Use Of Manometry Research Articles

Recent Developments in the Management of Malignant Pleural Effusions: a Narrative Review

The goal of this paper is to evaluate the literature published over past 3 years and emphasize the most recent updates in the diagnosis and management of malignant pleural effusions (MPE). The management of MPE is focused on palliation of symptoms and should take into account patient preferences and anticipated survival. Chemical pleurodesis and indwelling pleural catheters (IPC) are both definitive options for recurrent symptomatic MPE. IPC placement reduces hospitalization and can result in spontaneous pleurodesis, but these advantages must be weighed against the cost of materials and ongoing care. IPC is preferred over attempted pleurodesis in the presence of nonexpandable lung. The use of vacuum bottles during therapeutic thoracentesis is associated with increased pain and complications, and drainage via manual aspiration or to gravity is preferred. The routine use of manometry does not appear to reduce procedure-related discomfort. Several new advances have been made and discovered in relation to procedural aspects of thoracentesis, diagnosis, and management of MPE. We summarized the most relevant trials and studies and discuss their application in the clinical practice.

Detrimental Effects of Filling Laryngotracheal Airways To Excessive Pressure (DEFLATE-P): a quality improvement initiative

BackgroundThis quality improvement (QI) project was performed at a single center to determine the incidence of postoperative complications associated with use of cuffed airway devices. An educational program was then completed that involved training our anesthesia providers about complications related to excessive cuff pressure and how to utilize a quantitative cuff pressure measurement device (manometer). The impact of this educational initiative was assessed by comparing the incidence of postoperative complications associated with the use of airway devices before and after the training period.MethodsAfter approval by our institution’s Institutional Review Board, a pre-intervention (baseline) survey was obtained from 259 adult patients after having undergone surgery with general anesthesia with the use of an endotracheal tube (ETT) or laryngeal mask airway (LMA). Survey responses were used to determine the baseline incidence of sore throat, hoarseness, and dysphagia. Once these results were obtained, education was provided to the anesthesia department members addressing the complications associated with excessive cuff pressures, appropriate cuff pressures based on manufacturer recommendations, and instructions on the use of a quantitative monitor to determine cuff pressure (manometry). Clinical care was then changed by requiring intraoperative cuff pressure monitoring throughout our institution for all surgical patients. After this educational period, 299 patients completed the same survey describing postoperative airway complications.ResultsThe use of manometry reduced the incidence of moderate-to-severe postoperative sore throat in the pre- vs. post-intervention groups (35 patients vs 31 patients, p = 0.045), moderate to severe hoarseness (30 patients vs 13, patients p = 0.0001), and moderate-to-severe dysphagia (13 patients vs 5 patients, p = 0.03).ConclusionCaring for patients in the perioperative setting frequently entails placement of an airway device. This procedure is associated with several potential complications, including sore throat, coughing, and vocal cord damage. Our quality improvement initiative has shown that intraoperative management of intra-cuff pressure based on manometry is feasible to implement in clinical practice and can reduce postoperative airway complications.

Can intraoperative manometry influence the outcome of the surgical treatment of achalasia?

Introduction. Achalasia is defined as incomplete or even absent relaxation of the lower esophageal sphincter secondary to the chronic degeneration of unspecified etiology of the myenteric nerve plexus. Material and method. The retrospective study extended over 1 year. The collected variables were: age, sex, type of surgical intervention, intraoperative manometry results, and postoperative complications. Results. We identified 8 patients. The mean operative time was 100 minutes. The use of manometry determined an increase in time of 30 to 40 minutes. Manometry was successfully achieved in all cases, although in one case the sensor could not pass through the lower esophagus, so a prior pneumatic dilation was required. Manometry has proven useful during fundoplication as it offers a direct view of the pressure produced when knots set at 12 - 15 mmHg with a length of 4-5 cm were tightened. Of the 8 patients, 6 required an increase in the length of the resection of the esophagus after the results of the intraoperative manometry were reviewed. Conclusion. In our opinion, after reviewing our experience and the literature data, intraoperative manometry should become a standard procedure in the laparoscopic treatment of achalasia.

