Nos gustaría dar las gracias al departamento de anestesia del Hospital de Niños de Michigan, por sus esfuerzos y la financiación de este proyecto. Nos gustaría dar las gracias al departamento de BMC en el Hospital de Investigación St. Jude Children por su trabajo de arte.

<ol><li> Un tamaño de tubo endotraqueal para la edad del paciente para la intubación endotraqueal debe ser elegido. Usamos la fórmula: tamaño de ETT = edad (años) / 4 +4. </li><li> Hemos elegido un un tamaño más pequeño tubo endotraqueal sin manguito que se inserta por vía nasal, en caso de que la intubación endotraqueal falla después de que el paciente se pone a dormir. </li><li> Antes de la inserción del tubo nasal, medimos la distancia aproximada desde la nariz hasta el nivel de las cuerdas vocales, que suele ser a nivel del cartílago tiroideo medio. </li><li> Después de que el paciente está anestesiado, y después de un fallido intento de la ventilación y la intubación endotraqueal no, el bien lubricada un tamaño más pequeño tubo endotraqueal se inserta por vía nasal a un nivel justo por encima de las cuerdas vocales. </li><li> Uno tiene que asegurar un buen sellado de la boca y las fosas nasales del paciente. El circuito de anestesia puede ser conectado al conector de tubo endotraqueal, y con el sello correspondiente de la boca y la nariz, los pulmones pueden ser ventilados adecuadamente. </li></ol> Después de sellar la boca y la nariz, los pulmones son ventilados adecuadamente según lo confirmado por ETCO2 forma de onda, el aumento de pecho del paciente y la saturación de oxígeno en buena oxímetro de pulso.

<ol>
	<li>Heidegger, T., Gerig, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Algorithms+for+management+of+the+difficult+airway.">Algorithms for management of the difficult airway.</a> Curr Opin Anaesthesiol. 17, 483-484 (2004).</li><li>Krafft, P., Schebesta, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Alternative+management+techniques+for+the+difficult+airway:+esophageal-tracheal+Combitube.">Alternative management techniques for the difficult airway: esophageal-tracheal Combitube.</a> Curr Opin Anaesthesiol. 17, 499-504 (2004).</li></ol>

Esta técnica es comparable a un dispositivo supraglótico, como una máscara laríngea 1 o un 2 Combitube, los cuales se han descrito con éxito las técnicas de rescate en situación CICV para asegurar la ventilación y oxigenación como técnica no quirúrgica. Esta técnica ETT sin embargo, tiene la facilidad de la disponibilidad y preparación, que no requiere ningún entrenamiento o equipo especial. En los casos de CICV y, sobre todo en neonatos y lactantes pequeños, desaturación de oxígen...

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<td>ETT size appropriate for patient's age: ETT=age/4 +4</td>
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<td>tape to protect the eyes</td>
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<td>ASA standard anesthesia monitors</td>
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<td>red rubber suction catheter</td>
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a novel rescue technique for difficult intubation and difficult ventilation

Se describe una nueva técnica no quirúrgica para mantener la oxigenación y la ventilación en caso de intubación difícil y difícil ventilación, que funciona especialmente bien con el ajuste máscara pobres. No se puede intubar, no se puede ventilar &quot;(CICV) es una situación que potencialmente amenaza la vida. En este video se presenta una simulación de la técnica que hemos utilizado en un caso de CICV, donde se mantuvo la oxigenación y la ventilación mediante la inserción de un tubo endotraqueal (ETT) por vía nasal hasta el nivel de la nasofaringe, mientras que cierre la boca y las fosas nasales para la ventilación a presión positiva con éxito. Un paciente de 13 años de edad, fue llevado a la sala de operaciones de incisión y drenaje de absceso del cuello y un laryngobronchoscopy directa. Después de preoxigenación, la anestesia fue inducida por vía intravenosa. Ventilación con mascarilla se encontró que era extremadamente difícil debido a la hinchazón de los tejidos blandos. La máscara no podía encajar correctamente en la cara debido a la hinchazón facial importante también. La laringoscopia directa se intentó, sin visualización de la laringe. Saturación de oxígeno era difícil de mantener, con saturaciones de la caída de 80%. Con el fin de oxigenar y ventilar al paciente, un tubo endotraqueal se inserta a continuación, por vía nasal después de spray nasal con descongestionantes nasales y el lubricante. El tubo se empuja suavemente y ciegamente en la hipofaringe. La boca y la nariz de la paciente fueron sellados con la mano y la ventilación con presión positiva ha sido posible con O 100 2% con una buena saturación de oxígeno durante ese período de tiempo. Una vez que el paciente se encontraba estable y sedado, así, un broncoscopio rígido fue presentado por el otorrinolaringólogo que muestra edema extenso subglótica y la epiglotis, y un efecto de masa del absceso, lo que contribuye al compromiso de las vías respiratorias. La vía aérea fue asegurada con un tubo endotraqueal por el vídeo otolaryngologist.This mostrará una simulación de la técnica en un paciente sometido a anestesia general para restauraciones dentales.

