Stylet Removal Research Articles

Techniques to increase lumbar puncture success in newborn babies: the NeoCLEAR RCT.

Lumbar puncture is an essential tool for diagnosing meningitis. Neonatal lumbar puncture, although frequently performed, has low success rates (50-60%). Standard technique includes lying infants on their side and removing the stylet 'late', that is, after the needle is thought to have entered the cerebrospinal fluid. Modifications to this technique include holding infants in the sitting position and removing the stylet 'early', that is, following transection of the skin. To the best of our knowledge, modified techniques have not previously been tested in adequately powered trials. The aim of the Neonatal Champagne Lumbar punctures Every time - An RCT (NeoCLEAR) trial was to compare two modifications to standard lumbar puncture technique, that is, use of the lying position rather than the sitting position and of 'early' rather than 'late' stylet removal, in terms of success rates and short-term clinical, resource and safety outcomes. This was a multicentre 2 × 2 factorial pragmatic non-blinded randomised controlled trial. Infants requiring lumbar puncture (with a working weight ≥ 1000 g and corrected gestational age from 27+0 to 44+0 weeks), and whose parents provided written consent, were randomised by web-based allocation to lumbar puncture (1) in the sitting or lying position and (2) with early or late stylet removal. The trial was powered to detect a 10% absolute risk difference in the primary outcome, that is, the percentage of infants with a successful lumbar puncture (cerebrospinal fluid containing < 10,000 red cells/mm3). The primary outcome was analysed by modified intention to treat. Of 1082 infants randomised (sitting with early stylet removal, n = 275; sitting with late stylet removal, n = 271; lying with early stylet removal, n = 274; lying with late stylet removal, n = 262), 1076 were followed up until discharge. Most infants were term born (950/1076, 88.3%) and were aged < 3 days (936/1076, 87.0%) with a working weight > 2.5 kg (971/1076, 90.2%). Baseline characteristics were balanced across groups. In terms of the primary outcome, the sitting position was significantly more successful than lying [346/543 (63.7%) vs. 307/533 (57.6%), adjusted risk ratio 1.10 (95% confidence interval 1.01 to 1.21); p = 0.029; number needed to treat = 16 (95% confidence interval 9 to 134)]. There was no significant difference in the primary outcome between early stylet removal and late stylet removal [338/545 (62.0%) vs. 315/531 (59.3%), adjusted risk ratio 1.04 (95% confidence interval 0.94 to 1.15); p = 0.447]. Resource consumption was similar in all groups, and all techniques were well tolerated and safe. This trial predominantly recruited term-born infants who were < 3 days old, with working weights > 2.5 kg. The impact of practitioners' seniority and previous experience of different lumbar puncture techniques was not investigated. Limited data on resource use were captured, and parent/practitioner preferences were not assessed. Lumbar puncture success rate was higher with infants in the sitting position but was not affected by timing of stylet removal. Lumbar puncture is a safe, well-tolerated and simple technique without additional cost, and is easily learned and applied. The results support a paradigm shift towards sitting technique as the standard position for neonatal lumbar puncture, especially for term-born infants during the first 3 days of life. The superiority of the sitting lumbar puncture technique should be tested in larger populations of premature infants, in those aged > 3 days and outside neonatal care settings. The effect of operators' previous practice and the impact on family experience also require further investigation, alongside in-depth analyses of healthcare resource utilisation. Future studies should also investigate other factors affecting lumbar puncture success, including further modifications to standard technique. This trial is registered as ISRCTN14040914 and as Integrated Research Application System registration 223737. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/188/106) and is published in full in Health Technology Assessment; Vol. 27, No. 33. See the NIHR Funding and Awards website for further award information.

Assessment of infant position and timing of stylet removal to improve lumbar puncture success in neonates (NeoCLEAR): an open-label, 2 × 2 factorial, randomised, controlled trial

