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It acts on G-protein coupled receptors on It is secreted from the cells of intestinal mucosa cheap 100mg viagra capsules with mastercard. Thus viagra capsules 100mg with visa, it prepares intestinal lumen and therefore regulates fluid movement the intestine for next meal quality 100 mg viagra capsules. In these Applied Physiology organs discount viagra capsules 100 mg on line, guanylin appears to control fluid movement and Erythromycin can be used in patients having hypomotility particularly integrates the actions of intestine and kidneys. They activate guanylin receptors in intestine and produce fluid secre- Neurotensin tion into the intestinal lumen. It Somatostatin is a strong orexigenic agent that increases food intake by acting on arcuate nucleus of hypothalamus. Its secretion is stimulated by presence of Substance P is secreted from endocrine cells and neurons fat in jejunum. Understand the dysfunctions that occur due to abnormalities of salivary secretion. These phases are classified based soon as food arrives in the gut, especially in the intes- on stimulus location. Therefore, it is desirable to spend some time in taking Cephalic Phase soup and starters before taking a major meal. Taste of food (food in mouth) and stomach are: 342 Section 5: Gastrointestinal System 1. Chemical composition (especially, amino acids, and dases that digest proteins and lipases that digest lipids. This is essential for thorough exposure of food particles with chemicals for proper digestion of each 2. Protection of mucosa: the mucus and alkaline pH of biliary, and intestinal secretions. It is secreted from a heterogeneous group of sali- food particles in which the first step is to hydrolyze macro­ vary glands located in and around the mouth cavity. Through reflex mechanisms, food in intestine inhibits eponymously for the discovery of the duct of the gastric secretion and motility. Major salivary glands are three pairs: parotid, sublin- gual and submandibular glands. There are many minor salivary glands located in the mucosa of oral cavity, at the pharyngeal outlet, in the palates and in buccal pouches. Based on nature of secretion: Salivary glands may be serous that exclusively release watery secretions, mucous that secrete viscous secretion mainly containing mucus and mixed that secrete moderately viscous secretions. They pour their secretion into the mouth cavity by means of parotid duct (duct of Stensen), which opens into the oral cavity at the level of second molar tooth (Fig. Histology of Salivary Glands Sublingual Glands Salivary gland consists of base units called salivon. Each salivon consists of acinus, intercalated duct and striated These glands are situated below the tongue in the floor of duct (Fig. Secretions from these glands drain directly into the Acinus mouth by means of sublingual ducts (ducts of Rivinus). Sublingual glands Acinus is a sac like structure containing many pyramidal are predominantly mucous glands. Serous cells of acinus contain many endoplasmic retic- Submandibular Glands ulum and zymogen granules, and secrete digestive Submandibular, also called submaxillary glands are situ- enzyme, whereas mucous cells contain mucin droplets ated below the inner ramus of mandible on both sides. Preganglionic fibers for parotid gland are present in 9th cranial nerve that originate in inferior salivary nucleus These ducts are lined by cuboidal cells. Secretion from and terminate in otic ganglion from where postgangli- these duct epithelial cells modifies the ionic composition onic fibers originate and innervate the gland (Fig. Secretion coming out of duct is called present in the 7th cranial nerve that originate from modified or final secretion. In normal situation, parasym- pathetic innervation is the major neural factor for salivary Sympathetic Innervation secretion. Sympathetic fibers originate from upper cervical segments and terminate in superior cervical ganglion. Postganglionic Parasympathetic Innervation fibers leave the ganglion and innervate acini, duct and blood the centers for parasympathetic fibers are located in medulla. Blood flow and metabolism are proportionate nate concentration as time to add more bicarbonate to the rate of saliva formation. However, if the increase in flow is due to parasympathetic 50 mL/min/100 g of salivary tissue. Blood flow to salivary glands is about 10 times the more that increases salivary content of bicarbonate. Salivary Secretion Functions of Saliva Saliva performs many important digestive and non-diges- Rate of Secretion tive functions. Normally, we never realize the amount of saliva vary amylase, which causes splitting of starch. However, an orexigenic stimulus, especially sight, absence of salivary amylase (if pancreas is intact). We realize the importance of salivation when digestion by ptyalin takes place in the stomach, as food the secretion becomes less and mouth becomes dry. IgA in saliva provides local immunity and lactoferrin in saliva Organic Solids is bacteriostatic. Saliva keeps