Uso de una guía de punta flexible (FlexTip) para manejar el fallo del primer intento de intubación con el videolaringoscopio C-MAC D-Blade en la unidad de cuidados intensivos: serie prospectiva de casos / Use of a flexible tip bougie (FlexTip) in the management of the first-attempt failure intubation with the C-MAC D-Blade videolaryngoscope in the intensive care unit: A prospective, case series

Describimos una serie de 11 casos en los que hemos utilizado la nueva guía de punta flexible (FlexTip) como rescate tras el fallo de un primer intento de intubación con el videolaringoscopio C-MAC D-Blade en nuestra UCI. Durante un periodo de 16 meses se recogieron datos de todas las intubaciones donde se utilizó el videolaringoscopio C-MAC D-Blade. Noventa y un pacientes fueron incluidos en el estudio, donde 79 (86,8%) fueron intubados al primer intento, 11 (12,1%) necesitaron 2 intentos, y un paciente necesitó 3 intentos. Entre los 12 pacientes que necesitaron más de un intento de intubación, en un paciente se utilizó una guía «Frova», y en el resto, la nueva guía de punta flexible (FlexTip). En la presente investigación observamos que la nueva guía de punta flexible (FlexTip) puede ser una buena opción para aquellos casos en los que con un videolaringoscopio no somos capaces de intubar en el primer intento.(AU)

We describe a series of 11 cases in which we used the new flexible tip (FlexTip) bougie as a rescue device following first-attempt failure at intubation with the C-MAC D-Blade video laryngoscope in our UCI. We collected data from all intubations performed using the C-MAC D-Blade video laryngoscope over a 16-month period. Ninety six patients were included in the study: 79 (86.8%) were intubated at the first attempt; 11 (12.1%) required 2 attempts; and one patient required 3 attempts. The Frova Intubating Introducer was used in one of the 12 patients requiring more than one intubation attempt, and the FlexTip was used in the remaining 11. This study shows that the new FlexTip bougie is a good rescue device when the first attempt at video laryngoscope intubation fails.(AU)

Factors of easy and difficult cecal intubation during unsedated colonoscopy

Background and aims: difficulty of cecal intubation should be a main indicator for the need of sedated colonoscopy and skilled endoscopists. The present study aimed to explore the factors associated with easy and difficult cecal intubation in unsedated colonoscopy. Methods: all consecutive patients who underwent unsedated colonoscopy at our department by the same endoscopist from December 3, 2020 to August 30, 2022 were retrospectively collected. Age, gender, body mass index (BMI), reasons for colonoscopy, position change, Boston Bowel Preparation Scale score, cecal intubation time (CIT) and major colonoscopic findings were analyzed. CIT < 5 min, CIT 5-10 min and CIT > 10 min or failed cecal intubation were defined as easy, moderate and difficult cecal intubation, respectively. Logistic regression analyses were performed to identify independent factors associated with easy and difficult cecal intubation. Results: overall, 1,281 patients were included. The proportions of easy and difficult cecal intubation were 29.2 % (374/1,281) and 27.2 % (349/1,281), respectively. Multivariate logistic regression analysis found that age ≤ 50 years, male, BMI > 23.0 kg/m2 and the absence of position change were independently associated with easy cecal intubation, and that age > 50 years, female, BMI ≤ 23.0 kg/m2, position change, and insufficient bowel preparation were independently associated with difficult cecal intubation. Conclusions: some convenient factors independently associated with easy and difficult cecal intubation have been identified, which will be potentially helpful to determine whether a colonoscopy should be sedated and a skilled endoscopist should be selected. The current findings should be further validated in large-scale prospective studies. (AU)

A novel 125I seeds fixed on gastric tube for treatment of inoperable esophageal carcinoma: A case report.

ABSTRACT: To explore the treatment benefit of 125I seeds fixed on a gastric tube in the early inoperable esophageal carcinoma (EC).Three senile patients with early inoperable EC who were treated with brachytherapy between October 2017 and February 2019 were included in this study. 125I seeds were fixed on the gastric tube, which was then inserted on the surface of the EC. One patient suffered from severe pulmonary insufficiency; 1 patient underwent colon cancer surgery one week before treatment and suffered from liver dysfunction and esophageal varices; 1 patient suffered from venous embolism of lower extremities and pulmonary artery embolism.All three patients were successfully operated and completed treatment. During the operation, no displacement and shedding of 125I seed gastric tube occurred. After surgery, the discomfort while swallowing and pain after eating were significantly improved. Moreover, dysphagia was relieved in patient 3. In addition, no complications, such as perforation or bleeding, occurred. Local lesions were effectively controlled.Gastric tube with 125I seeds provides a new treatment protocol for inoperable EC and malignant obstruction of esophageal carcinoma.

