Volume-Time Curve: An Alternative for Endotracheal Tube Cuff Management

BACKGROUND: Despite numerous studies on endotracheal tube cuff pressure (CP) management, the literature has yet to establish a technique capable of adequately tilling the cuff with an appropriate volume of air while generating low CP in a less subjective way. the purpose of this prospective study was to evaluate and compare the CP levels and air volume required to fill the endotracheal tubes cuff using 2 different techniques (volume-time curve versus minimal occlusive volume) in the immediate postoperative period after coronary artery bypass grafting. METHODS: A total of 267 subjects were analyzed. After the surgery, the lungs were ventilated using pressure controlled continuous mandatory ventilation, and the same ventilatory parameters were adjusted. Upon arrival in the ICU, the cuff was completely deflated and re-inflated, and at this point the volume of air to fill the cuff was adjusted using one of 2 randomly selected techniques: volume-time curve and minimal occlusive volume. We measured the volume of air injected into the cuff, the CP, and the expired tidal volume of the mechanical ventilation after the application of each technique. RESULTS: the volume-time curve technique demonstrated a significantly lower CP and a lower volume of air injected into the cuff, compared to the minimal occlusive volume technique (P < .001). No significant difference was observed in the expired tidal volume between the 2 techniques (P = .052). However, when the subjects were submitted to the minimal occlusive volume technique, 17% (n = 47) experienced air leakage as observed by the volume-time graph. CONCLUSIONS: the volume-time curve technique was associated with a lower CP and a lower volume of air injected into the cuff, when compared to the minimal occlusive volume technique in the immediate postoperative period after coronary artery bypass grafting. Therefore, the volume-time curve may be a more reliable alternative for endotracheal tube cuff management.

Clinical Use of the Volume-Time Curve for Endotracheal Tube Cuff Management

BACKGROUND: Previous investigation showed that the volume-time curve technique could be an alternative for endotracheal tube (ETT) cuff management. However, the clinical impact of the volume-time curve application has not been documented. the purpose of this study was to compare the occurrence and intensity of a sore throat, cough, thoracic pain, and pulmonary function between these 2 techniques for ETT cuff management: volume-time curve technique versus minimal occlusive volume (MOV) technique after coronary artery bypass grafting. METHODS: A total of 450 subjects were randomized into 2 groups for cuff management after intubation: MOV group (n = 222) and volume-time curve group (n = 228). We measured cuff pressure before extubation. We performed spirometry 24 h before and after surgery. We graded sore throat and cough according to a 4-point scale at 1, 24, 72, and 120 h after extubation and assessed thoracic pain at 24 h after extubation and quantified the level of pain by a 10-point scale. RESULTS: the volume-time curve group presented significantly lower cuff pressure (30.9 +/- 2.8 vs 37.7 +/- 3.4 cm H2O), less incidence and intensity of sore throat (1 h, 23.7 vs 51.4%; and 24 h, 18.9 vs 40.5%, P < .001), cough (1 h, 19.3 vs 48.6%; and 24 h, 18.4 vs 42.3%, P < .001), thoracic pain (5.2 +/- 1.8 vs 7.1 +/- 1.7), better preservation of FVC (49.5 +/- 9.9 vs 41.8 +/- 12.9%, P = .005), and FEV1, (46.6 +/- 1.8 vs 38.6 +/- 1.4%, P = .005) compared with the MOV group. CONCLUSIONS: the subjects who received the volume-time curve technique for ETT cuff management presented a significantly lower incidence and severity of sore throat and cough, less thoracic pain, and minimally impaired pulmonary function than those subjects who received the MOV technique during the first 24 h after coronary artery bypass grafting.

Minimal local anesthetic volume for peripheral nerve block: a new ultrasound-guided, nerve dimension-based method

BACKGROUND AND OBJECTIVES: Nerve blocks using local anesthetics are widely used. High volumes are usually injected, which may predispose patients to associated adverse events. Introduction of ultrasound guidance facilitates the reduction of volume, but the minimal effective volume is unknown. In this study, we estimated the 50% effective dose (ED50) and 95% effective dose (ED95) volume of 1% mepivacaine relative to the cross-sectional area of the nerve for an adequate sensory block. METHODS: To reduce the number of healthy volunteers, we used a volume reduction protocol using the up-and-down procedure according to the Dixon average method. The ulnar nerve was scanned at the proximal forearm, and the cross-sectional area was measured by ultrasound. In the first volunteer, a volume of 0.4 mL/mm of nerve cross-sectional area was injected under ultrasound guidance in close proximity to and around the nerve using a multiple injection technique. The volume in the next volunteer was reduced by 0.04 mL/mm in case of complete blockade and augmented by the same amount in case of incomplete sensory blockade within 20 mins. After 3 up-and-down cycles, ED50 and ED95 were estimated. Volunteers and physicians performing the block were blinded to the volume used. RESULTS: A total 17 of volunteers were investigated. The ED50 volume was 0.08 mL/mm (SD, 0.01 mL/mm), and the ED95 volume was 0.11 mL/mm (SD, 0.03 mL/mm). The mean cross-sectional area of the nerves was 6.2 mm (1.0 mm). CONCLUSIONS: Based on the ultrasound measured cross-sectional area and using ultrasound guidance, a mean volume of 0.7 mL represents the ED95 dose of 1% mepivacaine to block the ulnar nerve at the proximal forearm.