Newborn infants are the highest-risk age group for bacterial meningitis. Lumbar punctures are therefore frequently performed in neonates, but success rates are low (50-60%). In Neonatal Champagne Lumbar punctures Every time-A Randomised Controlled Trial (NeoCLEAR), we sought to optimise infant lumbar puncture by evaluating two modifications to traditional technique: sitting position versus lying down and early stylet removal (stylet removal after transecting the subcutaneous tissue) versus late stylet removal. NeoCLEAR was an open-label, 2 × 2 factorial, randomised, controlled trial, conducted in 21 UK neonatal and maternity units. Infants requiring lumbar puncture at 27+0 to 44+0 weeks corrected gestational age and weighing 1000 g or more were randomly assigned (1:1:1:1) to sitting position and early stylet removal, sitting position and late stylet removal, lying position and early stylet removal, or lying position and late stylet removal using a 24/7, web-based, secure, central randomisation system. Block randomisation was stratified within site by corrected gestational age (27+0 to 31+6 weeks, 32+0 to 36+6 weeks, 37+0 to 40+6 weeks, or 41+0 to 44+0 weeks), using variable block sizes of four and eight with equal frequency. Laboratory staff were masked to allocation. The primary outcome was successful first lumbar puncture, defined as obtaining a cerebrospinal fluid sample with a red blood cell count of less than 10 000 cells per μL. The primary and secondary (including safety) outcomes were analysed by the groups to which infants were assigned regardless of deviation from the protocol or allocation received, but with exclusion of infants who were withdrawn before data collection or who did not undergo lumbar puncture (modified intention-to-treat analysis). This study is registered with ISRCTN, ISRCTN14040914. Between Aug 3, 2018, and Aug 31, 2020, 1082 infants were randomly assigned to sitting (n=546) or lying (n=536), and early (n=549) or late (n=533) stylet removal. 1076 infants were followed-up until discharge and included in the modified intention-to-treat analysis. 961 (89%) infants were term, and 936 (87%) were younger than 3 days. Successful first lumbar puncture was more frequently observed in sitting than in lying position (346 [63·7%] of 543 vs 307 [57·6%] of 533; adjusted risk ratio 1·10 [95% CI 1·01 to 1·21], p=0·029; number needed to treat=16). Timing of stylet removal had no discernible effect on the primary outcome (338 [62·0%] of 545 infants in the early stylet removal group and 315 [59·3%] of 531 in the late stylet removal group had a successful first lumbar puncture; adjusted risk ratio 1·04 [95% CI 0·94-1·15], p=0·45). Sitting was associated with fewer desaturations than was lying (median lowest oxygen saturations during first lumbar puncture 93% [IQR 89-96] vs 90% [85-94]; median difference 3·0% [2·1-3·9], p<0·0001). One infant from the sitting plus late stylet removal group developed a scrotal haematoma 2 days after lumbar puncture, which was deemed to be possibly related to lumbar puncture. NeoCLEAR is the largest trial investigating paediatric lumbar puncture so far. Success rates were improved when sitting rather than lying. Sitting lumbar puncture is safe, cost neutral, and well tolerated. We predominantly recruited term neonates younger than 3 days; other populations warrant further study. Neonatal lumbar puncture is commonly performed worldwide; these results therefore strongly support the widespread adoption of sitting technique for neonatal lumbar puncture. UK National Institute for Health and Care Research.

Comparison between Direct Laryngoscopy with and without Aerosol Box for Intubation in Patients Undergoing General Anaesthesia during COVID-19 PandemicA Randomised Controlled Study

Introduction: The airway management of patients with COVID19 is a high risk task for anaesthesiologists. Several innovations have been born as a result of this problem, including aerosol boxes and clear plastic sheets. Aim: To compare the timing and attempt of direct laryngoscopy with and without aerosol box for intubation in patients undergoing general anaesthesia during the COVID-19 pandemic. Materials and Methods: This was a randomised controlled study was conducted in Parul Sevashram Hospital, Parul University, Vadodara, Gujrat, India from April 2021 to September 2021. A total of 50 patients were randomly divided into two equal groups as group A was intubated with an aerosol box and a macintosh laryngoscope, while group B was intubated with a clear plastic sheet and macintosh laryngoscope. With proper airway precautions and Personal Protective Equipments (PPE) comparative assessment of patients undergoing surgery in general anaesthesia was done. Time to intubate, number of attempts, ease of Endotracheal Tube (ETT) tube insertion, quality of Laryngoscopy view and Cormack Lehane scores were assessed in both the groups. Results: The mean time for intubation was high at 29.72 seconds in group A, while it was 23.16 seconds in group B; the difference was significant. Overall, 20 out of 25 (80%) patients could be intubated in 1st attempt in group B as compared to 15 out of 25 (60%) in group A. Airway visualisation using Percentage of Glottic Opening (POGO) scoring and Cormack Lehane staging were suggestive of better visualisation in group B than group A. Difficulties encountered during intubation like laryngoscopy, glottic visualisation, arm movement restriction, ETT negotiation, and stylet removal were lesser in group A as compared to group B. The incidence of complications like sore throat and airway bleeding were lower in group B as compared to group A. Conclusion: In the COVID-19 era, aerosol box and clear plastic sheets are effective barrier measures for airway management to prevent the anaesthesiologists from the aerosol transmission. But airway management with clear plastic sheet is technically easier than aerosol box.