High-flow nasal cannulae for respiratory support in adult intensive care patients.

BACKGROUND: High-flow nasal cannulae (HFNC) deliver high flows of blended humidified air and oxygen via wide-bore nasal cannulae and may be useful in providing respiratory support for adults experiencing acute respiratory failure, or at risk of acute respiratory failure, in the intensive care unit (ICU). This is an update of an earlier version of the review. OBJECTIVES: To assess the effectiveness of HFNC compared to standard oxygen therapy, or non-invasive ventilation (NIV) or non-invasive positive pressure ventilation (NIPPV), for respiratory support in adults in the ICU. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane COVID-19 Register (17 April 2020), clinical trial registers (6 April 2020) and conducted forward and backward citation searches. SELECTION CRITERIA: We included randomized controlled studies (RCTs) with a parallel-group or cross-over design comparing HFNC use versus other types of non-invasive respiratory support (standard oxygen therapy via nasal cannulae or mask; or NIV or NIPPV which included continuous positive airway pressure and bilevel positive airway pressure) in adults admitted to the ICU. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures as expected by Cochrane. MAIN RESULTS: We included 31 studies (22 parallel-group and nine cross-over designs) with 5136 participants; this update included 20 new studies. Twenty-one studies compared HFNC with standard oxygen therapy, and 13 compared HFNC with NIV or NIPPV; three studies included both comparisons. We found 51 ongoing studies (estimated 12,807 participants), and 19 studies awaiting classification for which we could not ascertain study eligibility information. In 18 studies, treatment was initiated after extubation. In the remaining studies, participants were not previously mechanically ventilated. HFNC versus standard oxygen therapy HFNC may lead to less treatment failure as indicated by escalation to alternative types of oxygen therapy (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.45 to 0.86; 15 studies, 3044 participants; low-certainty evidence). HFNC probably makes little or no difference in mortality when compared with standard oxygen therapy (RR 0.96, 95% CI 0.82 to 1.11; 11 studies, 2673 participants; moderate-certainty evidence). HFNC probably results in little or no difference to cases of pneumonia (RR 0.72, 95% CI 0.48 to 1.09; 4 studies, 1057 participants; moderate-certainty evidence), and we were uncertain of its effect on nasal mucosa or skin trauma (RR 3.66, 95% CI 0.43 to 31.48; 2 studies, 617 participants; very low-certainty evidence). We found low-certainty evidence that HFNC may make little or no difference to the length of ICU stay according to the type of respiratory support used (MD 0.12 days, 95% CI -0.03 to 0.27; 7 studies, 1014 participants). We are uncertain whether HFNC made any difference to the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) within 24 hours of treatment (MD 10.34 mmHg, 95% CI -17.31 to 38; 5 studies, 600 participants; very low-certainty evidence). We are uncertain whether HFNC made any difference to short-term comfort (MD 0.31, 95% CI -0.60 to 1.22; 4 studies, 662 participants, very low-certainty evidence), or to long-term comfort (MD 0.59, 95% CI -2.29 to 3.47; 2 studies, 445 participants, very low-certainty evidence). HFNC versus NIV or NIPPV We found no evidence of a difference between groups in treatment failure when HFNC were used post-extubation or without prior use of mechanical ventilation (RR 0.98, 95% CI 0.78 to 1.22; 5 studies, 1758 participants; low-certainty evidence), or in-hospital mortality (RR 0.92, 95% CI 0.64 to 1.31; 5 studies, 1758 participants; low-certainty evidence). We are very uncertain about the effect of using HFNC on incidence of pneumonia (RR 0.51, 95% CI 0.17 to 1.52; 3 studies, 1750 participants; very low-certainty evidence), and HFNC may result in little or no difference to barotrauma (RR 1.15, 95% CI 0.42 to 3.14; 1 study, 830 participants; low-certainty evidence). HFNC may make little or no difference to the length of ICU stay (MD -0.72 days, 95% CI -2.85 to 1.42; 2 studies, 246 participants; low-certainty evidence). The ratio of PaO2/FiO2 may be lower up to 24 hours with HFNC use (MD -58.10 mmHg, 95% CI -71.68 to -44.51; 3 studies, 1086 participants; low-certainty evidence). We are uncertain whether HFNC improved short-term comfort when measured using comfort scores (MD 1.33, 95% CI 0.74 to 1.92; 2 studies, 258 participants) and responses to questionnaires (RR 1.30, 95% CI 1.10 to 1.53; 1 study, 168 participants); evidence for short-term comfort was very low certainty. No studies reported on nasal mucosa or skin trauma. AUTHORS' CONCLUSIONS: HFNC may lead to less treatment failure when compared to standard oxygen therapy, but probably makes little or no difference to treatment failure when compared to NIV or NIPPV. For most other review outcomes, we found no evidence of a difference in effect. However, the evidence was often of low or very low certainty. We found a large number of ongoing studies; including these in future updates could increase the certainty or may alter the direction of these effects.

