Confirmation Of Placement Research Articles

Schlemm's Bidirectional Fluid Wave and Luminal Blood Reflux as Novel Intra-Operative Signs Confirming Optimal Placement of the iStent.

Trabecular micro-bypass devices (TBDs) such as the iStent series (Glaukos Corporation, Laguna Hills, CA), are effective in reducing intraocular pressure (IOP). However, precise placement of TBDs is crucial in achieving surgical efficacy, as device malpositioning may lead to suboptimal IOP reduction. We demonstrate two novel intra-operative signs to aid confirmation of accurate iStent placement, without reliance on imaging technologies. Surgical technique report with video accompaniment. Two intra-operative clinical signs which confirm optimal iStent placement are described: (1) Luminal Blood Reflux - achieved by gently decompressing the anterior chamber, with or without flushing of the stent lumen with balanced salt solution (BSS), thereby confirming stent positioning in the Schlemm's Canal (SC). (2) Schlemm's Bidirectional Fluid Wave (SBFW) - observable when flushing with BSS, suggesting fluid movement in the canal segments adjacent to the iStent device, thereby confirming stent patency and positioning in the SC. The identified signs are useful, feasible and reproducible indicators of accurate iStent placement. Future studies may evaluate the application of these confirmatory manoeuvres in diverse clinical contexts and further establish correlation with clinical outcomes.

A Surgical Technique Guide for Percutaneous Screw Fixation for Metastatic Pelvic Lesions.

The pelvis is one of the most common areas for metastatic bone disease. We recently described the use of a minimally invasive percutaneous screw fixation of metastatic non-periacetabular pelvic lesions, with excellent results. The procedure can be completed in a standard operating theater without the need for special instruments. In our video we describe the appropriate intraoperative patient positioning, surgical equipment, surgical approach, and obtainment of the necessary fluoroscopic views for placement of various pelvic percutaneous screws. Alternative treatments include surgical procedures such as curettage, cement packing, and modified Harrington total hip arthroplasty through extensive open approaches. Additionally, as an alternative to standard fluoroscopy, intraoperative navigation and an O-arm could be utilized for the placement of screws. In our experience, intraoperative navigation has been helpful for confirmation of final screw placement and length. Overreliance on intraoperative navigation in the setting of poor bone quality and an abandonment of tactile feedback and the various tips described in this video article can lead to inadvertent extraosseous screw placement and injury. Furthermore, as navigation involves only a virtually computed image, we have found it challenging to utilize in complex, curved bones, such as the superior pubic ramus. Percutaneous screw fixation is safe and effective for the treatment of metastatic non-periacetabular pelvic lesions. Given the simplicity of the technique and instrumentation, and the tolerance of concomitant treatments, this approach is worthy of broader consideration. In our recent study, 22 consecutive patients with painful non-periacetabular pelvic metastatic cancer underwent percutaneous screw fixation. There were no surgical complications. Postoperatively, there was significant improvement in visual analog scale pain scores and functional Eastern Cooperative Oncology Group scores, as compared with baseline3. Despite the simplicity of the intraoperative set-up and instrumentation, the procedure is technically demanding. Obtaining the correct fluoroscopic views and troubleshooting intraoperative hurdles can be challenging. CT = computed tomographyASIS = anterior superior iliac spineGT = greater trochanterAP = anteroposteriorAIIS = anterior inferior iliac spineSI = sacroiliacTSTI = transsacral-transiliacVAS = visual analog scaleECOG = Eastern Cooperative Oncology GroupDVT = deep vein thrombosis.

Precision of Intraoperative Cone-Beam Computed Tomography in Electrode Placement and Complications in Asleep Deep Brain Stimulation Surgery: A Multidetector Computed Tomography-Verified Comparative Study.