Comparative evaluation of intubation performances using two different barrier devices used in the COVID-19 era: A manikin based pilot study.

Background and Aims:Protection of anaesthesiologists from contaminated aerosols of COVID 19 patients during endotracheal intubation has spurred the development of barrier devices like aerosol boxes and clear transparent plastic sheets and usage of videolaryngoscopes in COVID 19 patients. However, the efficiency, feasibility and difficulties faced by anaesthesiologist while performing endotracheal intubations under barrier devices require scientific validation. This manikin-based pilot study aims to assess the laryngoscopic performances of experienced anaesthesiologists under two different barrier enclosures.Methods and Materials:53 anaesthesiologists (14 Consultants and 39 Senior Residents) who were undergoing an airway training module as a part of preparedness for handling the COVID 19 pandemic were recruited. Using an aerosol box over a manikin, the participants attempted intubation using a Glidescope Videolaryngoscope and Macintosh laryngoscopes (GA and MA Groups). Subsequently, intubation was attempted under a transparent plastic sheet using both laryngoscopes (GP and MP groups). Time required for intubation, first pass success rates, subjective ease of intubation and the feedback obtained from the participants were recorded and analysed.Results:Time required for accomplishing successful intubation was 38.55 ± 12.16 seconds, 26.58 ± 5.73 seconds, 46.89 ± 15.23 seconds and 37.26 ± 8.71 seconds for GA, MA, GP and MP groups respectively. Time for intubation and difficulty (VAS) was least for Macintosh group with aerosol box (MA) and maximum time was taken in Glidescope group with transparent polythene drape (GP). First attempt success rate for Glidescope groups (GP and GA) were 100% and in MA and MP group was 98% and 96% respectively. Restriction in hand movement and stylet removal were the major difficulties reportedConclusion:Longer intubation times were observed while using Glidescope Videolaryngoscopes with either of the two barrier devices in place compared to Macintosh laryngoscopes.

Study protocol: NeoCLEAR: Neonatal Champagne Lumbar punctures Every time \u2013 An RCT: a multicentre, randomised controlled 2\u2009\xd7\u20092 factorial trial to investigate techniques to increase lumbar puncture success

BackgroundThe neonatal period carries the highest risk of bacterial meningitis (~ 1 in 5000 births), bearing high mortality (~ 10%) and morbidity (20–50%) rates. Lumbar puncture (LP) remains essential to the diagnosis of meningitis. Though LP is a common procedure in neonates, success rates are lower (50–60%) than in other patient populations. None of the currently-practised neonatal LP techniques are supported by evidence from adequately-powered, randomised controlled trials (RCTs). NeoCLEAR aims to compare two modifications to the traditional technique which are free, accessible, and commonly practised: sitting (as opposed to lying) position, and ‘early’ (as opposed to ‘late’) stylet removal.Methods/designWritten parental informed consent permitting, infants in neonatal/maternity wards, of 27+ 0 to 44+ 0 weeks corrected gestational age and weighing ≥1000 g, who require an LP, will be randomly allocated to sitting or lying position, and to early or late stylet removal. The co-primary objectives are to compare success rates (the proportion of infants with cerebrospinal fluid red cell count < 10,000/mm3 on first LP procedure) in 1020 infants between the two positions, and between the two methods of stylet removal. Secondary outcomes relate to LP procedures, complications, diagnoses of meningitis, duration of antibiotics and hospital stay. A modified intention-to-treat analysis will be conducted.DiscussionTwo modifications to the traditional LP technique (sitting vs lying position; and early vs late stylet removal) will be simultaneously investigated in an efficient and appropriately-powered 2 × 2 factorial RCT design. Analysis will identify the optimal techniques (in terms of obtaining easily-interpretable cerebrospinal fluid), as well as the impact on infants, parents and healthcare systems whilst providing robust safety data. Using a pragmatic RCT design, all practitioners will be trained in all LP techniques, but there will inevitably be variation between unit practice guidelines and other aspects of individual care.An improved LP technique would result in:• Fewer uninterpretable samples, repeated attempts and procedures• Reduced distress for infants and families• Decreased antibiotic use and risk of antibiotic resistance• Reduced healthcare costs due to fewer procedures, reduced length of stay, shorter antibiotic courses, and minimised antibiotic-associated complicationsTrial registrationISRCTN14040914. Date assigned: 26/06/2018.