ANTECEDENTES: Las cánulas nasales de alto flujo (HFNC) administran flujos elevados de una mezcla humedecida de aire y oxígeno a través de cánulas nasales de gran calibre y pueden ser útiles para proporcionar asistencia respiratoria a los adultos que presentan insuficiencia respiratoria aguda, o que tienen riesgo de presentarla, en la unidad de cuidados intensivos (UCI). Esta es una actualización de una versión anterior de la revisión. OBJETIVOS: Evaluar la eficacia de las HFNC en comparación con la oxigenoterapia estándar, o la ventilación no invasiva (VNI) o la ventilación con presión positiva no invasiva (VPPNI), para la asistencia respiratoria de adultos en la UCI. MÉTODOS DE BÚSQUEDA: Se realizaron búsquedas en CENTRAL, MEDLINE, Embase, CINAHL, Web of Science y en el Registro Cochrane de covid­19 (17 de abril de 2020), registros de ensayos clínicos (6 de abril de 2020) y se realizaron búsquedas de citas prospectivas y retrospectivas. CRITERIOS DE SELECCIÓN: Se incluyeron los estudios controlados aleatorizados (ECA) con un diseño de grupos paralelos o cruzados que compararon el uso de HFNC versus otro tipo de asistencia respiratoria no invasiva (oxigenoterapia estándar a través de cánulas nasales o mascarilla; o VNI o VPPNI que incluía la presión positiva continua en las vías respiratorias y la presión positiva de dos niveles en las vías respiratorias) en adultos ingresados en la UCI. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Se utilizaron los procedimientos metodológicos estándar previstos por la Colaboración Cochrane. RESULTADOS PRINCIPALES: Se incluyeron 31 estudios (22 de grupos paralelos y nueve de diseño cruzado) con 5136 participantes; esta actualización incluyó 20 estudios nuevos. Veintiún estudios compararon la HFNC con la oxigenoterapia estándar, y 13 compararon la HFNC con la VNI o la VPPNI; tres estudios incluyeron ambas comparaciones. Se encontraron 51 estudios en curso (con una estimación de 12 807 participantes) y 19 estudios en espera de clasificación en los que no fue posible determinar la información de elegibilidad del estudio. En 18 estudios el tratamiento se inició después de la extubación. En el resto de los estudios, los participantes no habían recibido de forma previa ventilación mecánica. HFNC versus oxigenoterapia estándar La HFNC podría conducir a un menor fracaso del tratamiento, según lo indicado por el escalamiento a tipos alternativos de oxigenoterapia (razón de riesgos [RR] 0,62; intervalo de confianza [IC] del 95%: 0,45 a 0,86; 15 estudios, 3044 participantes; evidencia de certeza baja). La HFNC probablemente da lugar a poca o ninguna diferencia en la mortalidad cuando se compara con la oxigenoterapia estándar (RR 0,96; IC del 95%: 0,82 a 1,11; 11 estudios, 2673 participantes; evidencia de certeza moderada). La HFNC probablemente da lugar a poca o ninguna diferencia con respecto a los casos de neumonía (RR 0,72; IC del 95%: 0,48 a 1,09; cuatro estudios, 1057 participantes; evidencia de certeza moderada), y no se sabe con certeza su efecto sobre la mucosa nasal ni el traumatismo cutáneo (RR 3,66; IC del 95%: 0,43 a 31,48; dos estudios, 617 