330 Guide Wire Sheath: A Novel Approach to Central Venous Manometry

Combined use of manometry and ultrasound significantly reduces the risk of arterial cannulation during central line placement. We report a novel approach to manometry that eliminates the need for extra personnel and equipment by utilizing the plastic guide wire sheath from the central line kit as a manometer. We performed a bench study utilizing a traditional mercury gauged sphygmomanometer to create a series of increased pressure levels within a 1L bag of saline as the reference standard. The saline bag was cannulated with a typical central line catheter. The guide wire sheath was then straightened, marked in 0.5 cm increments and placed into a stopcock in a vertical orientation. The sphygmomanometer pressures were increased in increments of 2 mm Hg and the corresponding rise in the saline column within the guide wire sheath was recorded. The guide wire sheath can theoretically measure pressures up to 40 mm/hg provided that it is positioned vertically. If a patient’s blood were to flow over the top of the guide wire sheath, then it would be reasonable to conclude that the catheter is located in an artery and should not be cannulated in an actual clinical scenario. A correlation coefficient was calculated to assess the relationship between the device measurements and the reference standard. We obtained a total of 20 measurements. The initial measurement of 4 mmHg was then increased in increments of 2 mmHg for each subsequent reading. 19 out of the 20 measurements were included in the analysis as the novel device overflowed at 40 mmHg. The mean difference in measurement between the reference standard and the novel devices was 2.89 sd 1. 38 (95% CI 2. 23-3. 56). With respect to the 19 measurements included in the analysis, 11 (58%) had differences lower than the mean difference of 2.89. Of the 9 measurements that were greater than the mean the greatest difference was only 1.61 above the mean difference of 2.89 mmHg, with the average amount above the mean difference being only 1.22 mmH above the reference standard, sd 0.42 (95% CI 90-1. 54). We observed a strong positive correlation between the reference standard and novel device measurements (r=0. 99, p<0. 001). Table 1 shows the raw measurement data. This simple, novel method of vascular pressure measurement had strong positive correlation with reference standard values. Further studies are warranted to assess the feasibility of this tool in a variety of clinical settings.

A randomised controlled trial of the effect of laryngeal mask airway manometry on postoperative sore throat in spontaneously breathing adult patients presenting for surgery at a university teaching hospital.

Laryngeal mask airways (LMAs) are widely used in anaesthesia and are considered to be generally safe. Postoperative sore throat (POST) is a frequent complication following LMA use and can be very distressing to patients. The use of an LMA cuff pressure of between 30 and 32cm of H2O in alleviating post-operative sore throat has not been investigated. To compare the occurrence of POST between the intervention group in which LMA cuff pressures were adjusted to 30-32cm of H2O and the control group in which only monitoring of LMA cuff pressures was done, to compare the severity of POST between the two study groups and to compare the LMA cuff pressures between the two study groups. Eighty consenting adult patients scheduled to receive general anaesthesia with use of an LMA were randomized into two groups of 40 patients each. Intervention group: LMA airway cuff pressures were adjusted to 30 to 32cm of H2O. Control group: Only had LMA cuff pressures monitored throughout the surgery. All patients were interviewed postoperatively at two, six and twelve hours. Data of their baseline characteristics, occurrence and severity of POST was collected. If POST was present; a Numerical Rating Scale (NRS) was used to assess the severity. Cuff pressures between the two study groups were also determined. The baseline demographic characteristics of the participants were similar. The use of manometry to limit LMA AMBU® AuraOnce™ intracuff pressure to 30-32cm H2O reduced POST in surgical patient's by 62% at 2 hours and 6 hours (Risk Ratio 0.38 95%CI 0.21-0.69)in the intervention group. The median POST pain score in the intervention group was significantly lower than the control group with scores of 0 at 2, 6 and 12 hours post operatively. Routine practice of LMA cuff inflation by anesthesiologists is variable, and the intracuff pressures in the control group were higher than in the intervention group. (P<0.001). Among this population, reduction of LMA AMBU® AuraOnce™ intracuff pressure to 30-32cm H2O reduces the occurrence and severity of POST. The LMA cuff pressures should be measured routinely using manometry and reducing the intracuff pressures to 30-32 cm of H2O recommended as best practice.