the mouth cavity and tongue moist, which lysozyme, lactoperoxidase, carbonic anhydrase, lingual facilitates speech. Other organic solids include saliva is realized when mouth becomes dry due to kallikrein, blood group substances, secretory immuno- decreased salivary secretion that impairs speech. Taste is perceived by Cations like sodium, calcium, potassium, and magnesium the taste buds present in the tongue. For taste of food ions, and anions like chloride, bicarbonate, phosphate, to be well appreciated, food particles should better sulfate, and bromide ions constitute the inorganic solids. The mucin in saliva the concentration of sodium and chloride ions in saliva lubricates food. Saliva contains bicarbonate which buffers gastric acid of secretion, higher is the tonicity. The tonicity of saliva is to some extent in the stomach, and therefore reduces about 70% of that of plasma. Proline rich protein in saliva protects enamel of the the pH and K Content of Saliva teeth and thus provides them strength. In animals, salivation (panting) is an important process anticipation, thought, sight and smell of food, discussion of dissipation of heat and therefore, has contribution on food, and presence of foodin the mouth cavity. Control of Salivary Secretion Salivary secretion is controlled exclusively by the neu- Mechanism of Secretion ral mechanisms. Both sympathetic and parasympathetic Salivary secretion occurs in two stages: secretion in the stimuli influence salivary secretion. Secretion in Acinus of Gland Neural Control In the gland acini, the secretion is called primary secretion Parasympathetic Stimulation in which amylase concentration is more. Secretion in Ducts the composition of secretion in the ducts when the fluid passes through the intercalated and striated ducts, is modified. The ducts do not change the volume of saliva but only modify the composition of the primary secretion (Fig. The important stimuli are determine ionic compositions of primary and modified secretions. It increases secretion by causing vasodilation (via regulation of saliva is negligible. Applied Physiology Sympathetic Stimulation Xerostomia Stimulation of sympathetic fibers (sympathetic fibers to This is a condition in which there is consistent decreased salivary gland originate from superior cervical ganglion) secretion of saliva. This causes dryness of mouth, and pre- temporarily increases secretion but finally decreases it. The transient increase is due to contraction of myoepi- is a common in acute stressful situation that happens due thelial cells of the glandular tissue. However, sympathetic stimulation causes vasocon- striction that decreases saliva formation and makes Sialorrhea the secretion thick. In this condition, salivary secretion is increased persis- Reflex Secretion tently. This reflex secretion is unconditioned as this Sialolithiasis is present since birth (does not need learning).

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This is an absolute contraindication for There was uniformity of opinion that a seton should always undertaking this procedure 100mg viagra capsules overnight delivery. However cheap viagra capsules 100 mg with amex, the use of a seton Preoperative Preparation prior to implantation was unnecessary if there was no acute inflammatory process buy viagra capsules 100mg free shipping. Some surgeons experienced in using the plug have prepared the bowel as for a major colon resection order viagra capsules 100mg mastercard, with laxatives and Preparing the Plug antibiotics. Allowing immersion for >5 min risks stool was preferable to solid for prevention of extrusion of fragmentation of the plug. When the use of a small-volume preoperative nonhydrated plug is extremely painful. It was accepted that there was Managing the Recessed Internal Opening no evidence base for this consideration. Therefore, in the If there is epithelialization of the internal opening (dimpled absence of data, the Panel concluded that bowel preparation or recessed), limited mobilization of the mucosal edges and⁄or the use of a small-volume enema should be left to the with debridement prior to suture placement should be individual surgeon’s personal preference. Passing the Plug the use of a suture or ligature was recommended to pull the narrow end of the plug from the internal opening through the Intraoperative Management track to the external opening until the plug is snug. Anaesthetic Trimming the Plug Any excess plug should be trimmed at the level of the inter- This was deemed to be a matter of the patient’s or surgeon’s nal opening (the wide end) and sutured with 2-0 long-term, preference. Positioning the Patient There was no consensus, however, as to whether the plug should be buried under the mucosa. The excess external plug This was regarded as a matter of the surgeon’s preference. The the critical element, however, was to ensure adequate visu- external opening may be enlarged if necessary to facilitate alization of the internal opening to place the suture drainage. Postoperative Care Surgical Technique