participantes; evidencia de certeza muy baja). Se encontró evidencia de certeza baja de que la HFNC podría dar lugar a poca o ninguna diferencia en la duración de la estancia en la UCI según el tipo de asistencia respiratoria utilizada (DM 0,12 días; IC del 95%: ­0,03 a 0,27; siete estudios, 1014 participantes). No se sabe con certeza si la HFNC dio lugar a alguna diferencia en el cociente entre la presión parcial de oxígeno arterial y la fracción de oxígeno inspirado (PaO2/FiO2) en las primeras 24 horas del tratamiento (DM 10,34 mmHg; IC del 95%: ­17,31 a 38; cinco estudios, 600 participantes; evidencia de certeza muy baja). No se sabe con certeza si la HFNC dio lugar a alguna diferencia en la comodidad a corto plazo (DM 0,31; IC del 95%: ­0,60 a 1,22; cuatro estudios, 662 participantes, evidencia de certeza muy baja), o en la comodidad a largo plazo (DM 0,59; IC del 95%: ­2,29 a 3,47; dos estudios, 445 participantes, evidencia de certeza muy baja). HFNC versus VNI o VPPNI No se encontró evidencia de una diferencia entre los grupos en el fracaso del tratamiento cuando se utilizó la HFNC después de la extubación o sin el uso previo de ventilación mecánica (RR 0,98; IC del 95%: 0,78 a 1,22; cinco estudios, 1758 participantes; evidencia de certeza baja), ni en la mortalidad hospitalaria (RR 0,92; IC del 95%: 0,64 a 1,31; cinco estudios, 1758 participantes; evidencia de certeza baja). No hay certeza sobre el efecto del uso de la HFNC en la incidencia de la neumonía (RR 0,51; IC del 95%: 0,17 a 1,52; tres estudios, 1750 participantes; evidencia de certeza muy baja), y la HFNC podría dar lugar a poca o ninguna diferencia en el barotraumatismo (RR 1,15; IC del 95%: 0,42 a 3,14; un estudio, 830 participantes; evidencia de certeza baja). La HFNC podría suponer una diferencia escasa o nula en la duración de la estancia en la UCI (DM ­0,72 días; IC del 95%: ­2,85 a 1,42; dos estudios, 246 participantes; evidencia de certeza baja). El cociente PaO2/FiO2 podría ser menor hasta 24 horas con el uso de la HFNC (DM ­58,10 mmHg; IC del 95%: ­71,68 a ­44,51; tres estudios, 1086 participantes; evidencia de certeza baja). No se sabe si la HFNC mejoró la comodidad a corto plazo cuando se midió mediante puntuaciones de comodidad (DM 1,33; IC del 95%: 0,74 a 1,92; dos estudios, 258 participantes) y respuestas a cuestionarios (RR 1,30; IC del 95%: 1,10 a 1,53; un estudio, 168 participantes); la evidencia para la comodidad a corto plazo fue de certeza muy baja. Ningún estudio informó sobre la mucosa nasal ni el traumatismo cutáneo. CONCLUSIONES DE LOS AUTORES: La HFNC podría dar lugar a un menor fracaso del tratamiento en comparación con la oxigenoterapia estándar, pero probablemente suponga una escasa o nula diferencia en el fracaso del tratamiento en comparación con la VNI o la VPPNI. Para la mayoría de los demás desenlaces de la revisión, no se encontró evidencia de una diferencia en el efecto. Sin embargo, la certeza de la evidencia se consideró baja o muy baja. Se encontró un gran número de estudios en curso; incluirlos en futuras actualizaciones podría aumentar la certeza o podría alterar la dirección de estos efectos.

