Tube Fixation Research Articles

A pain in the neck—Securing endotracheal tubes in severe facial burns

Facial burns requiring endotracheal intubation face the unique problem of tube fixation whilst at the same time dealing with varying levels of facial oedema and wound dressings. Traditionally endotracheal tubes have been secured with cotton tape tied around the tube and then the patient's neck. Frequently these tapes cut in to the patient's soft tissues and can cause ulceration at the angle of the mouth through pressure necrosis.

A Novel Method of Nasotracheal Tube Fixation in Pediatric Patients Undergoing Neurosurgical Procedure in the Prone Position

To the Editor: Unplanned tracheal extubation may be life threatening, particularly in children in the prone position. Various methods of endotracheal tube (ETT) fixation have been described, including stitching the ETT, placing a transparent dressing over the face to secure the ETT, and intranasal threading of an infant feeding tube to tie over the ETT (1–3). We secure nasal ETTs using a 5-cm segment from a polyvinyl chloride ETT. As shown in Figures 1 and 2, a horizontal slit through both walls is made in the middle of this 5-cm tube with a scalpel (Fig. 1A). A silk thread is passed through the tube and a loop of thread is pulled out through one of the slits with forceps (Fig. 1A). After nasal intubation, the ETT circuit connector is removed (Fig. 1B) and the 5-cm tube, along with thread and loop, is glided over the proximal end of the ETT (Fig. 1C). A double loop of silk thread is made and passed over the ETT. Both the ends of the silk thread are pulled, firmly griping the ETT. The ends of thread are fixed to the face with adhesive plaster (Figs. 1D and 2).Figure 1.: Nasotracheal tube fixation technique in pediatric patients undergoing a neurosurgical procedure in the prone position.Figure 2.: The total assembly in situ before fixation with adhesive tape.Lovett et al. (4) described fourcomponents of ETT fixation. The present technique has all the four components of ETT fixation. We have been using this technique for last 6 months in more than 30 patients without complication. ACKNOWLEDGMENTS Authors thank Mr. Anil Kumar (senior artist, SGPGIMS, Lucknow, INDIA) for hand-made sketches. Devendra Gupta, MD Anil Agarwal, MD Sandeep Sahu, MD Prabhat K. Singh, MD Department of Anesthesia SGPGIMS Lucknow, India [email protected]

Endotracheal Tube Fixation in the Edentulous Facial Burn Patient

Statement of the Problem: Securing of the endotracheal tube (ET) in the facial burn patient is a challenge in the intensive care setting. There have been significantly higher reports of accidental extubation due to inadequate stabilization of the ET tube in burn ICU compared with surgical ICU. Traditional ET tube ties and tape have proven to be insufficient in facial burn patients. Options for these patients have been to wire fixate the ET tube to the dentition, or in the edentulous patient circum-mandibular or transpalatal wires to avoid ET tube ties and tape. We propose an alternative, reliable, efficient, and safe method for ET tube fixation in the edentulous facial burn patients.

Silicone Intubation with Trans-Sac Fixation to Prevent Tube Dislocation

To report a new technique for silicone tube fixation, after successful intubation for congenital nasolacrimal duct obstruction, to minimize its lateral dislocation. Thirty patients (40 eyes) aged 20 months to 5 years (median, 28 months) were treated using the Ritleng bicanalicular lacrimal intubation system. After drawing the silicone stent out of the nose, a piece of 7-O Prolene suture was tied securely around one of its limbs. This limb was then pulled up, pulling the tied end of the Prolene suture to the medial canthal area. The same procedure was repeated with the other limb of the stent, pulling up the other Prolene suture end. This suture end was then un-tied. After adjusting the exposed silicone loop, the free end of the Prolene suture was tied securely to the corresponding part of the silicon stent. The nasally drawn two ends of silicone tube were tied in a single square knot. After 2 to 3 months, stents were removed in the medical office for all the patients. This technique was used successfully for all the patients. Of the 40 tubes in this study, 39 did not displace and one tube was displaced laterally due to loosely tied Prolene suture. On follow-up, the trans-sac suture was well tolerated and no complications were noted. The trans-sac fixation suture prevents lateral displacement of square-knotted silicone tube, which still can be removed easily at the physician's office.