the Panel had a stimulating discussion on various postopera- Identifying the Internal and External Openings tive management alternatives. However, in the absence of the plug cannot be inserted unless there is clear delineation evidence-based data, opinions revolved around what seemed of the primary and secondary openings. Irrigation of the reasonable and appropriate with more emphasis on the “art” track with saline or peroxide was recommended. Activity: No strenuous activity, exercise, or heavy lifting tion of the track and to facilitate insertion of the plug. Abstinence from sexual intercourse for 2 Panel unanimously affirmed that debridement, curettage, or weeks. Outcome D e fi ning Failure Early extrusion of the plug is either a technical error [the track being too large, the plug pulled too tightly, faulty fixa- tion (i. The Panel unanimously agreed that the over- whelming majority of fistulas which heal do so within Fig. The tie is then whether the operation should be considered a failure rests affixed to the fistula plug so that it will be pulled through the internal orifice out the external. Alex Ky Conclusions nonantigenic because it is degraded via a combination of the anal fistula plug was felt to be a reasonable alternative hydrolytic and enzymatic pathways. Members of the Panel were copolymer indicate that the bioabsorption process should be asked to state what they felt to be a reasonable rate of success complete within 6 months [11]. The device consists of a and concluded that 50–60 % should be considered accept- disk 16 mm in diameter, attached to six tubes, each 9 cm in able. The size of the plug can be tailored by changing the concluded that patient selection, avoidance of local infec- number and length of the tubes so that it occupies the fistula tion, and meticulous technique were required. Besides the tract until the bioabsorbable nature of the material allows consideration of cost it was felt that the patient would not be the body to fill the defect with native tissue [12]. In com- adversely affected by insertion of the fistula plug because all parison to the Surgisis plug, the disk was devised to decrease other management options were still available. The plug is depicted in nized, however, that even in patients with apparent healing Fig. Finally it was unanimously agreed that the procedure should be undertaken only by trained surgeons familiar with anorec- tal anatomy and experienced in conventional anal fistula sur- Preparation gery and in the management of its complications. Prepare the patient and surgical site using standard tech- niques appropriate for anal fistula repair. Gore Bio-A Plug Remove the device from its sterile packaging using aseptic technique. Using sharp sterile scissors, trim the disk diameter to a the Gore Bio-A is a synthetic plug as compared to Surgisis, size appropriate for the defect allowing for adequate fixa- which is a biologic plug. Care should be taken porous fibrous structure composed solely of a synthetic to avoid the creation of sharp edges or corners when trim- bioabsorbable polyglycolide–trimethylene carbonate copo- ming the disk. Individual tubes can be removed from the device to accom- the copolymer has been found to be both biocompatible and modate the diameter of the fistula tract. When removing 13 Synthetic Fistula Plug 93 tubes, begin with the center-most tubes, carefully cutting the tube as close to the disk as possible (proximally adja- cent) without compromising tube attachment. To facilitate introduction and deployment of the device in the fistula tract, it is recommended that a suture be used to gather the tubes and pull the device through the fistula tract. A bite depth of approximately 3 mm is recom- mended to ensure adequate suture retention strength. Note: the use of a resorbable suture is recommended to minimize the potential that any permanent material is implanted. However, to facilitate passage of the tubes through the fistula tract, briefly immerse the entire device in sterile saline. Device Placement Use standard techniques to define, clean, and prepare the fistula tract. Alex Ky Insert a fistula probe or other suitable instrument through the fistula tract, entering through the external (secondary) opening and exiting via the internal (primary) opening. Note: Take care to ensure that disk lies flat and is well apposed to the rectal mucosa at the internal (primary) open- ing of the fistula tract. After the device is properly positioned in the fistula tract, one of the following fixation methods should be used to secure the disk at the internal (primary) opening. Alex Ky Fixation Method I – Using a suitable resorbable suture, secure the disk of the contents into the fistula tract. In regard to technique, the button was secured flush with the anal mucosa and secured with two to three 2-0 Vicryl sutures. Of note, patients whose fistula plug was inserted after pretreat- fistula plug [14]. There were a total of 27 plug insertions over ment of the fistula with a draining (loose) seton appeared to a 28-month period in 