508±0.079, respectively (P<0.05). The decrease of airway pressure and tidal volume gradually increased with the increase of ventilator setting pressure. When the ventilator setting parameter was 36/10 cmH2O, the decrease of airway inspiratory pressure was (14.82±0.51) cmH2O and the maximum reduction of tidal volume was (0.164±0.021)L. (3)The airway pressure (in cmH2O) was increased to(15.70±0.23)/(4.80±0.33), (19.01±0.81)/(5.71±0.34), (22.27±0.62)/(6.85±0.44), (25.35±2.09)/(7.94±0.16), (28.38±0.46)/(8.96±0.23), (33.34±0.71)/(9.71±0.25) when the suction tube was inserted from the suction port of the open extension tube in the open state, and the tidal volume (in L) was increased to 0.340±0.016, 0.563±0.020, 0.571±0.030, 0.556±0.026, 0.514±0.021, 0.512±0.031 as well.The airway pressure and tidal volume of the ventilation circuit were higher than those in the open state, but still lower than those in the closed state. Compared with the closed state of the suction port, the maximum pressure drop and tidal volume decrease were (3.53±0.46) cmH2O and (0.101±0.011) L, respectively. (4) The pressure of the ventilator was set between 16/5 cmH2O to 36/10 cmH2O. The airway pressure (in cmH2O) was decreased from (16.26±0.04)/(4.85±0.04), (20.74±0.15)/(6.42±0.11), (25.09±0.31)/(7.10±0.13), (29.38±0.24)/(8.17±0.09), (33.80±0.16)/(9.02±0.17), (37.89±0.19)/(9.83±0.07) to(16.36±0.06)/(4.85±0.04), (20.54±0.26)/(6.44±0.12), (24.36±0.24)/(7.01±0.33), (28.69±0.25)/(8.07±0.08), (32.97±0.33)/(8.93±0.09), (37.34±0.29)/(9.75±0.08), respectively during the insertion of the suction tube from the suction port of the closed extension tube, and the tidal volume (in L) was decreased from0.361±0.005, 0.592±0.003, 0.631±0.001, 0.642±0.007, 0.633±0.007, 0.626±0.08 to 0.335±0.005, 0.588±0.008, 0.631±0.002, 0.638±0.004, 0.628±0.004, 0.618±0.005.The maximum pressure change of the ventilation circuit was (0.83±0.27) cm H2O and the maximum tidal volume change was (0.008±0.006)L. The changes of airway pressure and tidal volume were significantly lower than those of ventilation circuit connected with open extension tube under the same pressure parameters. Conclusion: The connection of closed extension tube in mechanical ventilation circuit can reduce the airway leakage during artificial airway clearance, which is worthy of clinical recommendation.

A Novel Ocular Tonometry Task Trainer.

The measurement of intraocular pressure via ocular tonometry is a skill necessary for the evaluation of emergency department patients with ocular complaints. Accurate results inform the use of time-sensitive medications or invasive procedures. We sought to develop and evaluate an affordable, realistic, and reproducible task trainer to allow Emergency Medicine residents and medical students to practice tonometry. We placed an angiocatheter into the vitreous chamber of a swine eye through the optic nerve stump and sealed it with a purse string suture and cyanoacrylate glue. This allowed us to connect intravenous extension tubing and use a saline-filled syringe to repeatedly adjust intraocular pressure in real time. Optionally, this model can be mounted in a polystyrene foam mannequin head to enhance realism and facilitate practice. The task trainer was implemented in medical student and Emergency Medicine resident education at Vanderbilt University Medical Center. Thirty-six learners participated in the study, all of whom completed pre-course and post-course surveys. Among all learners, the mean comfort with performing tonometry improved significantly (3.26 to 7.64 {Z = -4.95, p < 0.005}). The mean confidence in the accuracy of measurements also increased (3.11 to 7.56 {Z = -4.8, p < 0.005}). On a 10-point scale, learners felt this task trainer was highly helpful in increasing their comfort with and the ability to perform tonometry (mean 9.19 {SD 1.19}). We have developed a low-cost and easily constructed ocular tonometry task trainer that resulted in significant improvement in learner comfort and confidence.