Watch this Scientific Journal Video about A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation at JoVE.com

A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation

Se describe una técnica para mantener la oxigenación y la ventilación con un tubo endotraqueal insertado por vía nasal hasta el nivel de la nasofaringe, mientras que cierre la boca y las fosas nasales para la ventilación a presión positiva con éxito.

Una técnica de rescate de Novela de la intubación difícil y ventilación difícil

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which ...

a-novel-rescue-technique-for-difficult-intubation-difficult

Research

JoVE Journal

Medicine

21.4K vistas.  Children’s Hospital of Michigan. Se describe una técnica para mantener la oxigenación y la ventilación con un tubo endotraqueal insertado por vía nasal hasta el nivel de la nasofaringe, mientras que cierre la boca y las fosas nasales para la ventilación a presión positiva con éxito.

Video: A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation

A Novel Capsulorhexis Technique Using Shearing Forces with Cystotome

Purpose:
To demonstrate a capsulorhexis technique using predominantly shearing forces with a cystotome on a virtual reality simulator and on a human eye.
Method:
Our technique involves creating the initial anterior capsular tear with a cystotome to raise a flap. The flap left unfolded on the lens surface. The cystotome tip is tilted horizontally and is engaged on the flap near the leading edge of the tear. The cystotome is moved in a circular fashion to direct the vector forces. The loose flap is constantly swept towards the centre so that it does not obscure the view on the tearing edge.
Results:
Our technique has the advantage of reducing corneal wound distortion and subsequent anterior chamber collapse. The capsulorhexis flap is moved away from the tear leading edge allowing better visualisation of the direction of tear. This technique offers superior control of the capsulorhexis by allowing the surgeon to change the direction of the tear to achieve the desired capsulorhexis size.
Conclusions:
The EYESI Surgical Simulator is a realistic training platform for surgeons to practice complex capsulorhexis techniques. The shearing forces technique is a suitable alternative and in some cases a far better technique in achieving the desired capsulorhexis.

This video demonstrates a novel capsulorhexis technique in modern cataract surgery. Capsulorhexis is the most difficult and important part of phacoemulsification surgery.

Una técnica de capsulorrexis novela usando las fuerzas de cizallamiento con cistítomo

Purpose:
To demonstrate a capsulorhexis technique using predominantly shearing forces with a cystotome on a virtual reality simulator and on a human eye....

Investigación

Medicina

Corneal Confocal Microscopy: A Novel Non-invasive Technique to Quantify Small Fibre Pathology in Peripheral Neuropathies

The accurate quantification of peripheral neuropathy is important to define at risk patients, anticipate deterioration, and assess new therapies. Conventional methods assess neurological deficits and electrophysiology and quantitative sensory testing quantifies functional alterations to detect neuropathy. However, the earliest damage appears to be to the small fibres and yet these tests primarily assess large fibre dysfunction and have a limited ability to demonstrate regeneration and repair. The only techniques which allow a direct examination of unmyelinated nerve fibre damage and repair are sural nerve biopsy with electron microscopy and skin-punch biopsy. However, both are invasive procedures and require lengthy laboratory procedures and considerable expertise. Corneal Confocal microscopy is a non-invasive clinical technique which provides in-vivo imaging of corneal nerve fibres. We have demonstrated early nerve damage, which precedes loss of intraepidermal nerve fibres in skin biopsies together with stratification of neuropathic severity and repair following pancreas transplantation in diabetic patients. We have also demonstrated nerve damage in idiopathic small fibre neuropathy and Fabry's disease.