Face mask versus nasal prong or nasopharyngeal tube for neonatal resuscitation in the delivery room: a systematic review and meta-analysis.

IMPORTANCE: The current neonatal resuscitation guidelines recommend positive pressure ventilation via face mask or nasal prongs at birth. Using a nasal interface may have the potential to improve outcomes for newborn infants. OBJECTIVE: To determine whether nasal prong/nasopharyngeal tube versus face mask during positive pressure ventilation of infants born <37 weeks' gestation in the delivery room reduces in-hospital mortality and morbidity. DATA SOURCES: MEDLINE (through PubMed), Google Scholar and EMBASE, Clinical Trials.gov and the Cochrane Central Register of Controlled Trials through August 2019. STUDY SELECTION: Randomised controlled trials comparing nasal prong/nasopharyngeal tube versus face mask during positive pressure ventilation of infants born <37 weeks' gestation in the delivery room. DATA ANALYSIS: Risk of bias was assessed using the Covidence Collaboration Tool, results were pooled into a meta-analysis using a random effects model. MAIN OUTCOME: In-hospital mortality. RESULTS: Five RCTs enrolling 873 infants were combined into a meta-analysis. There was no statistical difference in in-hospital mortality (risk ratio (RR 0.98, 95% CI 0.63 to 1.52, p=0.92, I2=11%), rate of chest compressions in the delivery room (RR 0.37, 95% CI 0.10 to 1.33, p=0.13, I2=28%), rate of intraventricular haemorrhage (RR 1.54, 95% CI 0.88 to 2.70, p=0.13, I2=0%) or delivery room intubations in infants ventilated with a nasal prong/tube (RR 0.63, 95% CI 0.39,1.02, p=0.06, I2=52%). CONCLUSION: In infants born <37 weeks' gestation, in-hospital mortality and morbidity were similar following positive pressure ventilation during initial stabilisation with a nasal prong/tube or a face mask.

Laparoscopic anterior resection with or without transanal tube for rectal cancer patients - A multicenter randomized controlled trial.

BACKGROUND: In rectal cancer surgery, insertion of transanal tube has been shown to have efficacy to prevent anastomotic leakage. This randomized controlled study aims to clarify the incidence of anastomotic leakage with or without transanal tube in patients with rectal cancer. METHODS: Patients who underwent elective low anterior resection were randomly allocated to either have transanal tube insertion or not for five days after surgery. We examined the incidence of anastomotic leakage, postoperative 30-day morbidity and mortality. RESULTS: 157 patients were randomized to the transanal tube group or the no-transanal tube group. Symptomatic anastomotic leakage occurred in six patients (7.6%) of the former group and eight patients (10.3%) in the latter group, without significant difference (p = 0.559). There was also no significant difference in morbidity between groups (p = 0.633) and no mortality was detected. CONCLUSIONS: Transanal tube insertion had no significant benefit towards prevention of anastomotic leakage in rectal cancer surgery.

Todos Contra o Coronavírus #12: capacitação Cirúrgica Via Aérea

Videoaula destinada para profissionais da Saúde produzida pela Secretaria de Estado da Saúde e Defesa Civil de Santa Catarina.

Todos Contra o Coronavírus #9: entubação de pacientes

Conteúdo produzido pela SES e Defesa Civil para orientar profissionais de saúde.

Todos contra o Coronavírus #3: procedimento de Intubação Orotraqueal

Confira vídeos produzidos pela Secretaria de Estado da Saúde em parceria com a Defesa Civil de Santa Catarina com orientações para profissionais de saúde.

Utility of the Montgomery salivary tubes for preventing pharyngocutaneous fistula in total laryngectomy.

PURPOSE: To evaluate the prophylactic, protocolized, and standardized use of a Montgomery tube in preventing pharyngocutaneous fistulas after total laryngectomy and neck dissection. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral centre. SUBJECT AND METHODS: A Montgomery salivary bypass tube was placed in 44 patients undergoing total laryngectomy and neck dissection, observing the percentage of fistula appearance and the time of start of deglutition. Comparison was made with a group of 28 patients prior to the implantation of the protocol in whom the tube was not used. RESULTS: There was a statistically significant decrease in the percentage of fistulas and an earlier onset of deglutition in the salivary bypass tube patients compared to those in whom the tube had not been used. CONCLUSION: Prophylactic and standardized use of the Montgomery salivary bypass tube in patients undergoing total laryngectomy and neck dissection might decrease the incidence of pharyngocutaneous fistula and improve the course of one that is already established.

[Congenital nasolacrymal duct obstruction: pulled monocanalicular intubation (Monoka) versus pushed monocanalicular intubation (Masterka)]. / Imperméabilité lacrymonasale simple de l'enfant : comparaison entre une intubation monocanaliculaire « tirée ¼ type Monoka versus intubation monocanaliculaire « poussée ¼ type Masterka.