16 patients. Successful closure (healing) was clinically defined as the the median age was 49 (range, 33–65) years. Patients with absence of any discharge or swelling, with the internal open- known hypersensitivity to materials in the plug, those who ing closed by the time the anoscopy was performed and all had more than three external openings or Crohn’s disease, external openings closed at the perineal examination at the and those who were under 18 years of age or were pregnant 13 Synthetic Fistula Plug 95 Table 13. Healing of the fistula was defined as complete the size of the external opening increased to allow for adequate drain- closure of the internal opening and the external wound and age. In describing the surgical technique, all arms of the plug were pulled tight and the were excluded form the study. The head was then covered with a the absence of any discharge or swelling, with the internal mucosa-submucosa-flap (Vicryl 2-0). Six months all external openings closed at the perineal examination at after surgery the fistula had healed in 20 patients (50. In regard to technique, the disk Three additional fistulas healed after 7, 9, and 12 months. Successful closure was varied significantly amongst the five surgeons with a range observed in only 3 out of 19 patients (15. In patients having only prior drainage of the results from this study were attributed to the learning curve abscess healing occurred in 63. In regard to surgical technique, the submucosal pocket was closed with 3-0 Vicryl Conclusion stitches. The disk was included in the suture to prevent plug migration and the protruding tubes were trimmed 2–3 mm the Gore Bio-A fistula plug is a new and evolving treatment beyond the surface of the perianal skin. All patients were evaluated by physical the data that has been published up to this point. Success was defined to the learning curve of the surgery, patient selection, and the as the absence of drainage, closure of the external opening, small number of patients. One technical aspect that needs to and the absence of perianal swelling or abscess formation.

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When free radicals exceed the capacity of or sulfur atoms 100mg viagra capsules sale, and inhibits virus replication generic viagra capsules 100mg with mastercard. Cell death induced by free radicals has characteristics of both apoptosis and necrosis 100 mg viagra capsules with visa. Superoxide dismutase is an enzyme that defends an organ- the most compelling observation that cell death resulting ism against oxygen-free radicals by catalyzing the interaction from free radicals is related to the apoptotic process is found of superoxide anions with hydrogen ions to yield hydrogen at the level of the mitochondria cheap viagra capsules 100mg otc. An adherent cell is a cell such as a macrophage (mononu- the radical-induced cell death may involve the mitochon- clear phagocyte) that attaches to the wall of a culture fask, drial permeability transition pore. Bcl-2 has been observed thereby facilitating the separation of such cells from B and T to be located near the permeability transition pore in the lymphocytes which are not adherent. Given the rapidly expanding of an experimental animal develop into epithelioid cells. On the con- trary, epithelioid cells are able to divide, resulting in round, Reactive oxygen species are oxygen-derived radicals that small daughter cells which mature in 2 to 4 d, gaining struc- are generated in the mitochondria as oxygen is reduced tural and functional characteristics of young macrophages. These can be produced Material that is taken up by macrophages but cannot be fur- by phagocytic cells to kill pathogens, but are also involved ther processed prevents the conversion of epithelioid cells. Damage from these toxic species is prevented by the epithelioid cell is a particular type of cell characteristic antioxidants (ascorbic acid, vitamin E, uric acid, glutathione, of some types of granulomas such as in tuberculosis, sarcoido- etc. During oxidative stress, these cloudy, abundant eosinophilic cytoplasm; and an elongated and protective mechanisms are overwhelmed leading to mem- pale nucleus. By electron microscopy, the cell shows a few short brane damage, protein modifcations, and apoptosis. Mitochondria are generally elongated, the Golgi com- A stimulated macrophage is one that has been acti- plex is prominent, and lysosomal dense bodies are scattered vated in vivo or in vitro. Enzyme the term resident macrophage refers to a macrophage nor- generated principally in phagocytes by products of microbes mally present at a tissue location without being induced to or proinfammatory cytokines. Molecules, Cells, and Tissues of the Immune Response 117 Macrophage immunity: Cellular immunity. Giant cells form are membrane-bound are termed “pattern recognition recep- from some of these fused cells. Activated macrophages rophages of lymph node, spleen, and tonsil germinal centers, trap antigen, which may cause T cells to release lymphokines, as well as in the dome