Minimal invasive surgery for coronoid fracture: technical note.

Operative treatment of coronoid fracture often requires a large dissection of soft tissue, resulting in elbow stiffness and functional limitation. The authors present a minimal invasive, safe technique, useful in the case of isolated coronoid fracture associated with elbow dislocation. This technique does not require soft tissue dissection and allows an early unlimited resumption of sports activities.

Studies on transport phenomena during solidification of an aluminum alloy in the presence of linear electromagnetic stirring

Numerical and experimental studies on transport phenomena during solidification of an aluminum alloy in the presence of linear electromagnetic stirring are performed. The alloy is electromagnetically stirred to produce semisolid slurry in a cylindrical graphite mould placed in the annulus of a linear electromagnetic stirrer. The mould is cooled at the bottom, such that solidification progresses from the bottom to the top of the cylindrical mould. A numerical model is developed for simulating the transport phenomena associated with the solidification process using a set of single-phase governing equations of mass. momentum, energy. and species conservation. The viscosity variation of the slurry, used in the model, is determined experimentally using a rotary viscometer. The set of governing equations is solved using a pressure-based finite volume technique, along with an enthalpy based phase change algorithm. The numerical study involves prediction of temperature, velocity, species and solid fraction distribution in the mould. Corresponding solidification experiments are performed, with time-temperature history recorded at key locations. The microstructures at various temperature measurement locations in the solidified billet are analyzed. The numerical predictions of temperature variations are in good agreement with experiments, and the predicted flow field evolution correlates well with the microstructures observed at various locations.

Effect of process parameters on transport phenomena during solidification in the presence of electromagnetic stirring

In the present work, a numerical study is performed to predict the effect of process parameters on transport phenomena during solidification of aluminium alloy A356 in the presence of electromagnetic stirring. A set of single-phase governing equations of mass, momentum, energy and species conservation is used to represent the solidification process and the associated fluid flow, heat and mass transfer. In the model, the electromagnetic forces are incorporated using an analytical solution of Maxwell equation in the momentum conservation equations and the slurry rheology during solidification is represented using an experimentally determined variable viscosity function. Finally, the set of governing equations is solved for various process conditions using a pressure based finite volume technique, along with an enthalpy based phase change algorithm. In present work, the effect of stirring intensity and cooling rate are considered. It is found that increasing stirring intensity results in increase of slurry velocity and corresponding increase in the fraction of solid in the slurry. In addition, the increasing stirring intensity results uniform distribution of species and fraction of solid in the slurry. It is also found from the simulation that the distribution of solid fraction and species is dependent on cooling rate conditions. At low cooling rate, the fragmentation of dendrites from the solid/liquid interface is more.

INVISCID BLADE-TO-BLADE PREDICTION OF A WAKE-GENERATED UNSTEADY FLOW.

A description is presented of a time-marking calculation of the unsteady flow generated by the interaction of upstream wakes with a moving blade row. The inviscid equations of motion are solved using a finite volume technique. Wake dissipation is modeled using an artificial viscosity. Predictions are presented for the rotor mid-span section of an axial turbine. Reasonable agreement is found between the predicted and measured unsteady blade surface static pressures and velocities. These and other results confirm that simple theories can be used to explain the phenomena of rotor-stator wake interactions.