INTRODUCTION: The primary cause of congenital epiphora, congenital nasolacrymal duct obstruction (CNLDO) affects 5 to 20% of newborns. In children over 12 months, it is currently recommended to treat with primary probing and intubation of the nasolacrymal duct under general anesthesia. The purpose of this study is to compare "pulled" monocanalicular intubation (Monoka) versus "pushed" monocanalicular intubation (Masterka). METHODS: This retrospective study included 73 children between 2014 and 2017 who presented with CNLDO with membranous (mucosal) obstruction. All procedures were performed under general anesthesia with endotracheal intubation. Children with CNLDO underwent either monocanalicular silicone intubation (Monoka) with classic nasal recovery or pushed monocanalicular intubation (Masterka) inserted via the canthus. Treatment success was defined as complete resolution of epiphora at two months after the procedure. RESULTS: Surgical outcomes were assessed in 53 eyes with Monoka and 20 eyes with Masterka intubation. The mean age at treatment was 25 months (range, 12-69 months) for the two groups. Treatment success was achieved in 19 of 20 eyes (95.0%) in the Masterka group compared with 50 of 53 eyes (94.0%) in the Monoka group. A tube loss occured in 14% of cases in both groups. CONCLUSION: In children over 12 months of age, the Masterka "pushed" monocanalicular intubation technique is an effective treatment for congenital nasolacrymal duct obstruction.

Safety and Efficacy of Early Tube Removal Following Percutaneous Transhepatic Gallbladder Drainage: an Observational Study.

BACKGROUND: There are currently no guidelines concerning the advisability and timing of tube removal following percutaneous transhepatic gallbladder drainage (PTGBD). The present study aimed to assess the feasibility and risks of early removal of the PTGBD tube under the scenario of subsiding inflammation, patent cystic and common bile ducts, and absence of intraperitoneal leakage. METHODS: Patient background and outcomes were assessed retrospectively in 701 cases of acute cholecystitis treated with PTGBD. The median times until tube removal and tube dislodgement and the cumulative rates of tube dislodgement were calculated. RESULTS: Tube removal was performed in 275 patients after a median time of 16 days (range: 6 to 213 d); biliary peritonitis was observed in 2 patients following tube removal. Tubes were removed in 8 and 35 patients within 7 and 10 days, respectively. Tube dislodgement was observed in 82 patients after a median time of 12 days (range: 1 to 125 d). CONCLUSION: The present study suggests that drainage tube removal is safe and effective when performed after a short drainage period of 7 to 10 days if the criteria for the removal of the drainage tube were met.

Comparação de eficácia entre as sondas monocanalicular e bicanalicular no tratamento da obstrução congênita das vias lacrimais / Efficacy of monocanalicular versus bicanalicular intubation in the treatment of congenital nasolacrimal duct obstruction

Resumo Objetivo: Avaliar e comparar a taxa de sucesso da intubação monocanalicular ou bicanalicular em pacientes com obstrução congênita do ducto lacrimonasal (OCDLN), levando-se em consideração a taxa de sucesso, a dificuldade do procedimento e o custo dos tubos. Métodos: Foram analisados retrospectivamente 54 prontuários, totalizando 58 vias lacrimais com diagnóstico de OCDLN, que realizaram intubação das vias lacrimais monocanalicular ou bicanalicular com tubos de silicone. Anamnese, exame oftalmológico geral, testes específicos, como o Teste do Desaparecimento do Corante (TDC) e Teste de Observação de Fluoresceína na Orofaringe (TOFO), e, caso necessário, exames complementares como a dacriocistografia, foram utilizados para diagnóstico e inclusão na pesquisa. Foram tratados com intubação os pacientes sem resposta adequada ao tratamento prévio, ou seja, que permaneceram com sintomas de secreção e epífora contínua após a realização de massagem de Crigler e sondagem. Resultados: A intubação monocanalicular foi realizada em 27 vias lacrimais e a intubação bicanalicular, em 31 vias lacrimais. A taxa de sucesso foi alta em ambos os métodos, com melhora em 26 (96,3%) vias lacrimais com sonda monocanalicular e em 30 (96,8%), com sonda bicanalicular (p=0,718). As duas técnicas apresentaram 100% de sucesso nos pacientes com até 2 anos e acima de 4 anos de idade (p=1). A taxa de sucesso entre os 2 e 4 anos de idade foi de 91,5% para as monocanaliculares e 87,5% para as bicanaliculares, (p=0,652). Conclusão: o presente estudo não mostrou diferença significativa no sucesso da intubação quando utilizando sondas mono ou bicanaliculares. A intubação monocanalicular mostrou-se de mais fácil execução, ao passo que o tubo bicanalicular possui menor custo.