of the appendix. Granulomas appear in cases of Tingible body macrophages are phagocytic cells that tuberculosis and develop under the infuence of helper T cells engulf apoptotic B cells which are formed in large numbers that react against Mycobacterium tuberculosis. There may also be occa- Phagocytosis is the uptake of particulate material, such as sional neutrophils and eosinophils. Particle ligands unite with numer- is a delayed type of hypersensitivity reaction that persists as ous receptors on the surface of the phagocyte in a “zippering” a consequence of the continuous presence of foreign body or effect and cause polymerization of actin, invagination of the infection. This monocytes are strongly adherent cells and have a rate of is an important clearance mechanism for the removal and locomotion slower than that of neutrophils. Tumors in man and animals may fbroblasts may show phagocytic properties; these are called produce an inhibitor that causes monocytes or macrophages facultative phagocytes. Phagocytosis may involve nonimmunologic or immunologic Nitric oxide synthetase is an enzyme or family of enzymes mechanisms. Nonimmunologic phagocytosis refers to the that synthesizes vasoactive and microbicidal compound ingestion of inert particles such as latex particles or of other nitric oxide from L-arginine. The activation of macrophages particles that have been modifed by chemical treatment or by microorganisms of cytokines can induce a form of this coated with protein. Damaged cells may become coated with immunoglobulin or other proteins which facili- A histiocyte is a tissue macrophage that is fxed in tissues tate their recognition. They may be Phagocytosis of microorganisms involves several steps: derived from monocytes in the circulating blood. After attachment, the particle is engulfed within a membrane fragment and a A mannose receptor is a lectin or carbohydrate-binding phagocytic vacuole is formed. The vacuole fuses with the receptor on macrophages that binds mannose and fucose primary lysosome to form the phagolysosome, in which the residues on the cell walls of microorganisms, thereby facili- lysosomal enzymes are discharged and the enclosed material tating their phagocytosis. Remnants of indigestible material can be recog- nized subsequently as residual bodies. Chemotactic factors are released by actively mul- also facilitates antigen processing. These chemotactic factors are powerful attractants for phagocytic cells which have specifc mem- Facultative phagocytes are cells such as fbroblasts that may brane receptors for the factors. However, certain intracellular microorgan- Armed macrophages are macrophages bearing surface IgG isms such as Mycobacteria or Listeria are not killed merely or IgM cytophilic antibodies or T cell lymphokines that ren- by ingestion and may remain viable unless there is adequate der them capable of inducing antigen-specifc cytotoxicity. Pinocytosis refers to the uptake by a cell of small liquid droplets, minute particles, and solutes. The extrinsic variety encompasses opsonin Endocytosis is a mechanism whereby substances are taken defciencies secondary to antibody or complement factor def- into a cell from the extracellular fuid through plasma mem- ciencies, suppression of phagocytic cell numbers by immu- brane vesicles. This is accomplished by either pinocytosis nosuppressive agents, corticosteroid-induced interference or receptor-facilitated endocytosis. In pinocytosis, extracel- with phagocytic function, neutropenia, or abnormal neutro- lular fuid is captured within a plasma membrane vesicle. Intrinsic phagocytic dysfunction is related receptor-facilitated endocytosis, extracellular ligands bind to defciencies in enzymatic killing of engulfed microorgan- to receptors, and coated pits and coated vesicles facilitate isms. Clathrin-coated vesicles become uncoated granulomatous disease, myeloperoxidase defciency, and glu- and fuse to form endosomes. Consequences within the endosomes, and the receptor returns to the cell of phagocytic dysfunction include increased susceptibility to surface. Endosomes fused with lysosomes form secondary bacterial infections but not to viral or protozoal infections. Low-density Selected phagocytic function disorders may be associated lipoproteins are handled in this manner. Severe bacterial infections associated with phagocytic dysfunction range from mild skin An endocytic vesicle is a membrane structure derived from infections to fatal systemic infections. Frustrated phagocytosis is the inability of a phagocyte to engulf a target particle because of its large size or fxation Endogenous means resulting from conditions within a cell or in a tissue, which leads to the external release of lysosomal organism, rather than externally caused; derived internally. A Kupffer cell is a liver macrophage that has become fxed A phagosome is a phagocytic membrane-limited vesicle in as a mononuclear phagocytic cell in the liver sinusoids. It is an a phagocyte that contains phagocytized material which is integral part of the mononuclear