Intracochlear Electrocochleography: Response Patterns During Cochlear Implantation and Hearing Preservation

Electrocochleography (ECochG) obtained through a cochlear implant (CI) is increasingly being tested as an intraoperative monitor during implantation with the goal of reducing surgical trauma. Reducing trauma should aid in preserving residual hearing and improve speech perception overall. The purpose of this study was to characterize intracochlear ECochG responses throughout insertion in a range of array types and, when applicable, relate these measures to hearing preservation. The ECochG signal in cochlear implant subjects is complex, consisting of hair cell and neural generators with differing distributions depending on the etiology and history of hearing loss. Consequently, a focus was to observe and characterize response changes as an electrode advances. In 36 human subjects, responses to 90 dB nHL tone bursts were recorded both at the round window (RW) and then through the apical contact of the CI as the array advanced into the cochlea. The specific setup used a sterile clip in the surgical field, attached to the ground of the implant with a software-controlled short to the apical contact. The end of the clip was then connected to standard audiometric recording equipment. The stimuli were 500 Hz tone bursts at 90 dB nHL. Audiometry for cases with intended hearing preservation (12/36 subjects) was correlated with intraoperative recordings. Successful intracochlear recordings were obtained in 28 subjects. For the eight unsuccessful cases, the clip introduced excessive line noise, which saturated the amplifier. Among the successful subjects, the initial intracochlear response was a median 5.8 dB larger than the response at the RW. Throughout insertion, modiolar arrays showed median response drops after stylet removal while in lateral wall arrays the maximal median response magnitude was typically at the deepest insertion depth. Four main patterns of response magnitude were seen: increases > 5 dB (12/28), steady responses within 5 dB (4/28), drops > 5 dB (from the initial response) at shallow insertion depths (< 15 mm deep, 7/28), or drops > 5 dB occurring at deeper depths (5/28). Hearing preservation, defined as < 80 dB threshold at 250 Hz, was successful in 9/12 subjects. In these subjects, an intracochlear loss of response magnitude afforded a prediction model with poor sensitivity and specificity, which improved when phase, latency, and proportion of neural components was considered. The change in hearing thresholds across cases was significantly correlated with various measures of the absolute magnitudes of response, including RW response, starting response, maximal response, and final responses (p's < 0.05, minimum of 0.0001 for the maximal response, r's > 0.57, maximum of 0.80 for the maximal response). Monitoring the cochlea with intracochlear ECochG during cochlear implantation is feasible, and patterns of response vary by device type. Changes in magnitude alone did not account for hearing preservation rates, but considerations of phase, latency, and neural contribution can help to interpret the changes seen and improve sensitivity and specificity. The correlation between the absolute magnitude obtained either before or during insertion of the ECochG and the hearing threshold changes suggest that cochlear health, which varies by subject, plays an important role.

Removal methods of rigid stylets to minimise adverse force and tracheal tube movement: a mathematical and in-vitro analysis in manikins.

This study investigated displacement of the tracheal tube caused by different methods of intubating stylet removal, using in-vitro experiments and mathematical analysis. In the first in-vitro experiment, we measured the distance travelled by the tube tip during stylet extraction. Then, we investigated the ideal technique for stylet extraction using mathematical analysis, which would cause minimal tube displacement. Then, using a training manikin, we measured the force applied to the vocal cords and stylet extraction force during tracheal intubation. When the stylet was extracted along a straight path towards the stylet end, the distance travelled by the tube tip significantly increased as the bending angle increased. Mathematical analysis revealed that the stylet should be diagonally extracted (in the sagittal plane) at an appropriate angle, rather than along a straight path towards the direction of the stylet end. In simulated tracheal intubation, extraction force and force applied to the vocal cords both significantly increased as the bending angle increased. Compared with the 'hockey stick'-shaped stylet, the arcuate-shaped stylet resulted in reduced force. Our results indicate the potential risk for vocal cord injury when using hockey stick-shaped stylets with large bending angles.

