The McGrath® Series 5 videolaryngoscope vs the Macintosh laryngoscope: a randomised, controlled trial in patients with a simulated difficult airway.

We compared the McGrath® Series 5 videolaryngoscope with the Macintosh laryngoscope in a simulated difficult airway, using manual in-line stabilisation in 88 anaesthestised patients of ASA physical status 1-2. The primary outcome was laryngoscopic view. Secondary outcomes included rates of successful tracheal intubation and complications. A Cormack and Lehane grade-1 or -2 view was found in all patients when using the McGrath compared with 45 (51%, p < 0.0001) using the Macintosh laryngoscopes. The mean (SD) percentage of glottic opening was 82 (23)% using the McGrath compared with 13 (23)% using the Macintosh (p < 0.0001). In 66 out of 88 patients (75%), the McGrath improved the glottic view by one to three grades compared with the Macintosh (p < 0.001). Intubation of the trachea was successful in all patients using the McGrath, while the Macintosh was successful in 26 (59%, p < 0.001). There was no significant difference in the complication rates between the devices.

Identification of key parameters controlling dissolved oxygen migration and attenuation in fractured crystalline rocks.

In the crystalline rocks of the Canadian Shield, geochemical conditions are currently reducing at depths of 500-1000 m. However, during future glacial periods, altered hydrologic conditions could potentially result in enhanced recharge of glacial melt water containing a relatively high concentration of dissolved oxygen (O2). It is therefore of interest to investigate the physical and geochemical processes, including naturally-occurring redox reactions, that may control O2 ingress. In this study, the reactive transport code MIN3P is used in combination with 2k factorial analyses to identify the most important parameters controlling oxygen migration and attenuation in fractured crystalline rocks. Scenarios considered are based on simplified conceptual models that include a single vertical fracture, or a fracture zone, contained within a rock matrix that extends from the ground surface to a depth of 500 m. Consistent with field observations, Fe(II)-bearing minerals are present in the fractures (i.e. chlorite) and the rock matrix (biotite and small quantities of pyrite). For the parameter ranges investigated, results indicate that for the single fracture case, the most influential factors controlling dissolved O2 ingress are flow velocity in the fracture, fracture aperture, and the biotite reaction rate in the rock matrix. The most important parameters for the fracture zone simulations are flow velocity in the individual fractures, pO2 in the recharge water, biotite reaction rate, and to a lesser degree the abundance and reactivity of chlorite in the fracture zone, and the fracture zone width. These parameters should therefore receive increased consideration during site characterization, and in the formulation of site-specific models intended to predict O2 behavior in crystalline rocks.

Multicomponent simulation of wastewater-derived nitrogen and carbon in shallow unconfined aquifers. I. Model formulation and performance.

One of the most common methods to dispose of domestic wastewater involves the release of septic effluent from drains located in the unsaturated zone. Nitrogen from such systems is currently of concern because of nitrate contamination of drinking water supplies and eutrophication of coastal waters. The objectives of this study are to develop and assess the performance of a mechanistic flow and reactive transport model which couples the most relevant physical, geochemical and biochemical processes involved in wastewater plume evolution in sandy aquifers. The numerical model solves for variably saturated groundwater flow and reactive transport of multiple carbon- and nitrogen-containing species in a three-dimensional porous medium. The reactive transport equations are solved using the Strang splitting method which is shown to be accurate for Monod and first- and second-order kinetic reactions, and two to four times more efficient than sequential iterative splitting. The reaction system is formulated as a fully kinetic chemistry problem, which allows for the use of several special-purpose ordinary differential equation (ODE) solvers. For reaction systems containing both fast and slow kinetic reactions, such as the combined nitrogen-carbon system, it is found that a specialized stiff explicit solver fails to obtain a solution. An implicit solver is more robust and its computational performance is improved by scaling of the fastest reaction rates. The model is used to simulate wastewater migration in a 1-m-long unsaturated column and the results show significant oxidation of dissolved organic carbon (DOC), the generation of nitrate by nitrification, and a slight decrease in pH.

Multicomponent simulation of wastewater-derived nitrogen and carbon in shallow unconfined aquifers. II. Model application to a field site.

A multicomponent reactive transport model as presented by MacQuarrie and Sudicky [MacQuarrie, K.T.B., Sudicky, E.A., this volume. Multicomponent simulation of wastewater-derived nitrogen and carbon in shallow unconfined aquifers: I. Model formulation and performance, J. Contam. Hydrol.] is applied to a well-studied wastewater plume in a sandy aquifer near Cambridge, Ontario. Domestic wastewater is released into the unsaturated zone via a drain field at a depth of about 0.8 m. The physical transport parameters for the model are obtained by simulating a non-reactive solute, while kinetic input data for the nitrogen and carbon reaction network are obtained from the literature. The model shows that the wastewater-loading rate has little influence on the moisture content in the unsaturated zone, thus oxygen diffusion in the air phase is an important transport mechanism. The model results are in general agreement with the field-determined moisture and oxygen profiles near the drain field. The simulation results show that oxidation of ammonium and dissolved organic carbon (DOC) goes to completion in the 1.5-m distance between the drain field and the water table, and that calcite dissolution limits the pH reduction to about 0.2 units. The model-predicted nitrate concentrations in the core of the plume are in the range of 20-25 mg N/l and are in good agreement with the field data. Overall, the results for the major reactive species from the model simulation agree well with the geochemical data obtained below the drain field and it is concluded that the major physical and biochemical processes have been correctly captured in the current model formulation.