PS01.005: HIGH-RESOLUTION MANOMETRY GUIDING SURGICAL PROCEDURE FOR TREATMENT OF ACHALASIA OF THE ESOPHAGUS. LONG-TERM RESULTS OF A PROSPECTIVE STUDY

Abstract Background Laparoscopic myotomy and fundoplication for the treatment of achalasia presents with 90% success rate. The intraoperative use of manometry during surgery has been previously introduced to improve the outcome. Recently, we presented our pilot study proposing the use of the HRM during surgery. The aim of this study is to evaluate the long-term outcome of the intraoperative use of High-Resolution Manometry (HRM) in achalasia patients. Methods In this prospective study, consecutive achalasia patients underwent laparoscopic myotomy and fundoplication along with real-time use of HRM. Eckardt scores (ES) and HRM results were collected before and after surgery. Results Twenty-three achalasia patients (22% Type I, 57% Type II, 22% Type III, according to Chicago Classification v3.0) with a mean age 48 years underwent calibrated and uneventful myotomy and fundoplication. Eleven myotomies were further extended, while sixteen fundoplications were intraoperatively modified, according to manometric findings. During postoperative follow-up, mean resting and residual pressures of the LES were significantly decreased after surgery (16,1 vs. 41,9, P = 0 and 9 vs. 28,7, P = 0, respectively). The ES was also diminished (1 vs. 7, P = 0). Conclusion The intraoperative use of HRM during laparoscopic myotomy and fundoplication for the treatment of achalasia of the esophagus is a safe, promising and efficient approach aiming to individualize both myotomy and fundoplication for each achalasia patient. Disclosure All authors have declared no conflicts of interest.

Applying manofluorography in the evaluation of dysphagia after brainstem injury

Objective To evaluate the swallowing function of patients with dysphagia after brainstem injury using manofluorography (MFG), analyzing the abnormal biomechanical and kinematic parameters as well as any correlation between changes in the pharynx and the upper esophageal sphincter (UES) measured manometrically and changes in the kinematics of the hyoid bone. Methods Thirteen patients with dysphagia after brainstem injury (the patient group) and 13 healthy participants (the control group) underwent manofluorography. Kinematics and biomechanical changes during swallowing were compared between the two groups and the correlations between the observations were analyzed. Results The patient group showed significantly lower maximum pressure and rate of pressure change at the base of the tongue and in the hypopharynx, as well as less hyoid anterior displacement, smaller and briefer UES opening, but significantly higher minimum pressure at UES relaxation. The duration of tongue root elevation and hypopharynx pressure was also shorter than in the control group, on average. There was a negative correlation between hyoid anterior displacement and the minimum pressure on UES relaxation in the control group, and a positive correlation between hyoid anterior displacement and the maximum pressure at the base of the tongue and in the hypopharynx in the patient group. Conclusions The concurrent use of manometry and video-fluorography for evaluating dysphagia can be an objective and effective diagnostic tool for the comprehensive evaluation of swallowing function. Key words: Dysphagia; Swallowing video fluoroscopy; Manofluorography; High-resolution manometry

Intestinal manometry: who needs it?

The use of manometry, i.e. the recording of pressures within hollow viscera, after being successfully applied to the study of esophageal and anorectal motor dysfunctions, has also been used to investigate physiological and pathological conditions of the small bowel. By means of this technique, it has been possible to understand better the normal motor functions of the small intestine, and their relationship and variations following physiologic events, such as food ingestion. Moreover, intestinal manometry has proved useful to document motor abnormalities of the small bowel, although recognition of altered patterns specific for a determinate pathologic condition is still unavailable. However, this technique often permits the detection of abnormal gut motility in patients with abdominal symptoms such as unexplained vomiting and diarrhea, and it is sometimes also useful to address therapeutic targeting.

Impact of pleural manometry on the development of chest discomfort during thoracentesis: a symptom-based study.