Corneal Confocal microscopy is a non-invasive clinical technique which may be used to quantify C fibre damage to diagnose and stratify patients with increasing neuropathic severity.

Microscopía Confocal de córnea: A Novel una técnica no invasiva para cuantificar pequeñas de fibra de Patología en neuropatías periféricas

The accurate quantification of peripheral neuropathy is important to define at risk patients, anticipate deterioration, and assess new therapies. ...

A Novel Technique of Rescuing Capsulorhexis Radial Tear-out using a Cystotome

Part 1 : Purpose: To demonstrate a capsulorhexis radial tear out rescue technique using a cystotome on a virtual reality cataract surgery simulator and in a human eye. Part 2 : Method: Steps: When a capsulorhexis begins to veer radially towards the periphery beyond the pupillary margin the following steps should be applied without delay. 2.1) Stop further capsulorhexis manoeuvre and reassess the situation. 2.2) Fill the anterior chamber with ophthalmic viscosurgical device (OVD). We recommend mounting the cystotome to a syringe containing OVD so that the anterior chamber can be reinflated rapidly. 2.3) The capsulorhexis flap is then left unfolded on the lens surface. 2.4) The cystotome tip is tilted horizontally to avoid cutting or puncturing the flap and is engaged on the flap near the leading edge of the tear but not too close to the point of tear. 2.5) Gently push or pull the leading edge of tear opposite to the direction of tear. 2.6) The leading tearing edge will start to do a 'U-Turn'. Maintain the tension on the flap until the tearing edge returns to the desired trajectory. Part 3 : Results: Using our technique, a surgeon can respond instantly to radial tear out without having to change surgical instruments. Changing surgical instruments at this critical stage runs a risk of further radial tear due to sudden shallowing of anterior chamber as a result of forward pressure from the vitreous. Our technique also has the advantage of reducing corneal wound distortion and subsequent anterior chamber collapse. Part 4 : Discussion The EYESI Surgical Simulator is a realistic training platform for surgeons to practice complex capsulorhexis tear-out techniques. Capsulorhexis is the most important and complex part of phacoemulsification and endocapsular intraocular lens implantation procedure. A successful cataract surgery depends on achieving a good capsulorhexis. During capsulorhexis, surgeons may face a challenging situation like a capsulorhexis radial tear-out. A surgeon must learn to tackle the problem promptly without making the situation worse. Some other methods of rescuing the situation have been described using a capsulorhexis forceps. However, we believe our method is quicker, more effective and easier to manipulate as demonstrated on the EYESi surgical simulator and on a human eye. Acknowledgments: List acknowledgements and funding sources. We would like to thank Dr. Wael El Gendy, for video clip. Disclosures: describe potential conflicting interests or state We have nothing to disclose. References: 1. Brian C. Little, Jennifer H. Smith, Mark Packer. J Cataract Refract Surg 2006; 32:1420 1422, Issue-9. 2. Neuhann T. Theorie und Operationstechnik der Kapsulorhexis. Klin Monatsbl Augenheilkd. 1987; 1990: 542-545. 3. Gimbel HV, Neuhann T. Development, advantages and methods of the continuous circular capsulorhexis technique. J Cataract Refract Surg. 1990; 16: 31-37. 4. Gimbel HV, Neuhann T. Continuous curvilinear capsulorhexis. (letter) J Cataract Refract Sur. 1991; 17: 110-111.

Capsulorhexis is an important step in phacoemulsification surgery. A surgeon creates a continous curvilinear tear on the anterior lens capsule by controlling the tearing vector forces. A peripherally extended tear is a serious complication. This video demonstrates a novel technique of rescuing capsular radial tear out using a cystotome.