Shock ignition of aluminium particle clouds in the low-temperature regime

In this paper, we present results from spontaneous ignition of aluminium particle clouds in a series of shock tube experiments. For all experiments, the shock propagates along a narrow pile of 40-upmu m aluminium particles. The study includes shock Mach numbers in the range from 1.51 to 2.38. The results are visualised using photographic techniques and pressure gauges. The combination of two Phantom high-speed video cameras and a beamsplitter allows a compact schlieren setup mounted together with a dark-film high-speed camera. While the schlieren technique allows the shock features to be identified, the dark-film camera is used to capture the ignition and burning of the aluminium particle clouds. Based on extensive image processing and shock tube relations for reflected shocks, spontaneous ignition of the aluminium particle cloud is found to take place for reflected shock gas temperatures above 635 K. For increasing Mach numbers, we find a decreasing trend for the ignition delay. Additionally, the burning time is observed to decrease with increasing Mach number, indicating that the burning process is more efficient with increasing gas temperature.

Methods to estimate subpixel level small motion from video of vibrating cutting tools

Cutting tools can vibrate with frequencies of up to a few kHz with amplitudes ranging from a few µm to hundreds of µm. To characterize these vibrations using vision-based modal analysis methods, video of vibrating tools must be acquired at high speed and resolution. High speed acquisition will ensure modes are temporally resolved without aliasing, whereas high resolution acquisition ensures that the pixel size is small enough to resolve small motion. However, since most digital cameras trade speed for resolution, estimating small motion of high frequency modes becomes difficult. To address this issue, this paper presents new methods to estimate small motion from video of vibrating cutting tools. Two methods are illustrated on a video of a slender end mill. One is hardware-based, and the other is software-based. In the hardware-based method, we use combinations of extension tubes and a reverse ring fitted with a standard lens to achieve a pixel size of as less as 1.3 µm. In the software-based method, we leverage the capability of intensity- and phase-based motion registration methods to detect small subpixel level motion, even when the pixel size is 83 µm. In both methods we use the object’s own features to detect and register motion, thus overcoming the limitation of digital image correlation schemes that need markers for target tracking. Modal parameters evaluated from motion estimated with both methods are found to agree with those extracted from twice integrated accelerations. Since methods proposed herein proffer new ways to register small oscillatory motion, we believe that our findings will further help leverage the adoption of vision-based modal analysis methods in machine tool systems as an alternative to the more traditional experimental modal analysis procedures.

A precision-designed gastrostomy button securement device

BackgroundGastrostomy buttons (g-buttons) are commonly placed in children to facilitate weight gain, correct nutritional deficiencies, and provide hydration and/or medication delivery. At our institution, parents are taught to place a gauze sponge under their child's g-button and secure it with strips of tape; however, the g-button still moves in the tract, which delays wound healing and leads to a variety of tract-related complications. We viewed this universal problem as a challenge and a prime opportunity for innovation. MethodsIn 2016, a pediatric surgeon and a team of graduate engineering students outlined the problem, created a list of design requirements, and began to iterate on a variety of device designs. ResultsOver 400 design ideas were iterated upon to various degrees. The first prototype was studied in a small clinical trial, in which 80% of caregivers reported satisfaction with the design, but 90% noted difficulty connecting the extension feeding tube. A second-generation prototype was developed, which included a reusable lid and disposable base layer. Third- generation prototypes added “edge-grippers” to facilitate attaching the extension tubing, plus pre-cut absorbent, sterile gauze pads to fit around the stem of the g-button. Finally, in 2020, the design was finalized with the addition of a childproof hinge between the lid and base layer. ConclusionsAn intuitive g-button securement device was created to simplify daily gauze replacement, reduce tract-related complications, and lower the cost of care. A randomized controlled trial comparing the securement device to the “tic-tac-toe” dressing will begin in early 2022 with results available later this year.