Efficacy of 3 fine-needle biopsy techniques for suspected pancreatic malignancies in the absence of an on-site cytopathologist

EUS-guided fine-needle aspiration/biopsy (EUS-FNA/B) has a high diagnostic accuracy for pancreatic tumors. Most reports have focused on the diagnostic yield of cytology or histology; the ability of various FNA/B techniques to obtain an adequate mass of cells or tissue has rarely been investigated. Patients with suspected pancreatic malignancy underwent EUS-FNB using a 22-gauge ProCore needle by either the stylet slow-pull-back technique (group A), conventional negative suction after stylet removal (group B), or non-suction after stylet removal (group C) in the absence of an on-site cytopathologist. The adequacy of the 3 techniques based on the diagnostic yield, cellularity, blood contamination, and core-tissue acquisition was evaluated. A total of 50 patients (27 males) were analyzed. The mean tumor size was 21 to 40mm in 54%. The rate of a good or excellent proportion of cellularity was highest in group A compared with groups B and C (72% vs 60% vs 50%, P= .049). A >25% rate of blood contamination was more prevalent in group B (30% vs 42% vs 10%, P= .009). The rate of adequate core-tissue acquisition was not different (52% vs 34% vs 50%, P= .140). Based on the multivariate generalized estimation equation, the stylet slow-pull-back technique and a tumor size >40mm were favorable factors for diagnostic adequacy. The stylet slow-pull-back technique might enable acquisition of tissue and assessment of cellularity for the diagnosis of pancreatic tumors suspected to be malignant. (Clinical trial registration number: KCT0002190.).

Use and perceived safety of stylets for neonatal endotracheal intubation: a national survey.

To examine the use and perceived safety of stylets for neonatal intubation in a cohort of providers in the United States. A cross-sectional survey was sent to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine. A total of 640 responses were received. 57% reported using a stylet 'every time' or 'almost every time' they intubated. The preferred stylet bend was a smooth bend of <30 degrees. 71% of respondents believed that stylets were safe. Reported complications from stylet use included tube dislodgement during stylet removal (32%), airway injury with bleeding (9%), and tracheal perforation (2%). Stylet use was common. There was fair consistency on preference for stylet bend and position. Stylet use was believed to be safe, but complications were observed by many respondents. Additional studies are needed to examine the risks and benefits of stylet use during neonatal intubation.

Reducing lumbar puncture failure rates in febrile neonates with multidisciplinary practical skills teaching, early stylet removal and atraumatic needles

Reducing lumbar puncture failure rates in febrile neonates with multidisciplinary practical skills teaching, early stylet removal and atraumatic needles

First Evidence of Thaumastocoris peregrinus (Heteroptera: Thaumastocoridae) Feeding From Mesophyll of Eucalyptus Leaves.

The bronze bug, Thaumastocoris peregrinus Carpintero & Dellapé, 2006 (Heteroptera: Thaumastocoridae) originally restricted to Australia, is an important emerging pest of Eucalyptus plantations in the Southern Hemisphere. It feeds on mature leaves, causing the loss of photosynthetic surface area and defoliation and, according to some studies, even tree death. In this work, feeding activities of T. peregrinus on Eucalyptus camaldulensis Dehn leaves and its primary food resources were identified. In cross sections of leaves, solid salivary deposits on epidermal cells and in the vicinity of stomata cells were detected. In subepidermal cells of the palisade parenchyma near the stylet penetration point, disorganization and removal of chloroplasts were also observed. The presence of chlorophyll in guts of adults and nymphs was analyzed using spectrophotometry and confocal laser scanning to obtain in situ fluorescent spectra. Both spectra showed chlorophyll absorbance peaks. In addition, the presence of chlorophyll in guts of T. peregrinus using fluorescence microscopy was identified. These results provide the first evidence that T. peregrinus feeds from the palisade parenchyma (chlorenchyma) of Eucalyptus leaves.

Are Graduating Pediatric Residents Prepared to Perform Infant Lumbar Punctures?: A Multi-Institutional Descriptive Study.