Successful deep brain stimulation (DBS) requires precise electrode placement. However, brain shift from loss of cerebrospinal fluid or pneumocephalus still affects aim accuracy. Multidetector computed tomography (MDCT) provides absolute spatial sensitivity, and intraoperative cone-beam computed tomography (iCBCT) has become increasingly used in DBS procedures. However, its accuracy is unclear. We examined iCBCT accuracy and the need for postoperative imaging to confirm electrode position and assess complications of DBS surgery. Thirty-two movement disorder patients, and 69 targets were retrospectively reviewed. All patients had preoperative non-stereotactic 3.0 Tesla magnetic resonance imaging (MRI), preoperative stereotactic MDCT, post-implantation iCBCT, and postoperative conventional MDCT scans. Stereotactic coordinates of electrode tips were compared between postoperative MDCT and iCBCT. We calculated the absolute and Euclidian differences (ED) between iCBCT and postoperative MDCT coordinates for each electrode. To assess whether intraoperative brain shifting influenced electrode tip localisation, subdural pneumocephalus volume was measured in iCBCT images. The mean absolute (scalar) differences in x, y, and z coordinates were not significantly different from the absolute precision value of 0 (p 0.05). The mean ED between the iCBCT electrode tip and the postoperative MDCT electrode tip coordinates was 1mm (0.55±0.03 mm) and differed significantly from zero (p 0.0001). There was no correlation between pneumocephalus volume and electrode coordinate deviation. iCBCT can eliminate the need for routine postoperative studies since it is a safe, effective, and rapid procedure that can be performed at any step of the surgery. It provides reliable and definitive confirmation of correct DBS electrode placement.

Preoperative Multivariable Model for Risk Stratification of Hypoxemia During One-Lung Ventilation.

Hypoxemia occurs with relative frequency during one-lung ventilation (OLV) despite advances in airway management. Lung perfusion scans are thought to be one of the most accurate methods to predict hypoxemia during OLV, but their complexity and costs are well-known limitations. There is a lack of preoperative stratification models to estimate the risk of intraoperative hypoxemia among patients undergoing thoracic surgery. Our primary objective was to develop a risk stratification model for hypoxemia during OLV based on preoperative clinical variables. This is a single-center, retrospective cohort study including 3228 patients who underwent lung resections with OLV from 2017 to 2022, at a tertiary academic health care center in the United States. Vital signs and ventilator settings were retrieved minute by minute. Intraoperative hypoxemia was defined as an episode of oxygen desaturation (Spo2 <90%) for at least 5 minutes. Demographic and clinical characteristics were included in a stepwise logistic regression, which was used for the selection of predictors of the risk score model. All patients included in this cohort underwent elective lung surgery in lateral decubitus position, with double lumen tube and placement confirmation with fiberoptic bronchoscopy. Our model was validated internally using area under the receiver operating curves (AUC) with bootstrapping correction. The incidence of hypoxemia during OLV was 8.9% (95% confidence interval [CI], 8.0-10.0). Multivariable logistic regression identified 9 risk factors with their corresponding scoring: preoperative Spo2 <92% (15 points), hemoglobin <10 g/dL (6 points), age >60 years old (4 points), male sex (4 points), body mass index >30 kg/m2 (8 points), diabetes mellitus (4 points), congestive heart failure (7 points), hypertension (3 points), and right-sided surgery (3 points). The AUC of the model after bootstrap correction was 0.708 (95% CI, 0.676-0.74). Based on the highest Youden index, the optimal score for predicting intraoperative hypoxemia was 13. The risk of hypoxemia increased from 4.7% in the first quartile of scores (0-13 points), to 32% in the third quartile (27-39 points), and 83.3% in the fourth quartile (>39 points). At scores of 20 or greater, the specificity of the model exceeded 90% and reached a positive predictive value of 80%. The risk of hypoxemia during OLV can be stratified preoperatively using accessible clinical variables. Our risk model is well calibrated but showed moderate discrimination for predicting intraoperative hypoxemia. The accuracy of preoperative models for risk stratification of hypoxemia during OLV should be explored in prospective studies.