Abstract Objective: to evaluate and to compare the success rate of monocanalicular or bicanalicular intubation in congenital nasolacrimal duct obstruction (CNDO) carriers in terms of success rate, difficulty of the procedure, and cost of the tubes. Methods: fifty-four CNDO carriers with 58 obstructed lacrimal vies (LV) who were submitted to lacrimal system intubation using mono or bicanalicular stent had their medical records analyzed. A clinical history, a general ophthalmologic examination, specific tests such as the fluorescein dye disappearance test (FDDT) and observation test of fluorescein in the oropharynx (OTFO) were used for diagnosis and inclusion in the study. Patients who continued exhibiting discharge and continuous epiphora after previous treatment, Crigler massage and probing, were treated surgically with intubation. Results: Monocanalicular intubation was performed on 27 LV and bicanalicular intubation was performed on 31 LV. High success rates were observed, with improvement in 26 (96.3%) with monocanalicular intubation and in 30 LV (96.8%) with bicanalicular intubation (p=0.718). Furthermore, both techniques were 100% successful in patients up to 2 and over 4 years of age (p=1). The success rates between 2-4 years of age were 91.6% in monocanalicular intubation and 87.5% in bicanalicular intubation (p=0.652). Conclusion: The success rate using monocanalicular or bicanalicular intubation to treat CNDO had no significant difference in the studied children. Furthermore, the monocanalicular tube was easier to use, while the bicanalicular tube had a lower cost.

Variation of the minimally invasive CDCR technique.

Purpose: Traditional (tCDCR) and endoscopic conjunctivodacryocystorhinostomy (eCDCR) are challenging surgical techniques requiring general anesthesia, a facial incision, and a large osteotomy and mucosal flap. Minimally invasive CDCR (miCDCR) techniques eliminate the need for some of the steps in t/eCDCR. Introduced here is a variation of the miCDCR technique using a Naugle-Fleming knurled dilator (NKD) to create the osteotomy and instruments within a central line catheter kit to help easily place or replace a Jones' tube into position within a bony conduit.Methods: This IRB-approved retrospective chart review examined all patients who underwent this miCDCR technique performed by two oculoplastic surgeons at Hamilton Eye Institute at the University of Tennessee Health Sciences Center from 2014 to 2016. Inclusion criteria: need for CDCR (either primary or repeat). Exclusion criteria: loss to follow up prior to six months. Primary endpoints: operative time, incidence of tube migration and complications, and cessation of epiphora.Results: Sixteen patients (nine men, seven women) were reviewed, with three undergoing bilateral procedure, totaling 19 cases. Age range: 47.0 to 84.0 years, average of 66.6 years (SD = 11.1). Ten patients had surgery under local/MAC augmented with IV sedation, and six had general anesthesia (38%). Average operative time was 17.4 min (SD = 10.9). One patient (5%) required revision in the six-month immediate post-operative period because of tube migration. All patients had cessation of epiphora.Conclusions: This procedure can be done safely and quickly without general anesthesia, resulting in a satisfactorily lower rate of tube migration and cessation of epiphora rates.

Corynebacterium kroppenstedtii as a pathogen of a Jones tube infection following conjunctivo-dacryocystorhinostomy.

A 35-year-old woman complained of an unpleasant odor for a few days after a change in foundation cream. The patient had previously undergone conjunctivo-dacryocystorhinostomy with a Jones tube fixed with non-absorbable suture. Slit-lamp examination revealed an orange-colored discharge in the tube. A culture test of the discharge showed Corynebacterium kroppenstedtii (1+), Aspergillus versicolor (1+), and Mycobacterium chelonae (1+). After medical treatment and suture removal, the discharge completely disappeared. This is the first reported case of a Jones tube infection following conjunctivo-dacryocystorhinostomy with multiple microorganisms, including C. kroppenstedtii.