Una nueva técnica de capsulorrexis rescate radial de arranque a utilizar un cistítomo

Part 1 : Purpose:   To demonstrate a capsulorhexis radial tear out rescue technique using a cystotome on a virtual reality cataract surgery simulator and ...

Guidelines for Elective Pediatric Fiberoptic Intubation

Fiberoptic intubation in pediatric patients is often required especially in difficult airways of syndromic patients i.e. Pierre Robin Syndrome. Small babies will desaturate very quickly if ventilation is interrupted mainly to high metabolic rate. We describe guidelines to perform a safe fiberoptic intubation while maintaining spontaneous breathing throughout the procedure. Steps requiring the use of propofol pump, fentanyl, glycopyrrolate, red rubber catheter, metal insuflation hook, afrin, lubricant and lidocaine spray are shown.

We describe guidelines to perform a safe and efficient elective fiberoptic intubation in pediatric patients while maintaining spontaneous ventilation.

Directrices para la intubación electiva de fibra óptica Pediátrica

Fiberoptic intubation in pediatric patients is often required especially in difficult airways of syndromic patients i.e. Pierre Robin Syndrome. Small ...

A Simple Method of Mouse Lung Intubation

A simple procedure to intubate mice for pulmonary function measurements would have several advantages in longitudinal studies with limited numbers or expensive animal. One of the reasons that this is not done more routinely is that it is relatively difficult, despite there being several published studies that describe ways to achieve it. In this paper we demonstrate a procedure that eliminates one of the major hurdles associated with this intubation, that of visualizing the trachea during the entire time of intubation. The approach uses a 0.5 mm fiberoptic light source that serves as an introducer to direct the intubation cannula into the mouse trachea. We show that it is possible to use this procedure to measure lung mechanics in individual mice over a time course of at least several weeks. The technique can be set up with relatively little expense and expertise, and it can be routinely accomplished with relatively little training. This should make it possible for any laboratory to routinely carry out this intubation, thereby allowing longitudinal studies in individual mice, thereby minimizing the number of mice needed and increasing the statistical power by using each mouse as its own control.

This paper describes a striaghforward and efficient method of intubating mice for pulmonary function measurements or pulmonary instillation, that allows the mice to recover and be studied at later times. The procedure involves an inexpensive fiberoptic light source that directly illuminates the trachea.

Un sencillo método de intubación ratón de pulmón

A  simple procedure to intubate mice for pulmonary function measurements would  have several advantages in longitudinal studies with limited numbers or  ...

Intubation-mediated Intratracheal (IMIT) Instillation: A Noninvasive, Lung-specific Delivery System

Respiratory disease studies typically involve the use of murine models as surrogate systems. However, there are significant physiologic differences between the murine and human respiratory systems, especially in their upper respiratory tracts (URT). In some models, these differences in the murine nasal cavity can have a significant impact on disease progression and presentation in the lower respiratory tract (LRT) when using intranasal instillation techniques, potentially limiting the usefulness of the mouse model to study these diseases. For these reasons, it would be advantageous to develop a technique to instill bacteria directly into the mouse lungs in order to study LRT disease in the absence of involvement of the URT. We have termed this lung specific delivery technique intubation-mediated intratracheal (IMIT) instillation. This noninvasive technique minimizes the potential for instillation into the bloodstream, which can occur during more invasive traditional surgical intratracheal infection approaches, and limits the possibility of incidental digestive tract delivery. IMIT is a two-step process in which mice are first intubated, with an intermediate step to ensure correct catheter placement into the trachea, followed by insertion of a blunt needle into the catheter to mediate direct delivery of bacteria into the lung. This approach facilitates a &#62;98% efficacy of delivery into the lungs with excellent distribution of reagent throughout the lung. Thus, IMIT represents a novel approach to study LRT disease and therapeutic delivery directly into the lung, improving upon the ability to use mice as surrogates to study human respiratory disease. Furthermore, the accuracy and reproducibility of this delivery system also makes it amenable to Good Laboratory Practice Standards (GLPS), as well as delivery of a wide range of reagents which require high efficiency delivery to the lung.