Clinical Evaluation of the NaviNetics Stereotactic System Using Intraoperative Portable Surgical Imaging System in DBS Surgery

BACKGROUND AND OBJECTIVES: A typical workflow for deep brain stimulation (DBS) surgery consists of head frame placement, followed by stereotactic computed tomography (CT) or MRI before surgical implantation of the hardware. At some institutions, this workflow is prolonged when the imaging scanner is located far away from the operating room, thereby increasing workflow times by the addition of transport times. Recently, the intraoperative O-arm has been shown to provide accurate image fusion with preoperative CT or MR imaging, suggesting the possibility of obtaining an intraoperative localization scan and postoperative confirmation. In this article, we aim to evaluate the compatibility of the stereotactic frame system with the intraoperative O-arm system regarding lead accuracy and surgical flow. METHODS: A total of 17 patients undergoing DBS surgery for movement disorders were evaluated. One patient underwent both the stereotactic CT and O-arm localization, while 16 patients underwent only intraoperative O-arm localization. Following lead placement, intraoperative O-arm imaging was obtained to evaluate the accuracy of the lead placement. Accuracy was defined as the error measured as the distance from the center of the planned trajectory to the cannula. RESULTS: Less than 0.1 mm difference was found between the O-arm imaging technique and CT image localization of the NaviNetics stereotactic head frame in DBS surgery. Of the 16 patients who underwent the intraoperative O-arm imaging alone, the targets included bilateral ventral intermediate nucleus (16 leads), bilateral globus pallidus internus (4 leads), and subthalamic nucleus (12 leads). The mean ± SD radial error in the probe's eye view was 0.71 ± 0.33 mm for n = 32 leads. No tract hemorrhage was observed. CONCLUSION: Intraoperative O-arm imaging can be used safely and effectively for stereotactic registration and lead placement confirmation with the stereotactic system in both awake and asleep DBS surgery.

Tracheostomy tube changes by speech-language pathologists: a service review of an expanded scope of practice

Background/Aims Patients in acute care who have received a tracheotomy require efficient management to adequately progress through the acute care setting. This progression is predicated on efficient tracheostomy weaning through tracheostomy downsizing, capping and decannulation. The objective of this retrospective study was to review the outcomes of tracheostomy tube changes by speech-language pathologists. Methods A retrospective cohort analysis was performed of adult patients who received a tracheostomy tube change during their acute care hospitalisation by speech-language pathologists during a 6-month span in 2022. A total of 38 consecutive referrals undergoing an initial tracheostomy tube change had their electronic medical records reviewed. Success was defined as the placement of the tracheostomy tube into the tracheal lumen with confirmation of placement with no adverse events. Complications were recorded at the time of the tracheostomy tube change. Results Speech-language pathologists performed 38 (100%) initial tracheostomy tube changes successfully at the bedside without complications. The primary referral services were trauma and neurology. The primary diagnoses were polytrauma with a traumatic brain injury and multiple trauma without a traumatic brain injury or spinal cord injury. The mean Glasgow Coma Scale score and number of intubations were 12.4 and 1.4 respectively. A total of 34 (89%) tracheostomy tube changes resulted in the downsizing of the tracheostomy tube, while the remainder of tracheostomy tube changes (n=4; 11%) maintained the same size but were cuffless. All the tracheostomy tube changes were completed without complications, and all patients were noted as stable after 24 hours. Conclusions The procedural success corroborates the data reported by an earlier study in the literature and further validates the efficacy of a competent and experienced speech-language pathologists' ability to perform low-risk tracheostomy tube changes in the acute setting. This study demonstrates real world data from a single large trauma centre of tracheostomy tube changes performed by speech-language pathologists. Such data better defines the emerging role expansion of speech-language pathologists in the acute care setting. Implications for practice This study has the potential to expand the discussion around speech-language pathologists changing tracheostomy tubes in the acute care setting for a low-risk cohort. The authors have outlined the requisite training that may serve as a resource for speech-language pathologists to develop procedural competency.

A Nurse-Driven Protocol for Neonatal Enteral Access Device Placement Confirmation.

