Endotracheal intubation ved hjælp af et fleksibelt intubationsendoskop som en standardiseret model for sikker luftvejsstyring hos svin
Summary
Brugen af svin i forskning er steget i de senere år. Ikke desto mindre er grise præget af vanskelig luftvejsanatomi. Ved at demonstrere, hvordan man udfører endoskopisk guidet endotracheal intubation, sigter denne protokol mod yderligere at øge forsøgsdyrs sikkerhed for at undgå dyrs lidelse og unødig død.
Abstract
Endotracheal intubation er ofte et grundlæggende krav til translationel forskning i svinemodeller til forskellige indgreb, der kræver en sikret luftvej eller højt ventilationstryk. Endotracheal intubation er en udfordrende færdighed, der kræver et minimum antal vellykkede endotrakeale intubationer for at opnå en høj succesrate under optimale forhold, hvilket ofte er uopnåeligt for ikke-anæstesiologiske forskere. På grund af den specifikke svineluftvejsanatomi kan der normalt antages en vanskelig luftvej. Umuligheden af at etablere en sikker luftvej kan resultere i personskade, bivirkninger eller laboratoriedyrets død. Ved hjælp af en prospektiv, randomiseret, kontrolleret evalueringsmetode har det vist sig, at fiberoptisk assisteret endotracheal intubation tager længere tid, men har en højere first-pass succesrate end konventionel intubation uden at forårsage klinisk relevante fald i iltmætning. Denne model præsenterer et standardiseret regime for endoskopisk guidet endotracheal intubation, hvilket giver en sikret luftvej, især for forskere, der er uerfarne i teknikken til endotracheal intubation via direkte laryngoskopi. Denne procedure forventes at minimere dyrs lidelser og unødvendige tab af dyr.
Introduction
Endotracheal intubation er ofte et grundlæggende krav til translationel forskning i svinemodeller til forskellige indgreb, der kræver en sikret luftvej eller højt ventilationstryk (såsom ventilation under kardiopulmonal genoplivning1 eller akut respiratorisk distress syndrom2) eller kræver, at cerebral blodgennemstrømning ikke kompromitteres gennem intern kompression af supraglottiske luftvejsanordninger3 , som lejlighedsvis formeres som alternativer i forbindelse med en forventet vanskelig luftvej hos svin 4,5.
Mens lungefysiologien hos svin viser lignende træk som hos mennesker6, er det undertiden betydeligt vanskeligere at sikre luftvejene7 på grund af specifikke forskelle i porcins orotracheale anatomi. Svinets snut har en smal åbning med en meget stor tunge, strubehovedet er ekstremt mobilt, og epiglottis er relativt stor, med en fri ende, der strækker sig til den bløde gane. Caudalt danner strubehovedet en stump vinkel med luftrøret. Arytenoidbrusk er store8. Den smalleste del af luftvejene er på det subglottiske niveau9, der kan sammenlignes med luftvejsanatomien hos børn10. Da strubehovedet hos svin er meget mobilt, er der risiko for, at enden af endotrakealrøret passerer gennem stemmebåndene, men strubehovedet forskydes kun kausalt med op til flere centimeter, hvilket kan forveksles med en korrekt intubation 8,11. Derudover er esophageal intubation en almindelig risiko, når man beskæftiger sig med porcint luftvejsstyring12.
Hyppigheden af vanskelige eller umulige endotrakeale intubationer med en tilsvarende negativ indvirkning på eksperimentet eller tidlig dødelighed er ikke systematisk registreret, men flere caserapporter er blevet offentliggjort13,14. Hos mennesker er der mulighed for at anvende et fleksibelt intubationsendoskop i forbindelse med en uventet vanskelig konventionel intubation15. Forskellige falske intubationer går ofte forud for denne foranstaltning. Disse gentagne intubationsforsøg er forbundet med bivirkninger hos mennesker16,17, især luftvejskomplikationer 18. Sådanne hændelser er skadelige hos forsøgsdyr, da de i det enkleste tilfælde repræsenterer en confoundervariabel i forsøget; I værste fald kan de føre til unødvendigt tab af dyret.
Denne undersøgelse har udviklet en model baseret på retningslinjerne for forventet vanskelig luftvejsstyring hos mennesker 15,19,20,21,22,23,24. Tidligere er en lignende teknik blevet beskrevet til læring af fiberoptisk intubation i humane undersøgelser25,26. Protokollen, der præsenteres i denne rapport, har til formål at tilvejebringe en standardiseret og let at tilpasse intubationsmodel, der også gør det muligt for ikke-luftvejsspecialister at udføre vellykket og sikker endotracheal intubation hos svin.
Protocol
Representative Results
Discussion
I tidligere undersøgelser har vores forskergruppe allerede beskrevet specifikke detaljer om de translationelle fordele ved svinemodellen 2,27,32,33. Generelt bør reduktion af dyrets stressniveau og unødig smerte være en integreret del af enhver undersøgelsesprotokol og er afgørende for at generere pålideligt reproducerbare data. Derfor er vågen endoskopisk styret intubation af grisen me…
Declarações
The authors have nothing to disclose.