Few published studies describe graduating pediatric residents' procedural skills or success rates. This information would help guide supervisors' decisions about graduating residents' preparedness, training, and supervision needs. This study aimed to measure success rates for graduating pediatric residents performing infant lumbar puncture (LP) during the final months of their training and to describe their experiences performing and supervising infant LPs during the course of their training. This survey-based study was conducted at 10 academic medical institutions in 2013. The survey consisted of 4 domains: (1) demographics, (2) exposure to infant LP training as an intern, (3) number of LPs performed and supervised during residency, and (4) specific information on the most recent clinical infant LP. One hundred ninety-eight (82%) of 242 eligible graduating residents responded to the survey. A 54% success rate was noted for graduating residents when they were the first provider performing the infant LPs. Success rates were 24% if they were not the first provider to attempt the LP. Overall, graduating residents were supervised on 29% of their LPs, used anesthesia for 29%, and used the early stylet removal technique for 63%. The graduating residents performed a median of 12 infant LPs and supervised others on a median of 5 infant LPs throughout their residency. The vast majority reported feeling confident and prepared to perform this procedure. At the end of residency, graduating pediatric residents were rarely supervised and had low infant LP success rates despite confidence in their skills. However, graduating residents frequently supervised others performing this procedure.

Screening residents for infant lumbar puncture readiness with just-in-time simulation-based assessments

BackgroundDetermining when to entrust trainees to perform procedures is fundamental to patient safety and competency development.ObjectiveTo determine whether simulation-based readiness assessments of first year residents immediately prior to their first...

Detection of modiolar proximity through bipolar impedance measurements.

To test the hypothesis that bipolar electrical impedance measurements in perimodiolar cochlear implants (CIs) may be used to differentiate between perimodiolar insertion technique favoring proximity to the modiolus or lateral wall. Bipolar impedances are a measure of electrical resistance between pairs of electrode contacts in a CI. Stimulation is through biphasic pulses at fixed frequency. Impedance measurements were made in real time through sequential sampling of electrode pairs. Perimodiolar electrodes were inserted in temporal bones using one of two techniques: 1) In the standard insertion technique (SIT), the electrode array slides along the lateral wall during insertion. 2) In the Advance Off Stylet (Cochlear Ltd. Sydney) technique (AOS), the electrode maintains modiolar contact throughout the insertion process. A set of 22 insertions were performed in temporal bone specimens using perimodiolar electrode arrays with both AOS and SIT. Buffered saline was used as a substitute for natural perilymph based on similar electrical conductivity properties. Impedance with and without stylet removal were recorded with a 30-second sampling window at final insertion depth. There is a significant difference in bipolar impedance measures between AOS and SIT, with impedances rising in measurements with stylet removal. Evaluation was based on two-sided analysis of variance considering technique and electrode with P < 0.025. Bipolar electrical impedance can be used to detect relative motion toward the modiolus inside the cochlea. This detection method has the potential to optimize intraoperative placement of perimodiolar electrode arrays during implantation. We anticipate that this will result in lower excitation thresholds and improved hearing outcome. NA. Laryngoscope, 127:1413-1419, 2017.

Comparison of polyvinyl chloride and elastic stannum stylet extraction forces with various lubricants: a simulation study.

BackgroundStylets are the most frequently used devices for tracheal intubation, but can be a source of postoperative pharyngeal pain or hoarseness. In this study, we evaluated extraction forces between polyvinyl chloride (PVC) and stannum (Sn) stylets with various lubricants.FindingsUsing a manikin, we compared extraction forces between PVC and Sn stylets under four different conditions: without lubricant, 3 ml of water (water), three sprays of 8 % lidocaine (lidocaine), and olive oil. A force measuring device was used to accurately measure the extraction force for stylet removal. The extraction force was significantly smaller with the Sn stylet compared to the PVC stylet, regardless of the lubricant used for all three tracheal tubes with different diameters tested (P < 0.05). In comparisons by lubricant, lidocaine and olive oil resulted in significantly lower extraction forces than with no lubricant or water with the PVC stylet for all tracheal tubes tested. In contrast, there were no significant differences in extraction force by lubricant for the Sn stylet across all tracheal tubes tested.ConclusionsThe Sn stylet required less extraction force compared to the PVC stylet, regardless of the lubricant used.