phagocyte (reticuloendothe- digested by lysosomal enzymes that enter the vesicle after lial) system. Monocytes become attached to the interior sur- fusion with lysosomes in the cytoplasm. They are actively phagocytic and membrane produced by the fusion of a phagosome with a remove foreign substances from the blood as they fow through lysosome. It is a bone marrow-derived perivascular cell of the Natural anti-viral immunity occurs when virus-infected mononuclear phagocyte system. This blocks virus tem, it may act as an antigen-presenting cell, functioning in replication. Both complement Tuftsin is a leukokinin globulin-derived substance that and phagocytosis play signifcant roles in removal of extra- enhances phagocytosis. Its actions that is present on pre-B cells, monocytes, granulocytes, and include neutrophil and macrophage chemotaxis, enhancing platelets. It by fbroblasts, monocytes, and endothelial cells as a result of may be signifcant in aggregation and activation of platelets. It is restricted to myel- that binds heparin and is resistant to cyclooxygenase inhibi- oid cells and is found on early progenitor cells, monocytes, tion. Macrophages stimulated by endotoxin may secrete this myeloid leukemias, and weakly on some granulocytes. It appears indistinguishable from hematopoietic tates T cell responses to protein antigens. B cells may also stem cell inhibitor and may function in growth regulation act as antigen-presenting cells, thereby serving an accessory of hematopoietic cells. Adhesion molecules facilitat- blasts, monocytes, lymphocytes, neutrophils, eosinophils, ing the interaction of T lymphocytes with other cells that smooth muscle cells, mast cells, platelets, and bone mar- signal transducing molecules which participate in T cell row stromal cells, among many other cell types. They are bone marrow derived and dis- tinct from follicular dendritic cells that present antigen to B cells. Immature dendritic cells are capable of antigen uptake and processing but are unable to activate T cells.

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It may also occur if an excessive inspiratory flow rate or ventilation pressure is used 100mg viagra capsules with amex. Gastric inflation after prolonged bag mask ventilation can limit effective ventilation12 but the inflation can be relieved by placing a nasogastric tube purchase viagra capsules 100 mg fast delivery. A second rescuer can apply cricoid pressure also may prevent regurgitation and aspiration of gastric contents viagra capsules 100 mg discount. Ineffective ventilation Reposition the head ensure that the mask is sealed snugly 2 effective viagra capsules 100 mg. Gastric inflation Place nasogastric tube Increase inspiratory time Apply cricoid pressure (sellick maneuver) 3. Neuromuscular weakness • Maximum negative inspiratory pressure >-20 cm H2O • Vital capacity <12-15 ml/kg e. Controlled therapeutic (Hyper) ventilation • Intracranial hypertension • Pulmonary hypertension Endotracheal Intubation When brief ventilation with bag and mask is not adequate to revive patient it may require intubation. Indication for Intubation Main indication of intubation is respiratory failure or if patient is unable to maintain airway (Table 5. When airway problems are anticipated, the intensivist should approach intubation with a plan specific to the difficulty noted and with a back up strategy in mind (Flow chart 5. Extra equipment should be on hand, including a variety of laryngoscope blades, forceps, tubes, bronchoscopes, tracheostomy or cricothyromy trays and additional skilled personnel as needed. If sedation is required, agents that can be reversed pharmacologically are desirable. Tracheal tube ventilation is the most effective and reliable method of assisted ventilation. A standard 15 mm adapter is firmly affixed to the proximal end for attachment to a ventilatory device. The distal end of the tracheal tube may provide an opening in the side wall (Murphy eye) to reduce the risk of atelectatis of the right upper lobe. The murphy eye also reduces the likelihood of complete tracheal tube obstruction, if the end opening is occluded. The tracheal tube should have calibrated marks (in cm) to use as reference points during placement and to facilitate detection of unintentional movement of the tube. Selection of a tracheal tube: 4 Selection and placement of the tracheal tube require assessment of the patients size and anticipated need for high airway pressures. An appropriately sized tube will permit an audible air leak around the tube when peak inflation pressure exceeds 20 to 30 cm H2O. Folded sheet under Folded sheet under shoulder with lifting chin into the occiput with lifting chin into the sniffing position sniffing position Preparation for Intubation Before elective intubation assemble the appropriate intubation and monitoring equipment and personnel. If the child has a perfusing rhythm administer supplementary oxygen before tracheal intubation. If trauma to the head and neck or multiple trauma is present, immobilize the cervical spine during