Preterm infants require the use of nasogastric and orogastric enteral access devices (EADs) to provide nutrition and medications. Confirmation of the location of the tip of the EAD is essential to minimize complications. At the study site, EAD location was limited to verifying the centimeter marking at the lip/nares and nonevidence-based methods of visual observation of aspirate and auscultation. Implement an evidenced-based EAD placement confirmation protocol, and by 90days post-education and implementation, achieve adherence of 90%. This quality improvement project implemented a nurse-driven evidence-based protocol for EAD verification. The intervention was based on the New Opportunities for Verification of Enteral Tube Location best practice recommendations. Prior to implementation, education sessions focused on insertion measurement technique and gastric pH measurement. Radiographs, insertion measurement technique, centimeter marking, and gastric pH measurement were used for EAD location confirmation. To determine compliance with the protocol, audits were conducted and questionnaires assessing current practice regarding EAD confirmation were administered pre- and postimplementation. The protocol increased nursing knowledge regarding evidence-based EAD insertion and verification procedures, incorporated pH measurement into practice, and reduced use of auscultation for confirmation. Nursing adherence to the protocol was 92%. This provides a model for how to successfully implement and achieve adherence to an evidence-based EAD placement confirmation nurse-driven protocol. Further research is needed to verify the effectiveness of the protocol and establish consensus on approaches specifically for the neonatal population.

Comparison between ultrasonography and capnography for ascertaining placement of endotracheal tube in patients undergoing general anesthesia – A prospective observational study

Background: Confirmation of the position of the endotracheal tube (ETT) is an essential step for verification of intubation. Failure to diagnose esophageal intubation may lead to fatal consequences. Capnography is the gold standard for confirmation of ETT position, but it is practically impossible to be performed in all situations. Ultrasonography (USG) or “visual stethoscope” can be used as an effective alternative for all intubators in all situations. Aims and Objectives: The study was conducted to evaluate the ultrasonography (USG) technique with respect to its efficacy to detect the proper endotracheal position of ETT compared to end-tidal capnography among patients undergoing general anesthesia; to compare the time taken by the USG technique with that of capnography for detection of proper placement of ETT; to assess the feasibility of USG to detect accidental esophageal intubation. Materials and Methods: This prospective comparative cross-sectional observational study was conducted on 68 patients. Both capnography and upper airway USG were performed immediately after intubation to confirm the ETT placement. Sensitivity, specificity, and positive and negative predictive values of upper airway USG were determined against capnography as the reference method. The time required to determine ETT placement by the two methods was found out and compared. Agreement between the methods was assessed with kappa statistics. Results: USG detected all three cases of esophageal intubation but could not detect two patients with correct tracheal intubation. Upper airway USG had a sensitivity of 96.92% (95% confidence interval [CI]: 93.54–100%), specificity of 100%, positive predictive value of 100%, and negative predictive value of 60% (95% CI: 50.4–69.6%). The Kappa value was found to be 0.735, indicating a good agreement between upper airway USG and capnography for confirmation of ETT placement. Time taken for confirmation of ETT by capnography was 21.68±2.63 s versus 11.44±1.38 s for upper airway USG (P&lt;0.001). USG demonstrated bilateral lung sliding in 60 (88.2%) patients, unilateral lung sliding in 3 (4.4%) patients, and lung sliding was absent in 5 (7.4%) patients. Conclusion: Real-time upper airway USG is an alternative method of confirmation of ETT that is not only sensitive and accurate but is faster than the current gold standard method, capnography.

Should We Stitch-Close the Fetoscopic Percutaneous Access? A Case-Series of Laparotomy to Trans-Amniotic Membrane Suturing for Intrauterine Port Placement in Fetoscopic Surgery for Twins