Depth of endoscopically placed sutures: an experimental study in a human cadaver model

Endoscopic suturing devices offer interesting access for interventional procedures used on the gastrointestinal tract. For the time being, the main indication is endoluminal suturing at the gastroesophageal junction for the management of gastroesophageal reflux disease. There is some evidence that endoluminal endoscopic suturing offers an alternative to the closure of esophageal fistulas and to the fixation of feeding tubes and stents in the near future. A review of the literature found no anatomic data on wall layers stitched by sutures. The aim of this study was to determine the depth of sutures placed endoscopically in the esophagus of a human cadaver model. Altogether, 62 sutures were placed in the esophagi of 10 cadavers (complete exenterative cadaver model) at three different suction levels (0.4, 0.6, and 0.8 bar) using the EndoCinch suturing machine. After preparation of the esophagus from its mediastinal bed, all sutures were fixed in formalin and stained with hematoxylin and eosin for histologic examination. No sutures were placed in the mucosa alone. As observed, 1.6% were placed in the submucosa, 4.8% in the circular muscularis propria, and 56.5% in the longitudinal muscularis propria, with 37% placed transmurally. At a suction level of 0.4 bar (0.6, 0.8 bar), 0% (0%, 1.6%) were placed in the submucosa, 3.2% (0%, 1.6%) in the circular muscularis propria, and 11% (25.8%, 12.9%) in the longitudinal muscularis propria, with 12.9% (6.5%, 17.7%) placed transmurally. This study reports, for the first time, a systematic examination of the depth of sutures placed endoscopically in the esophagus. Most of the sutures were found in the muscular wall of the esophagus at a suction level of 0.6 bar. Also, transmural placements were seen. Reduction of suction pressure may lead to a decrease in transmural sutures.

Comparison of F-actin fluorescent labeling methods in pollen tubes of Lilium davidii

Fluorescence labeling of F-actin in pollen tubes by various methods has produced inconsistent results in the literature. Here, we report that EGTA, which was always used in fixative buffers in the past and thought to help cytoskeleton stabilization, can significantly affect F-actin distribution and lead to the formation of thick F-actin bundles at the tip of the pollen tube. We also found that vacuum-infiltration for the first 5 min during pollen tube fixation can better preserve normal cytoplasm structure and F-actin distribution. In contrast, m-maleimidobenzoic acid N-hydroxysuccinimide ester (MBS) treatment before chemical fixation resulted in a shortening of the free zone of thick F-actin bundles in the pollen tube tip. Taken together, our results suggest that exclusion of EGTA and MBS from the fixative buffer, in combination with vacuum-infiltration in the first 5 min of fixation, can improve F-actin fluorescence labeling in pollen tubes of Lilium davidii.

Torsion of bilateral paramesonephric cysts in young girls

Torsion of bilateral paramesonephric cysts in young girls

Modified technique for tube fixation in conjunctivodacryocystorhinostomy.

The standard glass tube used with a conjunctivodacryocystorhinostomy is subject to spontaneous displacement or extrusion, especially in the early postoperative period. To anchor the tube in the surrounding tissues, a suture is commonly tied around the collar of the Pyrex tube and externalized to the skin of the medial canthal area where it is fixed. The loop can become loose around the tube, and displacement or extrusion can occur. We describe an alternative method to better secure the tube in place during the early postoperative period and until the time when the tissues around the tube contract.

Endotracheal tube fixation to the maxilla in patients with facial burns.

Endotracheal tube fixation to the maxilla in patients with facial burns.

Safe Retrieval and Transfer: the Practical Approach

There is a considerable number of published papers that demonstrate the risks associated with the interhospital transfer of sick patients. Unfortunately, with a national shortage of intensive care beds, the number of interhospital transfers shows no sign of reducing. This book provides a framework for safe transfer of sick patients and is written by a multi-professional group representing the Advanced Life Support Group. It is also the course manual for the Safe Transfer and Retrieval (StaR) course run by the same organization. The subject of effective patient transfer is not littered with entertaining anecdotes, and most readers are likely to want to be taken through the subject quickly and painlessly. The book is well laid-out with short chapters, many of which can be read in only a few minutes. Many readers might find the style too didactic but, if seen as one safe method of achieving the desired objectives, this ceases to be a problem. The subject is covered comprehensively. Areas that are vital (and often neglected), such as effective patient packaging and stabilization, are given good coverage. Other areas are of relevance, but are unlikely to be utilized regularly by most transfer doctors e.g. radio voice procedure. Three-and-a-half sides are devoted to diagrams and text on the fixation of tracheal tubes'obviously one of the authors has bad memories of a tube displacement on a rainy motorway somewhere. Most of the content is predictable and well thought out'unlike some multi-author texts, the editors have ensured consistency. Well-established ‘ABC’ type treatments form the mainstay of the guidelines. However, some areas touched upon are controversial, and it would be useful if they were highlighted as such for the less experienced reader. For example, it is suggested that not all critically ill patients necessarily need a doctor to transfer them from one hospital to another. It may be that the specific circumstances where this is appropriate are explained in the StaR course, but reading the book alone could cause problems. Also, the suggestion that the administration of steroids in spinal injury is mandatory will be questioned by some UK neurosurgical units. Overall, this book achieves its aims well, and adhering to the clear and well-presented guidelines will undoubtedly reduce the number of preventable adverse events during patient transfers by anyone that follows them.