intubation. If the child is in cardiac arrest, perform intubation immediately without stopping to apply physiologic monitors. Child more than 2 years of age—A folded sheet or towel to be placed under the occiput align the pharyngeal and tracheal axis (Fig. Hold the laryngoscope handle in left hand and insert the blade into the mouth in the midline, following the natural contour of the pharynx to the base of the tongue. Once the tip of the blade is at the base of the tongue (in vallecula: the space between the epiglottis and the base of the tongue, (Fig. Once epiglottis is seen sweep the proximal end of the blade and the handle to the midline. This movement toward the midline provides a channel in the right third of the mouth to pass the tracheal tube while maintaining direct visualization of the laryngeal structures. After the blade is properly positioned, traction is exerted upward in the direction of the long axis of the handle to displace the base of the tongue and the epiglottis anteriorly exposing glottis. In addition, application of cricoid pressure by an assistant may facilitate visualization of the glottic opening. Precautions • the risk of laryngeal trauma is increased if the blade is initially inserted in to the esophagus and then slowly with drawn to visualize the glottis. These practices may damage the teeth and reduce the ability to visualize the larynx. Confirmation of Tracheal Tube Placement After the tube is inserted, provide positive pressure ventilation and perform a clinical evaluation to confirm proper tube position. General orders of rapid sequence intubation steps can be performed simultaneously by different health care personnel, under the guidance of a specific team leader. Premedication with adjunctive agents (atropine, lignocaine, and defasciculating agent). Technique: Procedure should be done in operation theatre under general anesthesia. Transverse skin incision is made approx half way between cricoid cartilage and suprasternal notch. Strap muscles parted in middle and thyroid lithmus retracted to expose the anterior tracheal wall. A proline stay suture is placed on either side of midline and a vertical incision is made through 3-4 tracheal ring according to the size of the tube. Every possible precaution is taken to prevent displacement of tube in the first week4. Child should be discharged with tube of one size smaller, which can be inserted by parents during accidental decannulation if the same size tube insertion is difficult. Extubation should be attempted as soon as the primary disease process is taken care of unless the tracheotomy has been in place for longer than 2 weeks, the tracheotomy opening will usually close spontaneously with 48-72 hours of removal of tube. It is not a replacement for the endotracheal tube and does not protect against pulmonary aspiration. Its other end is fitted with a specially - shaped cuff which is inflated and deflated via a valve on the end of the inflation line. The mask is designed to conform to the contours of the hypopharynx with its lumen facing the laryngeal opening. The cricothyroid membrane is palpated between the inferior margin of thyroid cartilage and the superior edge of the cricoid cartilage. With one hand stabilize the larynx and trachea, the membrane is punctured in the midline with a large angiocath, the stylet is withdrawn, and the catheter is connected to the source of oxygen using connector to a 3 no endotracheal tube. Transtracheal jet ventilation is effective through such catheters, provided the upper airway permits exhalation. Simple and flexible connection setup for needle cricothyroidotomy is commercially available. Once the cricothyroid membrane has been punctured and the catheter placed in the tracheal lumen, a long wire from the vascular access kit is advanced cephalad on to the mouth. Some anatomic considerations of the infant larynx influencing endotracheal anaesthesia. American Heart Association in collaboration with International Liaison Committee on Resuscitation. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science, Part 10: Pediatric Advanced Life Support. Comparison of self-inflating bag with anesthesia bags for bag mask ventilation in the pediatric emergency department. Severe ventilatory compromise due to gastric distention during pediatric cardiopulmonary resuscitation. Efficacy of cricoid pressure on preventing gastric insuflation in infants and children. Cricoid pressure to prevent regurgitation of stomach contents during induction of anesthesia. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway: Anesthesiology. The position of the larynx in children and its relationship to the ease of intubation. Identification of endotracheal tube malpositions using computerized analysis of breath sounds via electronic stethoscopes: Anesth Analg 2005;101(3):735-9. Pediatric Emergency Medicine Committee of the American College of Emergency Physicians. Revised label regarding use of succinylcholine in children and adolescents (letter).

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