Pulmonary Magnetic Resonance Imaging Replaces Bedside Imaging in Diagnosing Pneumonia in Infants.

Neonatal Bronchopulmonary Bedside Photography (NBBP) evaluates the consumption of lung magnetic resonance imaging as a replacement for bedside imaging in diagnosing infant pneumonia. In premature baby respiratory support, Neonatal Bronchopulmonary (NB) is one of the most dangerous consequences of accurate diagnosis that impact health alternatives once steroids are administered. Infants may experience eating issues and vomit if their condition is bad enough; lower birth weight, younger gestational age, and extensive breathing tube damage are the most frequently established risk factors as a component of a neonatal habitat. This paper introduces the Intelligent Medical Care (IMC) for Neonatal Bronchopulmonary Bedside Photography (NBBP), which enhances various preventive efforts such as prenatal steroid therapy. Because of many prenatal and postnatal variables, growth hormone and diet nutrients influence alveolar and vascular development. For the future prevention of NB, it is more likely that a combination of different therapies working on diverse causal pathways would be beneficial. This research in NBBP-IMC technology that enhances prenatal care medicines are the most excellent and effective treatments for all these neonates throughout the decades. As a result, premature babies at risk for NB may benefit from the findings of this research, which experts anticipate can inspire further studies in the area. The purpose of this paper is to emphasize the work performed to improve respiratory outcomes for babies at risk of NB and to place this work in perspective with relevant research currently being conducted simultaneously.

A pilot randomized controlled trial of securement bundles to reduce peripheral intravenous catheter failure

BackgroundPeripheral intravenous catheters (PIVCs) are ubiquitous in acute care settings however failure rates are unacceptably high, with around half failing before prescribed treatment is complete. The most effective dressing and securement option to prolong PIVC longevity is unclear. ObjectivesTo determine feasibility of conducting a definitive randomized controlled trial (RCT) investigating evidence-based securement bundles (medical adhesive tapes and supplementary securement products) to reduce PIVC failure. MethodsIn this pilot non-masked 3-group RCT, adults requiring a PIVC for >24 hrs were randomized to Standard care (bordered polyurethane dressing plus non-sterile tape over extension tubing), Securement Bundle 1 (two sterile tape strips over PIVC hub plus Standard care) or Securement Bundle 2 (Bundle 1 plus tubular bandage) with allocation concealed until study entry. Exclusions: laboratory-confirmed positive blood culture, current/high-risk of skin tear, or study product allergy. Primary outcome: feasibility (eligibility, recruitment, retention, protocol fidelity, participant/staff satisfaction). Secondary outcomes: PIVC failure, PIVC dwell time, adverse skin events, PIVC colonization and cost. ResultsOf 109 randomized participants, 104 were included in final analyses. Feasibility outcomes were met, except eligibility criterion (79%). Absolute PIVC failure was 38.2% (13/34) for Bundle 2, 25% (9/36) for Bundle 1 and 23.5% (8/34) for Standard care. Incidence rate ratio for PIVC failure/1000 catheter days, compared to Standard care, was 1.1 (95% confidence interval [CI] 0.4–2.7) and 2.1 (95% CI 0.9–5.1) for Bundles 1 and 2, respectively. ConclusionsA large RCT testing securement bundles is feasible, with adjustment to screening processes. Innovative dressing and securement solutions are needed to reduce unacceptable PIVC failure rates.Trial registration ACTRN12619000026123.