Acknowledgements
Forfatterne vil gerne takke Dagmar Dirvonskis for hendes fremragende tekniske support.
Materials
| Ambu aScope Regular | Ambu GmbH, Medizinprodukte, Bad Nauheim, Germany | Disposable fiber optic outer diameter 5 mm | |
| Ambu aView Monitor | Ambu GmbH, Medizinprodukte, Bad Nauheim, Germany | monitor | |
| Atracurium Hikma 50 mg/5mL | Hikma Pharma GmbH, Martinsried | atracurium | |
| Azaperone (Stresnil) 40mg/mL | Lilly Deutschland GmbH, Bad Homburg, Germany | azaperone | |
| BD Discardit II Spritze 2, 5, 10, 20 mL | Becton Dickinson S.A. Carretera, Mequinenza Fraga, Spain | syringe | |
| BD Luer Connecta | Becton Dickinson Infusion Therapy, AB Helsingborg, Schweden | 3-way-stopcock | |
| BD Microlance 3 20 G | Becton Dickinson S.A. Carretera, Mequinenza Fraga, Spain | cannula | |
| Curafix i.v. classics | Lohmann & Rauscher International GmbH & Co. KG, Rengsdorf, Germany | Cannula retention dressing | |
| Engström Carestation | GE Heathcare, Madison USA | ventilator | |
| Fentanyl-Janssen 0.05 mg/mL | Janssen-Cilag GmbH, Neuss | fentanyl | |
| Führungsstab, Durchmesser 4.3 | Rüsch | endotracheal tube introducer | |
| IBM SPSS Statistics for Windows, Version 20 | IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) | Statistical software | |
| Incetomat-line 150 cm | Fresenius, Kabi Deutschland, GmbH | perfusor line | |
| Intrafix Primeline | B. Braun Melsungen AG, Melsungen, Germany | Infusion line | |
| JOZA Einmal Nitril Untersuchungshandschuhe | JOZA, München, Germany | disposable gloves | |
| Laryngoscope, 45.48.50, KL 2000 | Medicon | Laryngoscope handle | |
| Littmann Classic III Stethoscope | 3M Deutschland GmbH, Neuss, Germany | stethoscope | |
| Luer Lock | B.Braun Melsungen AG, Germany | ||
| Maimed Vlieskompresse | Maimed GmbH, Neuenkirchen, Germany | Fleece compress to fix the tongue | |
| Masimo LNCS Adtx SpO2 sensor | Masimo Corporation Irvine, Ca 92618 USA | saturation clip for the tail | |
| Masimo LNCS TC-I SpO2 ear clip sensor | Masimo Corporation Irvine, Ca 92618 USA | Saturation clip for the ear | |
| Masimo Radical 7 | Masimo Corporation Irvine, Ca 92618 USA | periphereal oxygen saturation | |
| Midazolam 15 mg/3 mL | Hameln Pharma GmbH, Hameln, Germany | midazolam | |
| Midmark Canine Mask Small Plastic with Diaphragm FRSCM-0005 | Midmark Corp., Dayton, Ohio, USA | dog ventilation mask | |
| Octeniderm farblos | Schülke & Mayr GmbH, Nordenstedt, Germany | Alcoholic disinfectant | |
| Original Perfusor syringe 50 mL | B.Braun Melsungen AG, Germany | perfusor syringe | |
| Perfusor FM Braun | B.Braun Melsungen AG, Germany | syringe pump | |
| Propofol 2% 20 mg/mL (50 mL flasks) | Fresenius, Kabi Deutschland, GmbH | propofol | |
| RÜSCH Führungsstab für Endotrachealtubus (ID 5.6 mm) | Teleflex Medical Sdn. Bhd, Malaysia | PVC coated tube guiding wire | |
| Rüschelit Super Safety Clear >ID 6/6.5 /7.0 mm | Teleflex Medical Sdn. Bhd, Malaysia | endotracheal tube | |
| Stainless Macintosh Größe 4 | Welch Allyn69604 | blade for laryngoscope | |
| Sterofundin | B.Braun Melsungen AG, Melsungen, Germany | Balanced electrolyte solution | |
| Ultrastop Antibeschlagmittel bottle with dropper 25 mL | Sigmapharm Arzneimittel GmbH, Wien, Austria | Antifog agent | |
| Vasofix Safety 22 G-16 G | B.Braun Melsungen AG, Germany | venous catheter | |
| VBM Cuff Manometer | VBM Medizintechnik GmbH, Sulz a.N., Germany | cuff pressure gauge | |
| Zelette | Lohmann & Rauscher International GmbH & Co. KG, Rengsdorf, Germany | Tissue swab |
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