Introduction: Maternal laparotomy-assisted fetoscopic surgery for in-utero myelomeningocele repair has shown that a trans-amniotic membrane suture during fetoscopic port placement can reduce postsurgical complications. Fetoscopic laser photocoagulation (FLP) for complex twins is typically performed percutaneously without a transmembrane stitch. However, in scenarios without a placental-free window, maternal laparotomy may be used for recipient sac access. Here, we present the outcomes of our series of laparotomy-assisted FLP cases, including a trans-amniotic membrane suturing of the fetoscopic port. Methods: Retrospective series of twin-twin transfusion syndrome or twin anemia-polycythemia sequence (TAPS) cases treated at 2 fetal centers that underwent maternal laparotomy to FLP from September 2017 to January 2023. We recorded preoperative and operative characteristics, as well as pregnancy and neonatal outcomes. Results: During the study period, 9 maternal laparotomy to FLP cases were performed. Two were excluded for prior percutaneous FLP in the pregnancy. The remaining seven utilized a maternal laparotomy to trans-amniotic membrane stitch with confirmation of proper suture placement under ultrasound guidance, and all surgeries were performed with a single 10 F Check-Flo® cannula. Mean gestational age (GA) at surgery was 19.1 weeks (range 16 weeks 4 days–23 weeks 3 days), with delivery occurring at a mean GA of 35.0 weeks (range 32 weeks 0 days–37 weeks 1 day), resulting in a mean latency of 15.8 weeks, significantly longer than what is reported in the literature and our own data (mean latency for percutaneous FLP 10.2, 95% CI 9.9–10.5). Furthermore, all cases underwent iatrogenic delivery before labor onset, with the lone delivery prior to 34 weeks due to concern for post-laser TAPS. Conclusion: This case series of laparotomy to FLP with trans-amniotic stitch, demonstrated no cases of spontaneous preterm birth and a longer-than-expected latency from surgery to delivery. Larger studies are warranted to investigate this approach.

A Quality Improvement Initiative to Increase Confirmation of Prehospital Endotracheal Tube Placement at Emergency Department Transfer of Care

Objectives Rates of prehospital unplanned extubation (UE) range from 0 to 25% and are the result of many factors, including patient movement. Transfer of care of intubated patients to the emergency department (ED) involves significant patient movement and represents a high-risk event for UE. Frequent confirmation of endotracheal tube (ETT) placement is imperative for early recognition of UE and to minimize patient harm. Methods Local Practice—Our baseline rate of verbal ETT position confirmation with a member of the ED team during ED transfer of care was 74%. Our goal was to increase this practice to >90% in six months. This project was completed in partnership with Toronto Paramedic Services. Prehospital electronic patient care records (ePCRs) were reviewed weekly to determine the proportion of intubated patients who had ETT placement confirmed in the ED at transfer of care. Interventions—Pre- and post-project paramedic focus groups were conducted to identify potential drivers, change ideas, and project feedback. Three staggered interventions were introduced over five months: (1) memorandums to paramedics, ED chiefs and respiratory therapy leads, (2) individualized paramedic feedback e-mails, and (3) ePCR changes and closing rules. Results The pre-project focus group identified several potential drivers, such as physical barriers, interprofessional relationships, and communication. ETT confirmation remained ≥90% for the last eight weeks and interventions resulted in special cause variation. Median cases without verbal confirmation between paramedics and ED staff reduced from 5/week (IQR 2.5, 6.5) to 1/week (IQR 0, 2). UE was identified in 0.6% (2/340) of patients with ETT confirmation. The post-project focus group noted improvements in perceived accountability, interprofessional relationships, and satisfaction with interventions. Conclusion Through a series of interventions, we improved the rate of ETT confirmation during ED transfer of care. Although rates of UE were low, improvement in ETT confirmation may lead to faster recognition of UE when it does occur thereby mitigating complications. The observed improvement was sustained after interventions ended.

Required volume for color flow injection test to confirm the intravascular placement of a peripheral venous catheter