Routine manometry is recommended to prevent complications during therapeutic thoracentesis, but has not definitively been shown to prevent pneumothorax or reexpansion pulmonary edema. As chest discomfort correlates with negative pleural pressures, we aimed to determine whether the use of manometry could anticipate the development of chest discomfort during therapeutic thoracentesis. A retrospective chart review of 214 consecutive adults who underwent outpatient therapeutic thoracentesis at our institution between January 1, 2011 and June 30, 2013 was performed. We compared preprocedural to postprocedural discomfort (using a linear analog scale from 0 to 10) in patients undergoing thoracentesis with or without manometry. We used a multivariate model to adjust for possible confounders. Changes of dyspnea scores were also analyzed. Manometry was performed in 82/214 patients (38%). On univariate and multivariate analyses, neither the change in chest discomfort nor dyspnea scores was significantly different in the manometry versus the control group (P=0.12 and 0.24, respectively). Similar results were also found in the subgroup of large-volume thoracentesis (P=0.32 for discomfort, P=1.0 for dyspnea). In our retrospective study, the use of manometry did not appear to anticipate the development of chest discomfort during therapeutic thoracentesis. Prospective studies are needed to confirm these findings.

Diagnostic testing for dyssynergic defecation in chronic constipation: meta‐analysis

Dyssynergic defecation (DD) results from inadequate relaxation of the pelvic floor on attempted defecation. The prevalence of DD in patients with chronic constipation (CC) is not certain. Aims of this study are to estimate the prevalence of abnormal findings associated with DD across testing modalities in patients referred for physiological testing for CC. Systematic search of MEDLINE, EMBASE and PUBMED databases were conducted. We included full manuscripts reporting DD prevalence in CC, and specific findings at pelvic floor diagnostic tests. Random effects models were used to calculate pooled DD prevalences (with 95% CI) according to individual tests and specific findings. A total of 79 studies on 7581 CC patients were included. The median prevalence of any single abnormal finding associated with DD was 37.2%, ranging from 14.9% (95% CI 7.9-26.3) for absent opening of the anorectal angle (ARA) on defecography to 52.9% (95% CI 44.3-61.3) for a dyssynergic pattern on ultrasound. The prevalence of a dyssynergic pattern on manometry was 47.7% (95% CI 39.5-56.1). The prevalence of DD was similar across specialty and geographic area as well as when restricting to studies using Rome criteria to define constipation. Dyssynergic defecation is highly prevalent in CC and is commonly detected across testing modalities, type of patient referred, and geographical regions. We believe that the lower prevalence of findings associated with DD by defecography supports use of manometry and balloon expulsion testing as an initial evaluation for CC.

Accuracy of ProSeal™ Laryngeal Mask Airway Intracuff Pressure Estimation using Finger Palpation technique – A Prospective, Observational Study

The incidence of pharyngolaryngeal adverse events associated with laryngeal mask airways can be reduced by the use of manometry to limit the laryngeal mask airway intracuff pressures. We conducted a prospective, observational study in 80 patients undergoing general anaesthesia with the ProSeal™ laryngeal mask airway to determine the accuracy of a finger palpation technique compared to actual readings obtained from a hand-held manometer by different anaesthesia personnel. The strength of association of estimated versus actual intracuff pressures, R, for nurse anaesthesia assistants, junior anaesthetists and senior anaesthetists were 0.21 (weak), 0.35 (moderate) and 0.78 (strong) respectively. Subgroup analysis showed that anaesthetists with more than three years of experience were more accurate than those with less than three years of experience. The actual versus estimated intracuff pressures were 4±17 vs 19±27 cmH2O (P value <0.001) respectively. In all groups, the palpation technique tended to underestimate the actual intracuff pressure by a mean of 10.3 cmH2O. Palpation accuracy decreased when actual intracuff pressures were >80 cmH2O. These findings suggest that cuff pressure manometry should be recommended as standard of care with the use of laryngeal mask airways.

Manofluorography in the Evaluation of Oropharyngeal Dysphagia

Manofluorography, that is, the concurrent use of manometry and videofluorography for the evaluation of pharyngeal dysphagia, has not been widely used clinically, partially because of various limitations of conventional manometry. Technological advancements in recent years have led to substantial improvements in manometric devises, which can now overcome many of the shortcomings of standard manometry. In parallel with this, studies examining the utility of high-resolution manometry for the evaluation of pharyngeal disorders of swallowing have begun to emerge. This review summarizes the technological developments in manometry and the existing literature on pharyngeal high-resolution manofluorography with pressure topography. The article also discusses the potential clinical value of high-resolution pharyngeal-esophageal pressure topography and suggests directions for future investigations. Studies conducted so far have shown heterogeneous approaches to utilizing high-resolution manofluorography. These studies have revealed important information regarding its diagnostic potential and researchers have devised innovative methods of measurements. However, substantial research is required to transform manofluorography into a clinically useful tool. There is a need to conduct validation studies, correlating manometric measures with structural changes in the swallow seen on videofluorography and devise diagnostic methods that utilize the advantages of both tools. Furthermore, studies comparing healthy and clinical populations are needed to identify measures most clinically significant in order to develop diagnostic paradigms.