Proposed Technique for Evaluation of Endotracheal Tube Fixation and Comparison of Four Fixation Methods

The fixation of an endotracheal tube must be rapid in conditions involving numerous casualties, such as a chemical warfare (CW) situation. The tube also should be fixed and strong to prevent unplanned extubations. We developed a technique for the evaluation of fixation methods. This technique was used to evaluate four methods. Three commercial fixators were compared with the fixation method used today in the Israeli Defense Forces (IDF) and commonly used in different out-of-hospital settings. The exercises were performed on adult intubation mannequins with and without CW protective gear. The fixations were timed, and their quality was evaluated by the participants and inspectors. The time score for the method used today in the IDF was significantly higher compared with the commercial fixation methods. The quality scores for the Thomas fixator and the IDF method were significantly higher than for the fixators by VBM and Rusch. The CW protective gear significantly prolonged the time but did not affect the quality of the fixation. With this technique, a good estimation of the time and quality of fixation can be achieved.

The Effect of Full Protective Gear on Intubation Performance by Hospital Medical Personnel

To assess the influence of protective gear on intubation performance. Prospective, controlled measurement of duration and quality of intubations performed on mannequins by medical personnel with and without protective gear in a crossover design. Eight teams each comprising an anesthesiologist and a nurse. Intubation duration with and without chemical warfare gear was 69.2 +/- 7 and 47.3 +/- 6 seconds (mean +/- SEM), respectively (p < 0.05). Moreover, rating of intubation quality as "very good" by the anesthesiologists declined significantly from 62.5% without chemical warfare protective gear to 6.25% with the garment and mask. Tube fixation was the rate-limiting step when performed with protective gear (p < 0.05); it was assessed by 81% of the anesthesiologists as the critical step. A learning curve was not observed during the study. Protective gear causes a significant prolongation of intubation duration; however, endotracheal intubation can be performed effectively. Technical improvements are warranted for tube fixation because it is the critical step.

Obstructed venous cranial blood flow caused by tracheal tube fixation

Airway management is paramount for the care of critically ill and severely injured patients. Rapid-sequence tracheal intubation following sedation and muscle relaxation is a standard procedure under emergency conditions [1]. While care may be taken to ensure smooth insertion of the laryngoscope blade and accurate placement of the tracheal tube, little emphasis may be paid to the fixation of the tube. Self-adhesive tape and tube holders may fail to stick especially when skin is moist or blood stained. Consequently bandages, tapes or ties are often used which hitherto have not been reported as potentially dangerous [2]. This communication documents the case of impaired cerebral blood flow possibly due to tracheal tube fixation with limited monitoring facilities.

Unplanned extubations in the adult intensive care unit: a prospective multicenter study. Association des Réanimateurs du Centre-Ouest.

The predisposing factors and complications of unplanned extubation (UEX) in mechanically ventilated adult patients are not well recognized. We designed a prospective multicenter observational study to identify risk factors and describe the complications of UEX. We followed 426 ventilated patients over a 2-mo period. Clinical characteristics such as diagnosis on admission and reasons for ventilation were used to classify the patients. The presence or absence of potential risk factors was daily noted, including the types of ventilators, tracheal tubes, tube fixations, ventilatory support modes, route for intubation, and the use of intravenous sedation. Circumstances and complications of UEX were prospectively recorded. Forty-six (10.8%) patients experienced at least one episode of UEX. Ten UEX occurred during nursing procedures. At the moment of UEX, 61% of patients were agitated. The rates of mortality, laryngeal complications, nosocomial pneumonia after extubation, and the length of mechanical ventilation were similar in UEX and non-UEX patients. Patients were more often reintubated after UEX (28 of 46) than after planned extubation (28 of 284). All the non-reintubated UEX patients survived. One death occurred as a direct consequence of UEX. By use of multivariate analysis, we identified four factors contributing to UEX: chronic respiratory failure, endotracheal tube fixation with only thin adhesive tape, orotracheal intubation, and the lack of intravenous sedation. Considering these factors, we hypothesized that simple measures should be adopted to minimize the incidence of UEX and its related complications: more vigilance during procedures at patients' bedsides, adequate sedation of agitated patients, strong fixation of the tracheal tube, particular attention paid to orally intubated patients, and daily reassessment of the possibility of weaning from the ventilator.