Design and application of an extension tube for ventilator pipeline

At present, the extension tube of the ventilator, a long corrugated tube used in clinical practice, needs to be disconnected from the endotracheal tube when performing open sputum suction. Under positive pressure, the condensed water containing pathogenic microorganisms in the ventilator will be splashed. Some will form aerosol suspended in the air, pollute the air, increase the risk of cross-infection and operator pollution, while the ventilator will emit a corresponding alarm sound, resulting in noise pollution. Based on the above factors, a ventilator pipeline extension tube was designed by the medical staff of department of critical care medicine of the Eighth Medical Center of People's Liberation Army General Hospital and department of critical care medicine of Beijing Friendship Hospital of Capital Medical University, and was obtained the National Utility Model Patent of China (ZL 2020 2 1476518.X). The device consists of the main pipe, first pipe sleeve, second pipe sleeve, valve body, joystick, axial sleeve, etc., which can not only effectively avoid air pollution and reduce the risk of cross-infection, but also reduce noise pollution and the negative impact of loud noise on patients and medical staff.

A simple technique to assess postoperative epidural functionality.

To describe an alternative method of measuring the Epidural Waveform Analysis (EWA), a technique through which anesthesiologists can confirm the position of a needle and/or catheter tip in the epidural space. EWA consists of epidural catheter transduction with a pressure system typically used for invasive arterial blood pressure monitoring which generates a characteristic oscillatory waveform (provided the catheter tip is within the epidural space) in synchrony with the pulsatile epidural circulation. The technique requires a double-male connector, a 3-way stopcock and an arterial pressure extension tubing along with the patient's existing arterial line setup while ensuring a meticulously sterile technique to mitigate the risks of neuraxial infection. The technique described herein has been successfully and routinely applied within our institution to measure EWA with the advantage of being potentially less wasteful. EWA allows anesthesiologists to confirm the correct position of an epidural needle/catheter. We describe a method of successfully measuring EWA while reducing wastefulness.

Effect of extension tube length on the damping coefficient and natural frequency in normotensive dogs.

To establish an acceptable extension tube length (ETL) to measure direct blood pressure (BP) in dogs. Prospective, experimental study. University-based small animal research facility. Eight healthy Beagle dogs: 6 males and 2 females. Each extension tube with lengths of 25, 50, 75, 115, 145, 205, and 275cm were connected after the catheterization with a 22-Ga catheter in the dorsal pedal artery in sternal recumbency. A square wave from the fast-flush test was consecutively recorded 5 times to analyze the system's dynamic response characteristics according to the ETL. After recording the square wave, the ETL was converted to a Latin square. The dynamic response was analyzed using natural frequency (NF) and the damping coefficient (DC), both of which affect the damping factor. The average values of NF and DC were plotted against a graph showing the damping factor. Linear regression was used to evaluate the between-group changes in NF and DC. The DC gradually increased from 0.21 to 0.29ξ, and the NF gradually decreased from 38 to 14Hz according to the increase in ETL (P<0.05). The dynamic response showed adequate damping with all ETLs. With an increase in ETL, the NF decreased significantly, while the DC demonstrated a less significant change. Therefore, NF had a greater influence on the damping factor of arterial BP measurement. There was no difference between ETLs from 25 to 275cm lines for measuring BP. An ETL of less than 275cm is recommended as the damping amount is adequate. Moreover, an ETL less than 275cm does not meaningfully affect BP measurement in dogs.

Numerical and experimental investigation of a solar absorber extension tube with turbulators for upgrading the performance of a solar dryer

PurposeDuring the past several years, research and studies in the field of solar energy have been continuously increased. One of the substantial applications of solar energy is related to industrial utilization for the drying process by efficient heat transfer methods. This study aims to upgrade the overall performance of an indirect solar dryer using a solar absorber extension tube (SET) equipped with ball-type turbulators.Design/methodology/approachIn this work, three various SETs including hollow (SET Type 1), 6-balls (SET Type 2) and 10-balls (SET Type 3), have been simulated using Fluent software to evaluate heat transfer characteristics and flow structure along the air passage. Then, the modified solar drying system has been manufactured and tested at different configurations.FindingsThe findings indicated that adding a SET improved the performance notably. According to the results, using turbulators in the tube has a positive effect on heat transfer. The highest overall thermal efficiency was found in the range of 51.47%–64.71% for the system with SET Type 3. The maximum efficiency increment of the system was found as 19% with the use of SET. Also, the average specific moisture extraction rate, which is a significant factor to survey the effectiveness of the dehumidification system was found between 0.20 and 0.38 kg kWh−1.Originality/valueIn the present study, a novel SET has been developed to upgrade the performance of the solar dehumidifier. This new approach makes it possible to improve both thermal and drying performances.