Background: Confirmation of adequate peripheral intravenous catheter placement is essential before using venous catheters. The color flow injection test has been reported as a method with high sensitivity and specificity for this purpose. The technique involves administrating saline through the peripheral venous route to observe changes in the color flow pattern around the same vein at a more central location. However, the required volume of saline remains uncertain. This study aims to determine the appropriate dosage for conducting the test in pediatric patients and explore any potential correlations between dosage and patient characteristics. Methods: A prospective study was conducted in children under 6 years of age with American Society of Anesthesiologists Physical Status 1–2 presenting for general anesthesia. After an intravenous cannula was placed in the forearm under general anesthesia, normal saline was injected at a speed of approximately 1 mL/s while the axillary artery and vein were observed with color flow Doppler imaging. The volume of normal saline required to induce a change in the color flow pattern around the vessels was measured. Measurements were performed twice and averaged for comparison with patient characteristics and other factors. Results: The study cohort included 30 patients aged from 0.3 to 5.5 (2.6 ± 1.6) years. The change in color flow Doppler imaging was noted in all the patients, and the average volume was 1.40 ± 0.36 mL (95% confidence interval (CI), 1.27–1.54; p &lt; 0.001), which was significantly correlated with age, with a correlation coefficient of 0.435 (95% CI, 0.09–0.69; p = 0.02). Conclusions: The required volume for the color flow injection test is small; therefore, the test is easy to perform and minimally invasive in pediatric patients.

Hampshire Sheep as a Large-Animal Model for Cochlear Implantation.

Sheep have been proposed as a large-animal model for studying cochlear implantation. However, prior sheep studies report that the facial nerve (FN) obscures the round window membrane (RWM), requiring FN sacrifice or a retrofacial opening to access the middle-ear cavity posterior to the FN for cochlear implantation. We investigated surgical access to the RWM in Hampshire sheep compared to Suffolk-Dorset sheep and the feasibility of Hampshire sheep for cochlear implantation via a facial recess approach. Sixteen temporal bones from cadaveric sheep heads (ten Hampshire and six Suffolk-Dorset) were dissected to gain surgical access to the RWM via an extended facial recess approach. RWM visibility was graded using St. Thomas' Hospital (STH) classification. Cochlear implant (CI) electrode array insertion was performed in two Hampshire specimens. Micro-CT scans were obtained for each temporal bone, with confirmation of appropriate electrode array placement and segmentation of the inner ear structures. Visibility of the RWM on average was 83% in Hampshire specimens and 59% in Suffolk-Dorset specimens (p = 0.0262). Hampshire RWM visibility was Type I (100% visibility) for three specimens and Type IIa (> 50% visibility) for seven specimens. Suffolk-Dorset RWM visibility was Type IIa for four specimens and Type IIb (< 50% visibility) for two specimens. FN appeared to course more anterolaterally in Suffolk-Dorset specimens. Micro-CT confirmed appropriate CI electrode array placement in the scala tympani without apparent basilar membrane rupture. Hampshire sheep appear to be a suitable large-animal model for CI electrode insertion via an extended facial recess approach without sacrificing the FN. In this small sample, Hampshire specimens had improved RWM visibility compared to Suffolk-Dorset. Thus, Hampshire sheep may be superior to other breeds for ease of cochlear implantation, with FN and facial recess anatomy more similar to humans.

An enigmatic Anthophorine bee from the south of France revealed as a new species: Anthophora (Paramegilla) ahlamae n. sp. (Hymenoptera: Apidae)

Summary A bee specimen identified as Anthophora planca Pérez, 1895, from France, was discovered in collections of Museum für Naturkunde, Berlin. This male specimen presents a morphology that does not conform to any of the Anthophora Latreille, 1803 species known from France, or indeed from Europe. After careful examination, it cannot be identified as Anthophora planca Pérez which is considered to be a nomen dubium (type lost), but furthermore it does not belong to any currently described species. Additional specimens of this species were collected in Morocco, Spain (Melilla) and Algeria. The new species is named Anthophora (Paramegilla) ahlamae Rasmont & Wood, n. sp. The new species is documented by numerous high-resolution photographs. Its diagnosis is compared with the near species Anthophora (Paramegilla) gallica (Dalla Torre & Friese, 1895) and A. (Paramegilla) podagra Lepeletier, 1841. DNA barcodes data are presented, allowing for confirmation of placement within the subgenus Paramegilla Friese, 1897. A detailed distribution map is provided along with ecological observations. Anthophora ahlamae n. sp. may be specialised on flowers of the genus Ballota L. (Lamiaceae).

Novel Cost-Effective Model for Training Post-intubation Endotracheal Tube Placement Confirmation.