Intubation-mediated Intratracheal IMIT Instillation: A Noninvasive, Lung-specific Delivery System

Intubation-mediated intratracheal (IMIT) instillation of reagents is an excellent, noninvasive method for studying respiratory disease, as well as a method for instilling therapeutic reagents directly into the lung. It is a rapid and highly reproducible method which is suitable for preclinical testing.

La intubación mediada intratraqueal (IMIT) instilación: A, Sistema de Entrega de pulmón-específica no invasiva

Respiratory disease studies typically involve the use of murine models as surrogate systems. However, there are significant physiologic differences ...

Topical Airway Anesthesia for Awake-endoscopic Intubation Using the Spray-as-you-go Technique with High Oxygen Flow

A patient&#39;s willingness to cooperate is an absolute precondition for successful awake intubation of the trachea. Whilst drug-sedation of patients can jeopardize their spontaneous breathing, topical anesthesia of the airway is a popular technique. The spray-as-you-go technique represents one of the simplest opportunities to anesthetize the airway mucosa. The application of local anesthetic through the working channel of the flexible endoscope is a widespread practice for anesthetists as well as pulmonologists. There is neither need for additional devices nor special training as a pre-requisite to perform this technique. However, a known clinical problem is the coughing and gagging reflex that may occur when the liquid anesthetic strikes the airway mucosa and other sensitive structures like the vocal cords. This can be avoided by the use of oxygen applied through the working channel with the aim of fogging the local anesthetic into finer particles. Furthermore, the oxygen flow provides a higher oxygen supply and contributes to a better view, dispersing mucus secretions and blood away from the lens. Using an atomizer with a high oxygen flow of 10 L/min we maximized these benefits, caused less coughing and had more satisfied and therefore cooperative patients. Possible, but very rare complications of using oxygen flow including gastric insufflation, organ rupture or barotrauma did not arise. We attribute the complication-free use of high oxygen flow to the design of the set, which permits flow and pressure release.

The topical anesthetic lidocaine was atomized using a high oxygen flow through the working channel of a flexible intubating endoscope to achieve topical airway anesthesia for awake endotracheal intubation. We prefer this modified spray-as-you-go technique for endoscopic intubation to classical bolus application because of higher patient satisfaction and better compliance.

Tópica de la vía aérea La anestesia para la intubación despierto-endoscópica de usar el spray-as-you-go Técnica con alto caudal de oxígeno

A patient&#39;s willingness to cooperate is an absolute precondition for successful awake intubation of the trachea. Whilst drug-sedation of patients can ...

Minimally Invasive Muscle Embedding (MIME) - A Novel Experimental Technique to Facilitate Donor-Cell-Mediated Myogenesis

Skeletal muscle possesses regenerative capacity due to tissue-resident, muscle-fiber-generating (myogenic) satellite cells (SCs), which can form new muscle fibers under the right conditions. Although SCs can be harvested from muscle tissue and cultured in vitro, the resulting myoblast cells are not very effective in promoting myogenesis when transplanted into host muscle. Surgically exposing the host muscle and grafting segments of donor muscle tissue, or the isolated muscle fibers with their SCs onto host muscle, promotes better myogenesis compared to myoblast transplantation. We have developed a novel technique that we call Minimally Invasive Muscle Embedding (MIME). MIME involves passing a surgical needle through the host muscle, drawing a piece of donor muscle tissue through the needle track, and then leaving the donor tissue embedded in the host muscle so that it may act as a source of SCs for the host muscle. Here we describe in detail the steps involved in performing MIME in an immunodeficient mouse model that expresses a green fluorescent protein (GFP) in all of its cells. Immunodeficiency in the host mouse reduces the risk of immune rejection of the donor tissue, and GFP expression enables easy identification of the host muscle fibers (GFP+) and donor-cell-derived muscle fibers (GFP-). Our pilot data suggest that MIME can be used to implant an extensor digitorum longus (EDL) muscle from a donor mouse into the tibialis anterior (TA) muscle of a host mouse. Our data also suggest that when a myotoxin (barium chloride, BaCl2) is injected into the host muscle after MIME, there is evidence of donor-cell-derived myogenesis in the host muscle, with approximately 5%, 26%, 26% and 43% of the fibers in a single host TA muscle showing no host contribution, minimal host contribution, moderate host contribution, and maximal host contribution, respectively.