PEG-J replacement for duodenal levodopa infusion in Parkinson\u2019s disease patients: a retrospective study

BackgroundReducing percutaneous endoscopic gastrostomies with jejunal extension tubes (PEG-J) related complications is vital to the long-term preservation of duodenal levodopa infusion (DLI) in advanced Parkinson’s disease (APD). Here, we provide data on the frequency of complications for both the standard “pull” and the non-endoscopic, radiologic assisted, “push” replacement PEG-J techniques in APD.MethodsWe retrospectively identified all patients treated with DLI from October 2009 to January 2020 at the Movement Disorders Center. Patients features and demographics, PEG-J procedures, causes for any discontinuation, reported complications and mortality were collected. In this cohort, PEG-J replacements were performed using the standard “pull” procedure or the radiologic assisted “push” method. Descriptive statistical analysis, t-test and paired t-test with False Discovery Rate correction was performed.ResultsThis retrospective study included 30 APD patients [median age 72 ± 5.6 years; mean disease duration 17.2 + 5.7 years]. Mean treatment duration was 35.6 (30.6) months. Overall, 156 PEG-J procedures were performed, and Nineteen patients (63.3%) had a total of 185 reported complications, 85 of which were peristomal complications. 17 (56.6%) underwent 100 replacement procedures due to complications. The most commonly reported complication for replacement was J-tube dislocation (36%). One patient discontinued treatment after 6 months, due to peripheral neuropathy. Six patients died for causes not related to DLI. PEG-J replacements performed with the “push” method had a higher turnover (5.6 vs. 7.6 mo.), but fewer reported complications (67 vs. 75%).ConclusionThe overall rate of complications was lower for “push” technique. This result might have been due to a higher replacement turnover that acted as a protective factor.

Prandial Diarrhea: A Rare Late Complication After Percutaneous Endoscopic Gastrostomy With Jejunal Extension Tube Placement

Prandial Diarrhea: A Rare Late Complication After Percutaneous Endoscopic Gastrostomy With Jejunal Extension Tube Placement

Abstract 14042: Characterization of Multi-Cell-Type Engineered Heart Tissues Containing Human iPSC-Derived Cardiomyocytes, Endothelial Cells, Fibroblasts, Smooth Muscle Cells and Macrophages

Introduction: Induction of a pathological type of hypertrophy in human engineered heart tissues (EHTs) has not yet been fully achieved. We hypothesized that this limitation is caused by the unicellularity of EHTs, which contain only cardiomyocytes (CMs) and lack the interactions with non-myocytes. Thus, we aimed to generate EHTs implementing five native cardiac cell types, i.e., CMs, endothelial cells (ECs), fibroblasts (Fbs), smooth muscle cells (SMCs), and macrophages (Mϕ). Methods and Results: CMs were differentiated from hiPSCs by mesodermal induction followed by inhibition of Wnt-signaling. Mesoderm progenitors were also used to differentiate ECs via VEGF stimulation. Differentiation into SMCs and Fbs required Wnt pathway activation followed by stimulation with TGFβ+bFGF or bFGF only, respectively. Finally, Mϕ differentiation required hematopoietic/myeloid specification by IL-3 and M-CSF treatment. Successful differentiation was analyzed by electron microscopy (EM) and expression profiling of hallmark genes and proteins. For instance, Mϕs exhibited high expression of myeloid markers (98.0% CD68 + , 90.9% CD14 + ) whereas Fbs showed upregulation in genes such as POSTN, DDR2, COL1A1 (all &gt;100 fold higher than iPSCs). Functionality of all cell types was demonstrated by multiple assays. For example, the native Mϕ function was demonstrated via degradation and phagocytosis assays while ECs exhibited fast and extensive tube formation in matrigel assays. Additionally, Fbs produced 4.6x more collagen after TGFβ stimulation than unstimulated controls. In effect, multi-cell-type EHTs were generated from 60% CMs, 20% ECs, 10% Mϕ, 5% SMCs and 5% Fbs. These EHTs were characterized by confocal microscopy, serial block-face scanning EM, gene expression profiling, and automated contractility measurements. Pilot experiments revealed that the addition of different cell types accelerated the development of EHTs which was associated with earlier onset of beating and shorter diameter of the EHTs. Conclusion: Successful application of cell differentiation protocols resulted in the integration of five cell types in a multi-cell-type EHT system. The full functional profile and reaction to a stress stimulus will be investigated in future experiments.