Numerical computation of laminar flow in a heated rotating cavity with an axial throughflow of air

A heated rotating cavity with an axial throughflow of cooling air is used as a model for the flow in the cylindrical cavities between adjacent discs of a high-pressure gas-turbine compressor. In an engine the flow is expected to be turbulent, the limitations of this laminar study are fully realised but it is considered an essential step to understand the fundamental nature of the flow. The three-dimensional, time-dependent governing equations are solved using a code based on the finite volume technique and a multigrid algorithm. The computed flow structure shows that flow enters the cavity in one or more radial arms and then forms regions of cyclonic and anticyclonic circulation. This basic flow structure is consistent with existing experimental evidence obtained from flow visualization. The flow structure also undergoes cyclic changes with time. For example, a single radial arm, and pair of recirculation regions can commute to two radial arms and two pairs of recirculation regions and then revert back to one. The flow structure inside the cavity is found to be heavily influenced by the radial distribution of surface temperature imposed on the discs. As the radial location of the maximum disc temperature moves radially outward, this appears to increase the number of radial arms and pairs of recirculation regions (from one to three for the distributions considered here). If the peripheral shroud is also heated there appear to be many radial arms which exchange fluid with a strong cyclonic flow adjacent to the shroud. One surface temperature distribution is studied in detail and profiles of the relative tangential and radial velocities are presented. The disc heat transfer is also found to be influenced by the disc surface temperature distribution. It is also found that the computed Nusselt numbers are in reasonable accord over most of the disc surface with a correlation found from previous experimental measurements. © 1994, MCB UP Limited.

Anisotropic adaptive resolution of boundary layers for heat conduction problems

We deal with the numerical solution of heat conduction problems featuring steep gradients. In order to solve the associated partial differential equation a finite volume technique is used and unstructured grids are employed. A discrete maximum principle for triangulations of a Delaunay type is developed. To capture thin boundary layers incorporating steep gradients an anisotropic mesh adaptation technique is implemented. Computational tests are performed for an academic problem where the exact solution is known as well as for a real world problem of a computer simulation of the thermoregulation of premature infants.

Curva de aprendizado em cirurgia aórtica videolaparoscópica: estudo experimental em porcos

CONTEXTO: A cirurgia videolaparoscópica (CVL) vem evoluindo como alternativa cirúrgica menos invasiva para o tratamento da doença aterosclerótica oclusiva aorto-ilíaca e do aneurisma da aorta abdominal. Poucos estudos avaliaram objetivamente a curva de aprendizado com essa técnica em cirurgia vascular. OBJETIVO: Avaliar objetivamente os tempos e a evolução de cada passo cirúrgico e demonstrar a exeqüibilidade dessa técnica. MÉTODOS: Entre outubro 2007 e janeiro de 2008, dois cirurgiões vasculares iniciantes na CVL operaram, após cursos e treinamentos, seis porcos consecutivos, com dissecção aórtica e interposição de um enxerto de dácron em um segmento da aorta infra-renal abdominal, com técnica totalmente laparoscópica. RESULTADOS: Todos os tempos cirúrgicos foram decrescentes ao longo do estudo, apresentando redução de 45,9% no tempo total de cirurgia, 85,8% no tempo de dissecção da aorta, 81,2% na exposição da aorta, 55,1% no clampeamento total, 71% na confecção da anastomose proximal e 64,9% na anastomose distal. CONCLUSÃO: O presente estudo mostrou que os resultados técnicos satisfatórios da CVL vascular ocorreram somente após longa curva de aprendizado, que foi decrescente ao longo do tempo, à medida que aumentou a experiência e vivência com os materiais e com a visão não-estereoscópica. Essa técnica pode ser realizada com perfeição por cirurgiões vasculares desde que façam cursos especializados, com treinamento em simuladores e animais, e desde que busquem constante aprimoramento a fim de conseguir resultados similares aos obtidos com a cirurgia convencional.

Comparative electrical behavior at low and high current of SnO(2)- and ZnO-based varistors

The complete I-V characteristics of SnO(2)-based varistors, particularly of the Pianaro system SCNCr consisting in 98.9%SnO(2)+1%CoO+0.05%Nb(2)O(5)+0.05%Cr(2)O(3), all in mol%, have been seldom reported in the literature. A comparative study at low and high currents of the nonohmic behavior of SCNCr- and ZnO-based varistors (modified Matsuoka system) is proposed in this work. The SCNCr system showed higher nonlinearity coefficients in the whole range of measured current. The electrical breakdown field (E(b)) was twice as high for the SCNCr system (5400 V/cm) than for the ZnO varistor (2600 V/cm) due to a smaller average grain size of the former (4.5 mu m) with respect to the latter (8.5 mu m). Nevertheless, we consider that another important factor responsible for the high E(b) in the SCNCr system is the great number of electrically active interfaces (85%) as determined with electrostatic force microscopy (EFM). It was also established that the SCNCr system might be produced in disks of smaller dimensions than that of commercial ZnO-based product, with a 5.0 cm(-1) minimal area-volume (A/V) ratio. The SCNCr reached the saturation current in a short time because of the high resistivity of the grains, which is five times higher than that of the grains in ZnO-based varistors.