Prevention of accidental extubation in ventilated infants and children

Objective: The purpose of the study was to evaluate the incidence of accidental extubation (AE) using a designated means of endotracheal tube (ETT) fixation. Design: Data collection for 320 consecutive ventilated infants and children. Setting: A six-bedded multi-disciplinary paediatric intensive care unit in a tertiary care hospital. Subjects: Three hundred and twenty consecutive intubated infants and children aged from one day to 17 years. Interventions: The ETT was fixed using one long strip of cloth tape. The tape was wrapped two revolutions around the ETT, then applied to one cheekbone and finally around the head at the maximal contour on to the other cheekbone. Post-intubation and daily chest X-ray were performed. The ETT fixation was replaced daily, using the same technique, or more frequently whenever the tape became too moist. The security and fixation of the ETT were examined every 4 hours. Measurements and results: Of 320 patients, 289 received sedation and/or analgesia and in 108 of these muscl...

A Multipurpose Four-Channel Fluid Swivel

This article describes the construction of a functional quadruple fluid swivel with low propensity to leaking and low resistance to rotation. It was obtained through the addition of a fourth channel and some modifications performed on the rotary unit of a triple channel fluid swivel recently described. Those modifications included alterations of the Touhey–Borst adapter (Becton-Dickinson), and the development of a new method of fixation of the rotary tubes to the rotary unit of the swivel using nuts and screws. With those improvements the former swivel was transformed in a still more versatile device that can be used in experimental designs requiring the use of this relatively high number of channels. It can be used, for instance, in simultaneous off-line brain microdialysis of up to four different areas or on-line brain microdialysis in two areas; in push–pull perfusions of two brain regions; in studies determining the neuropharmacokinetics and pharmacodynamics of any compound and combining continuous drug infusion through one channel, double brain microdialysis to describe the distribution characteristics of the drug into the central nervous system as well as to monitor the neurochemical modifications induced by the drug, and continuous plasma sampling to know the plasma pharmacokinetics of the drug. These and several other methods used in neuroscience research can also be combined using the swivel described here.

Metric Study of Upper Airway and Trachea in Nomal Korean Adults uing Fiberoptic Bronchoscopy: Study of endotracheal tube fixation positioning in adults

Metric Study of Upper Airway and Trachea in Nomal Korean Adults uing Fiberoptic Bronchoscopy: Study of endotracheal tube fixation positioning in adults

Decreasing unplanned extubations in the surgical intensive care unit

Background: Unplanned extubations are common, but can be life-threatening. Methods: We conducted a prospective evaluation of all intubated patients in our surgical intensive care unit to examine the effects of three parameters on the likelihood of accidental extubation. The parameters were the method of endotracheal tube fixation, the use of sedation/paralysis, and the use of hand restraints. During the baseline period, tubes were secured with cloth or velcro ties, sedation was used conservatively, and hand restraints were used routinely. A change in one study parameter was made prior to each period. Thus, in period II, tubes were secured using waterproof tape; in period III, tubes were secured with waterproof tape and sedation/paralysis was used liberally; and in period IV, tubes were secured with waterproof tape and limited use was made of hand restraints. Results: Accidental extubations were significantly less frequent when tubes were secured with waterproof tape ( P <0.0001). No difference was seen when sedation was instituted liberally. Restricted use of hand restraints was associated with significantly increased accidental extubations ( P <0.001). Conclusions: Our data support the use of water resistant tape to secure endotracheal tubes and the routine use of hand restraints.

Two-year study of the prevention of unintentional extubation.

Unintentional or accidental extubation is an undesirable complication in the mechanically ventilated patient. This is particularly dangerous in high-risk patients who are on neuromuscular blocking agents or positive end-expiratory pressure or are difficult to reintubate. This article identifies some of the factors resulting in intentional extubation as well as measures taken to prevent them. A protocol was developed and utilized in Catholic Medical Center. The results of a two-year study reveal a reduction of the incidence from an initial 12% to 5% and a reduction of high-risk extubations from five to an incidence of three. The investigator also assembled an airway system consisting of low pressure cuff endotracheal tube with a pressure monitoring device and several adapters along with a tube fixation system.

Naso-enteral fine-bore feeding tube fixation in the burned child: an audit of a technique

The burned patient requires aggressive nutritional support to compensate for increased caloric and nitrogen requirements, and if available, enteral feeding is the best route of administration. In the restless and uncooperative child, adequate fixation of a naso-enteral feeding tube can pose a major problem. A novel technique for naso-enteral tube fixation in children using a nasal septum halter was assessed in 30 patients. This method was found to be safe, reliable, and comfortable. The ease of application and the absence of complications make this method especially suitable for naso-enteral tube fixation in the burned child.