Intraoperative Simulation: Team Training for Resuscitation While Using Intraoperative Computed Tomography: 2-Dimensional Operative Video.

Spine surgeons increasingly use intraoperative computed tomography (iCT) to facilitate surgery. iCT has several advantages, including the ability to decrease radiation exposure, improve surgical accuracy, and decrease operative time.1-3 However, the large footprint of the equipment can impede fast patient access in the event of an emergency resuscitation. This challenge is compounded when the patient is prone with rigid head fixation. To achieve fast, high-quality resuscitation, a large team must overcome numerous challenges. Cohesive team functioning under these circumstances requires planning, practice, and refinement.4 As a result of our simulation sessions, we have made several changes to the setup of our iCT cases. The following equipment is now routinely used: extralong tubing between the anesthesia circuit and patient, portable vital monitor, additional intravenous access is obtained, and extension tubing is used with all lines. We have created educational diagrams to streamline 2 challenging processes: optimal bed placement (for supination) and removal of equipment from the operating room (OR) to accommodate an influx of emergency personnel and equipment. Since the implementation of this protocol, 1 prone posterior cervical patient had intraoperative cardiac arrest. The protocol was followed. Return of spontaneous circulation was achieved within 5 min. The patient was discharged from the hospital with no neurological sequelae. During debriefing, stakeholders uniformly credited the simulated practice with this positive outcome. Emergency planning is a multifaceted process that continually evolves. With a steady flux of personnel and equipment, ongoing practice is essential to ensure readiness. Here, we share the key elements of our twice-yearly simulation. This simulation was performed on a training mannequin. This study did not involve human subjects. Any depictions of care rendered to nonidentifiable patients were standard (nonexperimental).

Thermal decomposition of triruthenium dodecacarbonyl investigated by variable-temperature mass spectrometry in the gas phase

The thermal decomposition processes of chemically prepared triruthenium dodecacarbonyl, Ru3(CO)12, were investigated by variable-temperature mass spectrometry (MS) in the gas phase. Ru3(CO)12 was sublimated and merged in a molecular beam of He and CO gases and was heated to a high temperature in an extension tube. Subsequently, it was probed by MS after photoionization at 7.89 eV. CO ligand molecules were sequentially released in the temperature range of 500–900 K, forming Ru3. Among the intermediate cluster compositions, Ru3(CO)7 was the most thermally durable cluster, while Ru3(CO)3, Ru3(CO)5, and Ru3(CO)10 were less durable and decomposed within a narrow temperature range.

Design and application of a push-pull adjustable artificial dead space

Using artificial dead space to correct hypocapnia or induce hypercapnia is of particular significance for diagnosing and treating specific neurocritical diseases. At present, the above purpose is mainly achieved by adding an extension tube between the Y-type connector of the ventilator and the artificial airway in clinical practice. However, its volume is often fixed and cannot adapt to the individualized diagnosis and treatment in different clinical scenarios. The research group led by Professor Zhou Jianxin from the department of critical care medicine of Beijing Tiantan Hospital, Capital Medical University, has designed an artificial dead cavity with adjustable volume based on years of research in the respiratory field and has been granted a national utility model patent (patent number: ZL 2020 2 0496413.4). The artificial dead chamber is simple in structure, composed of a barrel body, a piston head, and a push-pull rod. By freely adjusting the size of the artificial dead chamber volume, it can accurately regulate the target carbon dioxide, correct the spontaneous hyperventilation, terminate intractable hiccup, and shorten the operation time of asphyxia test in clinical diagnosis of brain death while correcting hypocapnia or inducing hypercapnia. It has the advantages of solid reliability, convenient operation, and low production cost, which significantly facilitates scientific research and clinical diagnosis and treatment.