Models of liquid storage tanks

We present the results of a comparative study on thermally stratified tanks for hot storage. A two-dimensional model is employed. A numerical solution was obtained using the control-volume technique due to Patankar. The two-dimensional model was simplified for the pure conduction case. Results from the two models were compared with each other and with available numerical and experimental results. (C) 1997 Elsevier B.V. Ltd.

Modelo OLAM (ocean-land-atmosphere-model): descrição, aplicações, e perspectivas

O modelo OLAM foi desenvolvido com objetivo de estender a capacidade de representar os fenômenos de escala global e regional simultaneamente. Este modelo apresenta inovações quanto aos processos dinâmicos, configuração de grade, estrutura de memória e técnicas de solução numérica das equações prognósticas. As equações de Navier-Stokes são resolvidas através da técnica de volumes finitos que conservam massa, momento e energia. No presente trabalho, apresenta-se uma descrição sucinta do OLAM e alguns resultados de sua aplicação em simulações climáticas da precipitação mensal para a região norte da América do Sul, bem como em rodadas para previsão numérica de tempo regional. Os resultados mostram que o modelo consegue representar bem os aspectos meteorológicos de grande escala. Em geral, seu desempenho melhora quando são adotadas grades de maior resolução espacial, nas quais se verificam melhorias significativas tanto na estimativa da precipitação mensal regional, quanto na previsão numérica de tempo.

Comparative electrical behavior at low and high current of SnO(2)- and ZnO-based varistors

The complete I-V characteristics of SnO(2)-based varistors, particularly of the Pianaro system SCNCr consisting in 98.9%SnO(2)+1%CoO+0.05%Nb(2)O(5)+0.05%Cr(2)O(3), all in mol%, have been seldom reported in the literature. A comparative study at low and high currents of the nonohmic behavior of SCNCr- and ZnO-based varistors (modified Matsuoka system) is proposed in this work. The SCNCr system showed higher nonlinearity coefficients in the whole range of measured current. The electrical breakdown field (E(b)) was twice as high for the SCNCr system (5400 V/cm) than for the ZnO varistor (2600 V/cm) due to a smaller average grain size of the former (4.5 mu m) with respect to the latter (8.5 mu m). Nevertheless, we consider that another important factor responsible for the high E(b) in the SCNCr system is the great number of electrically active interfaces (85%) as determined with electrostatic force microscopy (EFM). It was also established that the SCNCr system might be produced in disks of smaller dimensions than that of commercial ZnO-based product, with a 5.0 cm(-1) minimal area-volume (A/V) ratio. The SCNCr reached the saturation current in a short time because of the high resistivity of the grains, which is five times higher than that of the grains in ZnO-based varistors.

Comparison of implant stability by means of resonance frequency analysis for flapless and conventionally inserted implants

Background: Resonance frequency analysis (RFA) is a noninvasive technique for the quantitative assessment of implant stability. Information on the implant stability quotient (ISQ) of transmucosally inserted implants is limited. Purpose: The aim of this investigation was to compare the ISQ of conventionally inserted implants by raising a muco-periostal flap with implants inserted using a flapless procedure. Materials and Methods: Forty elderly patients with complete edentulous maxilla were consecutively admitted for treatment with implant-supported prostheses. A computer tomography was obtained for the computer-assisted implant planning. One hundred ten implants were placed conventionally in 23 patients (flap-group) and 85 implants in 17 patients by means of the flapless method (flapless-group) using a stereolithographic template. RFA measurements were performed after implant placement (baseline) and after a healing time of 12 weeks (reentry). Results: All implants exhibited clinically and radiographically successful osseointegration. Bone level did not change significantly neither for genders nor type of surgical protocol. Mean ISQ values of the flapless-group were significantly higher at baseline (p < .001) and at reentry (p < .001) compared with the flap-group. The ISQ values were significantly lower at reentry compared with baseline for the flap-group (p = .028) but not for the flapless-group. This group showed a moderate, but insignificant increase. RFA measurements of males resulted in ISQ values that were thoroughly higher as compared with females at both time-points in both groups. Correlation between RFA and bone level was not found. Conclusions: The flapless procedure showed favorable conditions with regard to implant stability and crestal bone level. Some changes of the ISQ values that represent primary (mechanical) and secondary (bone remodeling) implant stability were observed in slight favor of the flapless method and male patients. In properly planned and well-selected cases, the minimal invasive transmucosal technique using a drill-guide is a safe procedure.