Intubation in emergency settings demands rapid confirmation of endotracheal tube (ETT) placement for establishing a definitive airway. Current methods, including capnography and auscultation, have limitations. This study introduces a cost-effective and easily accessible training model for confirming ETT placement using ultrasound, aiming to improve training and patient outcomes. We developed a gelatin and psyllium-based model that simulates adult ETT intubation, offering an alternative to costly cadaveric models. The model's construction is described, with materials costing approximately $7.34 per unit. Preliminary results show promise in simulating tracheal and esophageal intubation scenarios. This novel model provides an ethical and economical solution for training healthcare professionals in the ultrasound confirmation of ETT placement, paving the way for further validation and adoption in medical education.

Confirmation of correct placement of nasogastric / orogastric tube on Point of Care Ultrasound (POCUS) in pediatric critical care unit patients.

Objective: To determine frequency of correct placement of nasogastric /orogastric tube on POCUS in pediatric critical care unit patients. Study Design: Descriptive cross-sectional. Setting: High Dependency Unit and Pediatric Intensive Care Unit, Indus Hospital Health Network, Karachi, Pakistan. Period: November 2022 to April 2023. Methods: Patients of age 1 months to 15 years of age requiring NGT placement were enrolled into the study. Patients with nasal surgery, fracture of skull base/ face, bleeding, coagulopathy, esophageal varices, stricture, upper gastrointestinal surgery were excluded from this study. NG tube was passed by principal investigator after evaluating correct size and length measurement. After passing the NG tube, gastric aspiration and gastric auscultation were also performed by principal investigator. Results: In this study we enrolled 147children with median age of patient was 3 (IQR=0.75-07) years. Majority of patient in our study were male (63.9%). Gastric aspiration and gastric auscultation was seen in all of the study patients. Based on POCUS, frequency of correct placement of nasogastric tube in children admitted in PICU was 83%. Sensitivity of POCUS against gastric aspiration and gastric auscultation was 82.5% with 100% positive predictive value (PPV). Specificity was unable compute as there was no negative finding in reference standard and hence there was also no false positive case. Conclusion: POCUS seems to be helpful and could help with the placement of NGT in paediatric clinical settings. Nevertheless, NGT envision in the stomach was difficult, and if the operator is not skilled or there is abdominal distention, it may go unnoticed.

Colorimetric CO2 Detector to Improve Effective Mask Ventilations in Very Preterm Infants: A Pilot Randomized Controlled Study

Introduction: End-tidal CO2 (ETCO2) detector is currently recommended for confirmation of endotracheal tube placement during neonatal resuscitation. Whether it is feasible to use ETCO2 detectors during mask ventilation to reduce risk of bradycardia and desaturations, which are associated with increased risk of death in preterm babies, is unknown. Methods: This is a pilot randomized controlled trial (NCT04287907) involving newborns 24 + 0/7 to 32 + 0/7 weeks gestation who required mask ventilation at birth. Infants were randomized into groups with or without colorimetric ETCO2 detectors. Combined duration of any bradycardia (<100 bpm) and time below prespecified target oxygen saturation (SpO2) as measured by pulse oximetry were compared. Results: Fifty participants were randomized, 47 with outcomes analysed (2 incomplete data, 1 postnatal diagnosis of trachea-oesophageal fistula). Mean gestational age and birthweight were 28.5 ± 1.9 versus 29.4 ± 1.6 weeks (p = 0.1) and 1,252.7 ± 409.7 g versus 1,334.6 ± 369.1 g (p = 0.5) in the intervention and control arm, respectively. Mean combined duration of bradycardia and desaturation was 276.7 ± 197.7 s (intervention) and 322.7 ± 277.7 s (control) (p = 0.6). Proportion of participants with any bradycardia or desaturation at 5 min were 38.1% (intervention) and 56.5% (control) (p = 0.2). No chest compressions, epinephrine administration, or death occurred in the delivery room. Conclusion: This pilot study demonstrates the feasibility of a trial to evaluate colorimetric ETCO2 detectors during mask ventilation of very preterm infants to reduce bradycardia and low SpO2. Further assessment with a larger population will be required to determine if ETCO2 detector usage at resuscitation reduces risk of adverse outcomes, including death and disability, in very preterm infants.