Direct endoscopic placement of percutaneous endoscopic gastrostomies with jejunal extension tubes (PEG-J) using ultra-thin endoscopes - long-term outcomes from a U.S. tertiary referral center.

Several techniques for PEG-J tube placement have been described, commonly requiring fluoroscopic guidance and/or fixation of the jejunostomy tube (J-tube) into the small intestine. We describe a modified technique for placing jejunostomy tubes under direct visualization through a PEG with the use of ultra-thin endoscopes and steel guidewire. A retrospective study at a single tertiary academic center evaluating patients who underwent PEG-J placement between 2010 and 2020. All PEG tubes were placed with a pull-through technique. The Olympus GIF-N180 endoscope was advanced through the PEG to the jejunum and a Savary-Gilliard guidewire was used for placement of the J-tube extension. Fifty-eight patients underwent PEG-J placement (median age 61years; women 52%). Surgically altered gastric anatomy was observed in 11 patients (19%). Median procedure time was 44min for new PEG-J tube placement (range 26-103) and 20min for placement of a J-tube extension through an existing PEG tube (range 9-86) or gastrostomy tract. Technical success rate was in 100%. Sixty-two repeat procedures were performed for J-tube exchange in 27 patients (46%, range 1-9 per patient), of which 51 procedures (82%) were done using the same technique. The most common indication for tube replacement was tube dysfunction (63%, n = 39). The median procedure time for tube exchange was 20min (range 2-62). No major adverse events were encountered. PEG-J tubes can be placed effectively, rapidly, and safely using an ultra-thin caliber endoscope and a stiff steel wire through the PEG tube or mature gastrostomy site, precluding the need for fluoroscopy or oral access. J-tubes can be easily replaced utilizing the same technique.

"Cannot intubate, cannot oxygenate": A novel 2-operator technique for cannula tracheotomy in an infant animal model-a feasibility study.

Evidence regarding optimal management of the "Cannot Intubate, Cannot Oxygenate" (CICO) scenario in infants is scarce. When inserting a transtracheal cannula for front of neck access direct aspiration to confirm intratracheal location is standard practice. This postmortem "infant airway" animal model study describes a novel technique for cannula tracheotomy. To compare a novel technique of cannula tracheotomy to an accepted technique to assess success and complication rates. Two experienced proceduralists repeatedly performed tracheotomy using an 18-gauge BD InsyteTM cannula (BD, Franklin Lakes, NJ, USA) in 6 postmortem White New Zealand rabbits. Cannulas were attached either directly to a 5ml syringe (Direct Aspiration) or via a 25cm length minimum volume extension tubing set (TUTA Healthcare Lidcombe, NSW, Australia) (Indirect Aspiration, 2 operator technique). Each technique was attempted a maximum of 12 times per rabbit with an ENT surgeon assessing success and complication rates endoscopically for each attempt. 72 tracheotomy attempts were made in total, 36 for each technique. Initial aspiration through the needle was achieved in 93% (97.2% direct versus 89% indirect). Advancement of the cannula and continued aspiration (success) into the trachea occurred in 67% for direct compared with 64% for indirect aspiration. Direct aspiration was associated with higher rates of lateral (10.3% versus 5.6%) and posterior (19.4% versus 13.9%) wall injury compared with the indirect 2-operator technique. Cannula tracheotomy in infant-sized airways is technically difficult and seems frequently associated with tracheal wall injury. The reduced incidence of injury in the indirect group warrants further investigation in preclinical and clinical trials.