A novel technique for repositioning a nasobiliary catheter from the mouth to nostril in endoscopic retrograde cholangiopancreatography.

BACKGROUND: Endoscopic nasobiliary drainage (ENBD) is widely used for biliary decompression in patients with biliary disease. However, it is difficult to reposition a nasobiliary catheter from the mouth to nostril. We developed a new device, which has a curved flexible loop and bar-handle, for repositioning of ENBD catheter. The aim of this study was to evaluate the usefulness of the new loop-device for facilitating the repositioning of an ENBD catheter from the mouth to nostril. METHODS: Between January 2015 and December 2017, a comparative observational study was performed to evaluate the time taken for repositioning a nasobiliary catheter during endoscopic retrograde cholangiopancreatography (ERCP) and compare the results of ENBD procedure between the new loop-device and conventional techniques. In the subgroup analysis, we evaluated the occurrence of oral cavity injury and the time taken to transfer ENBD catheter from the mouth to nostril. RESULTS: In all, 145 ENBD procedures were performed using these two techniques. The procedure time was significantly shorter in the new technique group than in the conventional group. (44 s vs. 194 s, p < 0.001). The total success rate of new device technique was 97.3%. No complication, including oral cavity injury, was observed. CONCLUSIONS: The technique using our new loop-device was useful for repositioning a nasobiliary catheter from the mouth to nostril in ERCP. The new device does not require the removal of the mouthpiece before ENBD positioning, which can help perform the ENBD procedure rapidly and avoid the finger injury of endoscopists.

Challenges in making standardisation work in healthcare: lessons from a qualitative interview study of a line-labelling policy in a UK region.

OBJECTIVE: To identify and learn from efforts to design and implement a standardised policy for labelling of invasive tubing and lines across a regional health system. DESIGN: Single case study involving qualitative interviews and documentary analysis. SETTING: A devolved health system in the UK National Health Service (NHS). PARTICIPANTS: NHS staff (n=10) and policy-makers (n=8) who were involved in the design and/or implementation of the standardised policy. RESULTS: Though standardising labelling of invasive tubing and lines was initially seen as a common-sense technical change, challenges during the process of developing and implementing the policy were multiple and sociotechnical in nature. Major challenges related to defining the problem and the solution, limited sustained engagement with stakeholders and users, prototyping/piloting of the solution, and planning for implementation. Some frontline staff remained unconvinced of the need for or value of the policy, since they either did not believe that there was a problem or did not agree that standardised labelling was the right solution. Mundane practical issues such authorisation and resourcing, supply chains for labels, the need to restructure work practices to accommodate the new standard, and the physical features of the labels in specific clinical settings all had important impacts. CONCLUSIONS: Newly standardised tools and practices have to fit within a system of pre-existing norms, practices and procedures. We identified a number of practical, social and cultural challenges when designing and implementing a standardised policy in a regional healthcare system. Taking account of both sociocultural and technical aspects of standardisation, combined with systems thinking, could lead to more effective implementation and increase acceptability and usability of new standards.

Cobra-PLA provides higher oropharyngeal leak pressure than LMA-Classic and LMA-Unique: A meta-analysis with 22 studies.

Cobra Perilaryngeal Airway (Cobra-PLA) is a relatively new single-use supraglottic device employed during general anesthesia. This meta-analysis includes randomized controlled trials (RCTs) yielding extensive comparison results among Cobra-PLA, Laryngeal Mask Airway (LMA)-Classic, and LMA-Unique.Two authors performed searches in EMBASE, CENTRAL, PubMed, and ScienceDirect to identify RCTs that compared Cobra-PLA with LMA-Classic and with LMA-Unique in patients undergoing general anesthesia. Both random- and fixed-effects models were used. Begg's funnel plot was used to evaluate publication bias.Twenty-two RCTs with a total of 1845 patients were included. Cobra-PLA offered significantly higher oropharyngeal leak pressure than LMA-Classic [mean difference (MD) = 3.56 (1.56, 5.55), P = .0005] and LMA-Unique [MD = 4.44 (2.12, 6.76), P = .0002]. First-insertion success rate, ease of insertion, insertion time, and reported complications among Cobra-PLA, LMA-Classic, and LMA-Unique were similar.Compared with the commonly used LMA-Classic and LMA-Unique, Cobra-PLA provides superior airway sealing.