Manometric assessment of pharyngeal swallowing pressure after mandibular reconstruction

Oral cancer patients who undergo mandibular bone partial resection often exhibit swallowing disturbance after surgery. We examined the usefulness of manometry in obtaining quantitative data on swallowing function in patients after mandibular bone partial resection. Postsurgical swallowing function was investigated, using a combination of videofluorography (VF) and manometry, in five patients with oral cancer, who underwent mandibular bone partial resection. Three patients underwent reconstruction of soft tissue defects only, while the remaining two patients underwent reconstruction of both soft tissue defects and a bony segment using a reconstruction plate or vascularized fibula with a skin paddle. Oropharyngeal swallowing pressure ranged from 61 to 82 mmHg compared to the normal range of 109 ± 31 mmHg (mean ± SD). Partial resection of the mandible without reconstruction of the bony segment defect had a negative effect upon oropharyngeal swallowing pressure. Four of the five patients exhibited normal function in the oral stage. Elevation of the larynx was disturbed in 80% of the patients. None of the patients in this study experienced aspiration after surgery. In conclusion, a combination of VF and manometry revealed that mandibular bone partial resection resulted in disturbed elevation of the larynx while pharyngeal swallowing pressure decreases in those patients who do not undergo bony segment reconstruction. Our results suggested that the tongue, including the base of the tongue, should be set in a closed space so that pharyngeal swallowing pressure does not release.

Usefulness of manometry to select patients with anal fissure for controlled anal dilatation

To evaluate the use of anorectal manometry to select patients for controlled anal dilatation. A prospective study was performed using anorectal manometry on all patients with chronic anal fissure who did not have a good response to conservative treatment. Those with increased anal resting pressure were treated with controlled anal dilatation using a two valved anuscope. A second anorectal manometry was indicated after controlled anal dilatation. 19 patients without anorectal pathology (Healthy Control Group) and 57 patients with chronic anal fissure were included in this study. Controlled anal dilatation was performed on 27 patients, maximum resting pressure 122 ± 19 mmHg. In the controlled anal dilatation group the healing rate was 92.5%, mean maximum resting pressure post-controlled anal dilatation was 91 ± 30 mmHg. We found one case of transitory anal incontinence (3.7%). None of the patients had anal incontinence at 18 months of the follow-up. In the remaining 30 patients non selected for controlled anal dilatation (chronic anal fissure control group), a proportion of 53.3% recurrences were registered after conservative treatment. Anal healing of chronic anal fissure and a significant decrease in maximum resting pressure recorded by manometry confirms the success of this procedure. The manometric evaluation of the maximum resting pressure is useful in the selection of chronic anal fissure patients for controlled anal dilatation. The efficacy of dilatation to treat chronic anal fissure in patients with raised anal sphincter pressure was high and complications were rare.

What is new in radiology and pathology of motility disorders in children?

Disorders affecting colorectal motility lead to significant morbidity in children with surgical conditions. Etiology is frequently unknown, which in turn makes treatment empiric and compromises outcome. A thorough understanding of the normal mechanisms of control and the ability to recognize and manage defects is an important goal for clinicians. This article reviews recent advances made in the investigation of children with colorectal motility disorders, including the role of transit studies (marker studies and scintigraphy), options for assessing anatomy (ultrasound, contrast enema, and sectional imaging) and the use of manometry, both anorectal and colonic. Current concepts in microscopic evaluation are outlined.