Numerical simulation of a fine-grained denitrification layer for removing septic system nitrate from shallow groundwater.

One of the most common methods to dispose of domestic wastewater involves the release of septic effluent from drains located in the unsaturated zone. Nitrogen from such systems is currently of concern because of nitrate contamination of drinking water supplies and eutrophication of coastal waters. It has been proposed that adding labile carbon sources to septic distribution fields could enhance heterotrophic denitrification and thus reduce nitrate concentrations in shallow groundwater. In this study, a numerical model which solves for variably saturated flow and reactive transport of multiple species is employed to investigate the performance of a drain field design that incorporates a fine-grained denitrification layer. The hydrogeological scenario simulated is an unconfined sand aquifer. The model results suggest that the denitrification layer, supplemented with labile organic carbon, may be an effective means to eliminate nitrogen loading to shallow groundwater. It is also shown that in noncalcareous aquifers, the denitrification reaction may provide sufficient buffering capacity to maintain near neutral pH conditions beneath and down gradient of the drain field. Leaching of excess dissolved organic carbon (DOC) from the denitrification layer is problematic, and causes an anaerobic plume to develop in simulations where the water table is less than 5-6 m below ground surface; this anaerobic plume may lead to other down gradient changes in groundwater quality. A drain field and denitrification layer of smaller dimensions is shown to be just as effective for reducing nitrate, but has the benefit of reducing the excess DOC leached from the layer. This configuration will minimize the impact of wastewater disposal in areas where the water table is as shallow as 3.5 m.

The importance of conceptual models in the reactive transport simulation of oxygen ingress in sparsely fractured crystalline rock.

Redox evolution in sparsely fractured crystalline rocks is a key, and largely unresolved, issue when assessing the geochemical suitability of deep geological repositories for nuclear waste. Redox zonation created by the influx of oxygenated waters has previously been simulated using reactive transport models that have incorporated a variety of processes, resulting in predictions for the depth of oxygen penetration that may vary greatly. An assessment and direct comparison of the various underlying conceptual models are therefore needed. In this work a reactive transport model that considers multiple processes in an integrated manner is used to investigate the ingress of oxygen for both single fracture and fracture zone scenarios. It is shown that the depth of dissolved oxygen migration is greatly influenced by the a priori assumptions that are made in the conceptual models. For example, the ability of oxygen to access and react with minerals in the rock matrix may be of paramount importance for single fracture conceptual models. For fracture zone systems, the abundance and reactivity of minerals within the fractures and thin matrix slabs between the fractures appear to provide key controls on O(2) attenuation. The findings point to the need for improved understanding of the coupling between the key transport-reaction feedbacks to determine which conceptual models are most suitable and to provide guidance for which parameters should be targeted in field and laboratory investigations.

Tracheal intubation using Bullard laryngoscope for patients with a simulated difficult airway.

PURPOSE: To evaluate the utility and safety of orotracheal intubation in adult patients with simulated difficult airways using the Bullard Laryngoscope (BL). METHODS: A rigid cervical collar was used to simulate the difficult airway. The study consisted of two phases. Phase I evaluated the BL used in conjunction with an independently styletted endotracheal tube (ISETT) passed freehand into the trachea. Phase II evaluated the new Multifunctional Intubating Stylet (MFIS). Forty patients were studied in each phase. Following induction of anesthesia a rigid cervical collar was applied and the laryngoscopic grade assessed. Tracheal intubation was then performed using the BL with either an ISETT or the MFIS. The total time to intubate, number of attempts, failures, hemodynamic changes during intubation were recorded. RESULTS: The rigid collar effectively simulated a difficult laryngoscopy, 65% of patients had a grade 3 view. The success rates for tracheal intubation using the ISETT and MFIS were 88% and 83% respectively. The average times to intubation were similar for both intubating techniques (45.4 +/- 26.8 sec for the ISETT and 41.2 +/- 25.2 sec for the MFIS). Although there were minor hemodynamic changes, mucosal bleeding and sore throat following intubation, there were no major complications in any of the study patients. CONCLUSIONS: The BL, used with either an ISETT or the MFIS, is an effective and safe intubating device for patients with simulated restricted cervical spine movement. Further studies are needed to compare the effectiveness and safety of these two techniques in managing patients with a difficult airway.