Minimally Invasive Muscle Embedding MIME - A Novel Experimental Technique to Facilitate Donor-Cell-Mediated Myogenesis

We describe a novel experimental technique that we call Minimally Invasive Muscle Embedding (MIME), which is based on the evidence that skeletal muscle tissue contains viable myogenic cells that can facilitate donor-cell-mediated myogenesis when implanted into a host muscle.

Mínimamente invasiva músculo incrustación (MIME) - una nueva técnica Experimental para facilitar la miogénesis mediada por células de donantes

Skeletal muscle possesses regenerative capacity due to tissue-resident, muscle-fiber-generating (myogenic) satellite cells (SCs), which can form new ...

A Rat Model of Orthotopic Liver Transplantation Using a Novel Magnetic Anastomosis Technique for Suprahepatic Vena Cava Reconstruction

The rat model of orthotopic liver transplantation (OLT) is essential for transplant research. It is a very sophisticated animal model and requires a steep learning curve. The introduction of the cuff technique for anastomosis of the portal vein (PV) and infrahepatic vena cava (IHVC) has significantly simplified the transplant procedure in rats. However, due to the short anterior wall of the recipients' suprahepatic vena cava (SHVC), the cuff technique is very difficult to use for the reconstruction of the SHVC. Most researchers in this field still use the hand-suture technique for SHVC reconstruction, which makes it the bottleneck step in rat orthotopic liver transplantation. The magnetic anastomosis technique (i.e., magnamosis) is a method of connecting two vessels using the attractive force between two magnets. Our recent study has shown that the magnetic anastomosis technique is superior to the hand-suture technique for SHVC reconstruction in rats. In this article, we show a step-by-step protocol for SHVC reconstruction in rats using the novel magnetic anastomosis technique. In this model, the reconstruction of the PV and IHVC was performed by the standard cuff technique, while the reconstruction of the bile duct (BD) was performed by a stent technique. The hepatic re-arterialization was not performed. The magnetic anastomosis technique made SHVC reconstruction much easier and significantly shortened the anphepatic phase. After a reasonable learning curve, even researchers without advanced microsurgical skills can produce reliable and reproducible results using this rat model of OLT.

The reconstruction of the suprahepatic vena cava (SHVC) remains a difficult step in rat orthotopic liver transplantation. In this article, we show a step-by-step protocol for SHVC reconstruction in rats using a novel magnetic anastomosis technique.

Un modelo de rata de Orthotopic trasplante del hígado usando una técnica de Anastomosis magnética novela para la reconstrucción de la Vena Cava suprahepática

The rat model of orthotopic liver transplantation (OLT) is essential for transplant research. It is a very sophisticated animal model and requires a steep ...

Mechanical Ventilation Boot Camp Curriculum

Medical management of mechanically ventilated patients is challenging to novice providers. Incorrect management of this population may lead to increased morbidity and mortality. A three-day simulation-based boot camp serves to provide one-on-one instruction with a critical care provider. These intensivists may dispense personalized immediate feedback as learners engage in hands-on practice with a real mechanical ventilator. Multiple different pathologies can be reviewed that may not be encountered in the clinical setting. Learners can visualize immediate consequences of their actions and may troubleshoot and ask questions, all while in a safe learning environment. We describe the use of human-patient simulators connected to breathing simulators and mechanical ventilators. Potential curriculum executors should be aware of the cost of the equipment and the time needed to dedicate to boot camp execution; however, this intensive interactive training has been shown to increase provider competency, knowledge, and confidence in ventilator management. This curriculum outline provides guidance on how to execute a simulation-based boot camp to train providers on the management of mechanically ventilated patients.

This curriculum outlines how to execute a simulation-based boot camp to teach providers how to manage mechanically ventilated patients.

Plan de estudios campo de inicio de ventilación mecánica

Medical management of mechanically ventilated patients is challenging to novice providers. Incorrect management of this population may lead to increased ...