Use of Manometry for Laryngeal Mask Airway Reduces Postoperative Pharyngolaryngeal Adverse Events

Adverse events such as pharyngolaryngeal complications are indicators of quality patient care. Use of manometry to limit the laryngeal mask airway (LMA) intracuff pressure is not currently a routine practice. This double-blind randomized trial compared pharyngolaryngeal complications in patients managed with manometers to limit the LMA intracuff pressure (<44 mmHg) with patients under routine care. Two hundred consenting patients who underwent ambulatory surgery were randomly allocated to pressure-limiting and routine care groups. Anesthesia was induced with propofol and fentanyl, and maintained with desflurane in air-oxygen. An LMA was inserted, and the cuff was inflated as per usual practice. The patients breathed spontaneously. Research assistants measured the LMA intracuff pressure. In the pressure-limiting group, LMA intracuff pressure was adjusted to less than 44 mmHg. No intervention was performed in the routine care group. Sore throat, dysphonia, and dysphagia were assessed at 1, 2, and 24 h postoperatively. Composite pharyngolaryngeal complications were compared using chi-square test. Baseline demographic data were comparable between groups. Mean LMA intracuff pressure was less in the pressure-limiting group versus the routine care group (40 +/- 6 vs. 114 +/- 57 mmHg, P < 0.001). The incidence of composite pharyngolaryngeal complications was significantly lower in the pressure-limiting group versus the routine care group (13.4 vs. 45.6%, P < 0.001), with a relative risk reduction of 70.6%, and a number needed to treat of three (95% CI 2.2-7.5). Reduction of LMA intracuff pressure to less than 44 mmHg lowers the incidence of postoperative pharyngolaryngeal complications. The LMA cuff pressures should be measured routinely using manometry, and deflating the intracuff pressure to less than 44 mmHg should be recommended as anesthetic best practice.

THIS MONTH IN Anesthesiology

The role of these receptors in mediating peripheral pain in response to inflammation is reviewed.Family-centered care partners patients, families, health care providers, and hospitals.Preoperative C-reactive protein levels as low as 3 mg/l are associated with increased long-term mortality and extended length of stay.The goal of this Advisory is to reduce the risk of infectious complications associated with neuraxial techniques.Ultrasound imaging for pediatric neuraxial anesthesia is reviewed.General anesthetics have been reported to cause epileptiform electroencephalographic activity and seizure-like movements. Such events in neonates and infants are of concern as they may potentially result in neurologic and cognitive defects. The current study evaluated the effects of the Na+-K+-2Cl-cotransporter 1 inhibitor, bumetanide, in neonatal rats exposed to sevoflurane at postnatal days 4-17 (P4-P17). During anesthesia maintenance, epileptic seizures occurred in P4-P8 rats but not in P10-P17 rats. Bumetanide (5 μmol/kg, intraperitoneally) significantly decreased seizures in P4-P9 rats, but did not affect P10-P17 rats. A significant increase in activated caspase-3 and impairment of long-term potentiation induction occurred after 6 h of sevoflurane that was inhibited by bumetanide. The excitatory output of sevoflurane-potentiated γ-aminobutyric acid type A/glycine systems may contribute to epileptogenic and neurotoxic effects in early postnatal rats, and bumetanide is a possible therapy for these putative adverse effects of anesthetics. See the accompanying Editorial View on page 527 A safer and more effective hemoglobin-based oxygen carrier (HBOC) to substitute for red blood cell transfusion is needed. HBOC-induced vasoconstriction caused by scavenging of endothelium-derived nitric oxide appears to be responsible for the adverse effects of cell-free hemoglobin. In this study, the hemodynamic effects of infusion of PolyHeme (1.08 g hemoglobin/kg; Northfield Laboratories, Evanston, IL) or murine tetrameric hemoglobin (0.48 g hemoglobin/kg) were determined. In normal lambs and mice, infusion of HBOCs did not cause systemic hypertension, but produced acute systemic and pulmonary vasoconstriction. Mice with endothelial dysfunction were more sensitive to systemic vasoconstriction after infusion of either tetrameric hemoglobin or PolyHeme. This study suggests that reduced vascular nitric oxide levels associated with endothelial dysfunction contribute to adverse effects of HBOCs. These findings suggest that testing HBOCs in animals with endothelial dysfunction can provide a more sensitive indication of their potential adverse vasoconstrictor effects.Although use of manometry to limit laryngeal mask airway (LMA) intracuff pressure is not current practice, it may reduce adverse pharyngolaryngeal events. This double-blind randomized trial compared pharyngolaryngeal complications in ambulatory surgery patients (N=200) managed with manometers to limit LMA intracuff pressure (less than 44 mmHg) versus patients under routine care. Mean LMA intracuff pressure was less in the pressure-limiting group versus the routine care group. The incidence of composite pharyngolaryngeal complications was significantly lower in the pressure-limiting group versus the routine care group with a relative risk reduction of 70.6%, and a number-needed-to-treat of 3. Reduction of LMA intracuff pressure to less than 44 mmHg lowered the incidence of postoperative pharyngolaryngeal complications.