Correlation between extraction force during tracheal intubation stylet removal and postoperative sore throat

Study ObjectiveTo examine postoperative sore throat resulting from tracheal intubation stylet removal. DesignProspective cohort study. SettingOperating rooms and hospital ward. PatientsA total of 50 American Society of Anesthesiologists physical status 1 and 2 patients who underwent elective abdominal and/or orthopedic surgery under general anesthesia. InterventionsPatients were allocated to 2 groups: those who developed sore throat postoperatively (ST group) and those who did not (NST group). Comparative analysis of these 2 groups was performed to identify risk factors of the development of sore throat. MeasurementsThe extraction force during stylet removal was measured using a force measuring device. Postoperative sore throat was assessed by an anesthesiologist. Main ResultsNine patients (18%) complained of postoperative sore throat. Increased extraction force (P=.0054; odds ratio, 1.84; 95% confidence interval, 1.20-2.84) was the only significant risk factor for the development of postoperative sore throat. An extraction force of >10.3N was determined as a cutoff for developing postoperative sore throat. ConclusionPostoperative sore throat was significantly related to increased extraction force during stylet removal.

Improvements and innovations in endoscopic ultrasound guided fine needle aspiration.

Keywords: Algorithm; Core histology needle; Cytology; Endoscopic ultrasound guided fine needle aspiration fine needle biopsy; Histology

Effect of stylet removal on neural response telemetry and stapedial reflex thresholds during cochlear implantation

The purpose of this study was to analyze changes in neural response telemetry (NRT) and electrically evoked stapedial reflex thresholds (ESRT) before and after stylet withdrawal during cochlear implant surgery. Thirty children (21-92 months old) who were candidates for cochlear implantation took part in this study. In all of them Nucleus Contour Advance was implanted. NRT and ESRT responses were recorded initially with the stylet in and then when the stylet was taken out during the implant procedure. The recordings were performed in the basal, middle, and apical areas of the electrode array. The threshold levels required to obtain NRT and ESRT responses after stylet removal were lower. This decrease was observed in all parts of the cochlea. It was statistically significant in all areas with the exception of the basal ESRT measurements. Withdrawing the stylet results in better NRT and ESRT responses, most probably due to a favorable position change of the electrode array within the scala tympani.

Real‐time measurement of electrode impedance during intracochlear electrode insertion

This pilot study details the use of a software tool that uses continuous impedance measurement during electrode insertion, with the eventual potential to assess and optimize electrode position and reduce insertional trauma. Software development and experimental study with human cadaveric cochleae and two live surgeries. A prototype program to measure intracochlear electrode impedance and display it graphically in real time has been developed. The software was evaluated in human cadaveric temporal bones while simultaneously making real-time fluoroscopic recordings and in two live surgeries during intracochlear electrode insertion. Impedance changes were observed with various scalar positions, and values were consistent with those obtained using clinically available software. Using Contour Advance electrodes, impedance values increased after stylet removal, particularly when using the monopolar mode. Impedance values seem systematically affected by electrode position, with higher values being associated with proximity to the cochlear wall. The new software is capable of acquiring impedance measurements during electrode insertion, and these data may be useful to guide surgeons to achieve optimal and atraumatic electrode insertion, to guide robotic electrode insertion, and to provide insights about electrode position in the cochlea.

An Educational Video Improves Technique in Performance of Pediatric Lumbar Punctures

Unsuccessful or traumatic lumbar punctures (LPs) occur commonly and contribute to patient discomfort and to challenges in medical decision making in the pediatric emergency department (ED). We produced an instructional video demonstrating the best practices in pediatric LP technique. We hypothesized that the performance of LPs would change and the rate of successful LPs would increase after watching the video. This was a prospective study of LPs performed in an urban, academic pediatric ED before and after an educational intervention. Lumbar punctures performed during year 1 constituted the control arm. During year 2, all medical practitioners working in the ED watched the instructional video, and this constituted the interventional arm. The practitioner performing the LP completed a standardized data collection form after each LP procedure, and medical records were reviewed. Data forms were collected on 668 LPs during the study period, 391 during year 1 and 277 during year 2. There was neither a significant change in overall LP success rate between the 2 years (56.8% year 1 vs 53.4% year 2) nor a significant difference in median number of LP attempts required per patient (P = 0.78). Seventy-eight percent of participants who viewed the LP video during year 2 stated that the video helped increase their comfort level with performing LPs. The odds of using the techniques endorsed in the educational video were significantly higher during year 2 compared to year 1 for use of local anesthetic, early stylet removal, and vertical patient position. The video increased practitioners' comfort level with the performance of pediatric LPs and adherence to evidence-based best practices. It was not associated with an increased rate of successful LPs.