Intraoperative Handheld Digital X-ray for Assessment of Intracochlear Positioning of Electrode Arrays in Recipients of Cochlear Implants.

Objectives: This study aims to evaluate the practicality of handheld digital X-ray in determining the position of the electrode array following Cochlear implantation (CI). Methods: A retrospective study was conducted involving 11 patients (12 ears) who underwent intraoperative imaging via handheld X-ray (MINE ALNU®, OTOM, Gwangju, South Korea) post-CI between December 2021 and January 2023. Immediate confirmation of the correct electrode array placement in the cochlea was achieved, with subsequent comparisons made to C-arm image and postoperative transorbital view X-ray. Results: Rapid intraoperative imaging was achieved in all instances. The electrode types used included 9 Nucleus slim modiolar electrodes, 1 Nucleus contour electrode, and 2 Medel flex26 electrodes. A malpositioned electrode array was detected in one patient. The handheld digital X-ray also adeptly visualized the electrodes implanted in pediatric patients. Conclusions: The use of intraoperative handheld digital X-ray using MINE ALNU® proves to be a safe, efficient, straightforward, and reliable method for immediate identification of an inserted electrode array. It has potential to replace the traditional C-arm X-ray for verifying electrode positioning in the operating room.

Design of a nasopharyngeal tamponade device in canine cadavers.

To evaluate the feasibility of an improvised tamponade device allowing direct pressure to be applied to the canine nasopharynx. Proof-of-concept study using 8 canine cadavers. A tamponade device was made by placing a condom over a nasogastric tube and suturing it to match the length of the nasopharynx. The device was placed in the nasopharynx of canine cadavers via the nares and filled with diluted ioversol. Placement was then confirmed with radiography or computed tomography. Concentrated ioversol was infused into the rostral nasal cavity to assess for a nasopharyngeal seal, defined as no ioversol passing the device seen on imaging. Subjective assessment of adequate nasopharyngeal compression via digital palpation of the soft palate agreed with imaging findings. Repositioning was required in several cases, but with digital palpation, initial placement was more accurate. Subsequent effective placement and a nasopharyngeal seal were achieved in all 8 cadavers. This device can be placed in the canine nasopharynx, and an adequate nasopharyngeal seal can be achieved, allowing direct compression of the nasopharynx and filling of the nasal cavity with solution. Confirmation of placement was successful with digital palpation and imaging. Further studies are required to investigate the use of this device in live patients.

Neurosurgical precision at its peak: deep brain stimulation - patient selection strategy and surgical technique – a video article

Deep Brain Stimulation (DBS) has emerged as a promising therapeutic approach for various neurological disorders. This video article elucidates the intricacies of DBS surgery and patient selection criteria. The article comprehensively discusses the indications for DBS across diverse conditions including Parkinson’s disease, primary generalized dystonia, essential tremor, obsessive-compulsive disorder, Tourette’s syndrome, drug-resistant major depression, drug-resistant epilepsy, minimally conscious state, and certain addictive disorders. The article ensure optimal outcomes and patient safety. The surgical procedure is meticulously detailed, encompassing the pre-operative planning phase involving Magnetic Resonance Imaging (MRI) and stereotactic coordinates determination. The step-by-step surgical process is elucidated, from frame application and Computed Tomography (CT) fusion to electrode implantation and confirmation of placement. Post-operative management, including programming of the Implantable Pulse Generator (IPG) and addressing complications, is also discussed. By providing insights into the surgical nuances of DBS and patient selection criteria, this video article serves as a valuable resource for neurosurgeons and healthcare professionals involved in the management of neurological disorders amenable to DBS therapy.

A Novel Patellar Tendon Reconstruction Technique Using Semitendinosus Allograft

A Novel Patellar Tendon Reconstruction Technique Using Semitendinosus Allograft