Eliminating Arterial Injury During Central Venous Catheterization Using Manometry

Unintended arterial puncture occurs in 2%-4.5% of central venous catheterizations, resulting in arterial injury in 0.1%-0.5% of patients. Routine performance of manometry during catheterization may successfully identify unintended arterial puncture and avoid arterial cannulation and injury. We conducted a retrospective review of all cases of central venous catheter placement during a 15-yr period after implementation of a safety program requiring mandatory use of manometry to verify venous access. Arterial injuries were defined as unintended arterial cannulations with a 7-French or larger catheter or dilator. Arterial punctures were defined as the unintended placement of an 18-gauge catheter or needle into the artery. Data were reviewed for all arterial injuries during the entire 15-yr period. In addition, data on both arterial puncture and subsequent arterial injury were evaluated during the final year of analysis. A total of 9348 central venous catheters were placed during the observation period. During the full 15 yr of observation, there were no cases of arterial injury. During the final year of assessment, 511 central venous catheters were placed, with arterial punctures in 28 patients (5%). Arterial puncture was recognized without manometry in 24 cases. Arterial puncture was identified only with manometry in 4 cases, with no incidents of arterial injury. Consistent use of manometry, to verify venous placement, during central venous catheterization effectively eliminated arterial injury from unintended arterial cannulation during the 15-yr assessment.

Monitoring Tracheal Tube Cuff Pressures in the Intensive Care Unit: A Comparison of Digital Palpation and Manometry

Tracheal tube cuff overinflation is a recognized risk factor for tracheal injury and stenosis. International studies report a 55% to 62% incidence of cuff overinflation among intensive care unit (ICU) patients. However, there are no data on tracheotomy tubes, and no recent data from ICUs in the United States. It is unknown whether routine cuff pressure measurement is beneficial. We sought to determine the incidence of cuff overinflation in the contemporary American ICU. We performed an Institutional Review Board-approved, prospective, observational study of endotracheal and tracheotomy tubes at 2 tertiary-care academic hospitals that monitor cuff pressure differently. At hospital A, cuff pressures are assessed by palpation; at hospital B, cuff pressures are measured via manometry. We audited cuff pressures in an unannounced fashion at these hospitals, using a handheld aneroid manometer. Cuffs were considered overinflated above 25 cm H2O. We enrolled 115 patients: 63 at hospital A and 52 at hospital B. Overall, 44 patients (38%) were found to have overinflated cuffs. The incidence of overinflation was identical at the 2 hospitals (38%; p = .99). Of the endotracheal tubes, 43% were overinflated, as were 32% of the tracheotomy tubes (p = .24). Despite increasing awareness among intensivists and respiratory therapists, the incidence of tracheal tube overinflation remains high, with both endotracheal and tracheotomy tubes. Our finding that the use of manometry to assess cuff pressures did not reduce the incidence of overinflation suggests that a more vigilant management protocol may be necessary.

Lumbar discography

Purpose of review: This article will review recent advances in our understanding of lumbar discography and how it relates to the evaluation of patients with suspected discogenic low back pain. Recent findings: Several recent studies have added to our knowledge of lumbar discography. One interesting area is the use of manometry or pressure monitoring to reduce the incidence of false positive results. The idea that there may be subsets of patients with positive discograms based on pressure measurements is gaining popularity. It also appears that sufficiently high pressures may induce a pain response in otherwise asymptomatic discs. Despite these advances in our understanding, it has been shown that psychosocial factors probably play a greater role in predicting disability. Finally, as we move further into the era of motion preservation and disc arthroplasty the use of discography in the classification of degenerative disc disease of the lumbar spine may prove to be very helpful. Summary: Lumbar discography remains a valuable tool in the evaluation of patients with suspected discogenic low back pain. Use of manometric or pressure monitoring techniques may help reduce the incidence of false positive results and improve patient outcomes. Careful patient selection and attention to psychosocial factors remain critical to successful management of these patients.