本议定书遵循本机构人类研究伦理委员会的指导方针。
1. 安置前的评估准则
注: 虽然在美国标签上没有列出正式的禁忌症, 但建议在已知的食管畸形患者中使用食道温度管理装置, 并在食道外伤的证据已知在前24小时内摄入酸性或腐蚀性毒物的患者。
<ol><li>获取所有设备, 包括适当的换热装置、食道温度管理装置、适当的固定装置、水基润滑包和圆周咬合块。</li>
	<li>放置佛利热敏电阻和/或直肠温度探头, 并将一个连接到热交换单元。建议使用第二个温度源进行验证, 并可连接到患者监视器。</li>
	<li>将食道温度管理装置连接到相应的换热器, 在机组上通电, 根据医院协议设定患者目标温度, 并将换热器置于自动模式。确保水流经食道温度管理装置, 并确认不存在泄漏。</li>
</ol>2. 设备插入
<ol><li>测量食道温度管理装置的适当插入深度, 方法是将其从患者的唇部延伸到耳垂, 然后从耳垂到剑过程的尖端;标记设备上的插入深度 (图 2)。</li>
</ol><img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/56579/56579fig2.jpg"> 图2。测量用于放置的食道温度管理装置.此示意图说明了确定设备放置深度的适当步骤, 如步骤2.1 中所述。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56579/56579fig2large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<ol start="2"><li>用水溶性润滑剂 (图 3) 对食道温度管理装置进行慷慨的润滑 (大约15厘米远端)。</li>
</ol><img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/56579/56579fig3.jpg"> 图3。润滑食道温度管理装置.此示意图说明了在插入前将水溶性润滑应用于设备的适当程序, 如步骤2.2 所述。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56579/56579fig3large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<ol start="3"><li>将病人置于耐受的水平, 并将食道温度管理装置用温和的压力向后, 并通过口腔向下, 穿过咽, 进入食道。可能需要一个柔和的颚推力, 以协助通过的设备。如果临床可行, 增加轻微的颈部延长, 诱导与支持下的肩膀, 如果需要, 可能会进一步缓解设备的通过。在所需的管子长度入之前 , 先用轻压推进装置。将咬块固定到位 (图 4)。</li>
</ol><img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/56579/56579fig4v2.jpg"> 图4。插入食道温度管理装置.此示意图说明了插入设备的适当的患者定位, 如步骤2.3 所述。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56579/56579fig4v2large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<ol start="4"><li>根据医院规程确定食管温度管理装置的位置。<ol>
<li>通过中心腔注入空气, 而听诊在胃部进行 "旋风" 或 "打嗝", 表明胃放置。</li>
		<li>用注射器通过中心腔吸胃内容。</li>
		<li>用 x 光确认位置和放置。</li>
	</ol>
</li>
	<li>使用固定设备或磁带按照医院协议安全。确保管和管组的连接与患者的皮肤没有接触, 因为导管与暴露的皮肤之间的直接接触可能会引起寒战。</li>
	<li>对于胃减压, 使用标准吸入管将中心腔与 low-intermittent 吸入连接。</li>
</ol>3. 温度管理-冷却
<ol><li>确保换热器设置为自动模式, 适当的目标温度 (通常从32° c 到37° c, 取决于机构协议)。</li>
	<li>启动寒战预防与药物按单位协议 (预防性干预建议与 non-sedating 药物启动; 例如, 醋氨酚, 丁螺环酮, 镁, 皮肤 counterwarming)。</li>
	<li>评估颤抖使用床边颤抖的评估量表定期, 或任何时候的温度降低不按预期的时间。寒战发生在尾部进展, 将首先确定在下颌骨或胸肌;早期干预势在必行。其他治疗颤抖可能包括啶, 托, 芬太尼, 异丙酚, 或神经肌肉阻断。</li>
</ol>4. 温度管理-维护
<ol><li>每小时监测和记录水温;如果水温降到10° c 以下1小时 (或超过一次, 当病人在目标温度), 首先评估颤抖。</li>
	<li>根据医院规程定期调整食管温度管理装置。</li>
</ol>5. 温度管理-变暖
<ol><li>按照当地医院的指导方针, 温率, 如果温从有意低温。</li>
	<li>设置一个最大的温率, 如果温从意外低温, 或预防围手术期低温。</li>
</ol>6. 故障排除
注意: 系统中的扭结或夹紧可能会引起外部热交换器上的遮挡警报。如果找不到原因, 停止治疗并取出食道温度管理装置。
<ol><li>如果食道温度管理装置的中央管腔堵塞或堵塞, 使用标准的方法清除阻塞的胃导管;如果不成功, 请更换设备。</li>
	<li>如果有差异大于0.5 ° c 之间的温度源, 暂停治疗调查的问题。</li>
	<li>由于系统中的泄漏可能会导致吸入罐内积聚的液体增加, 如果吸入罐内积聚的水量大于预期, 则停止处理并取出食道温度管理装置检查渗漏。 注意: 可能影响变暖或降温的因素包括身体质量、环境条件、寒战和临床状况;大于120公斤的患者可能对预期温度变化反应较慢, 而较小的患者可能需要更长的时间来保暖。</li>
	<li>如果病人不像预期的那样降温或变暖:<ol>
<li>确保食道温度管理装置处于正确的深度。</li>
		<li>确保足够的水流, 并且设备是冷的或温暖的接触 (酌情)。</li>
		<li>确保外部热交换器在自动模式下设定适当的目标温度和适当的水温 (4 ° c 到42° c)。</li>
		<li>确认温度探头完好、准确;请检查辅助源。</li>
		<li>检查患者发热 (例如寒战或发热)、热损失 (血流动力学不稳定或用药管理), 确保环境温度与温度调制目标一致。</li>
	</ol>
</li>
</ol>7. 设备拆卸
<ol><li>按 "显示器" 停止外部热交换器, 关闭夹具如果存在, 并撤回设备。</li>
	<li>断开设备与管道设置的连接, 并按照机构政策进行处理。</li>
	<li>关掉热交换装置</li>
</ol>

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H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Blowing+hot+and+cold?+Skin+counter+warming+to+prevent+shivering+during+therapeutic+cooling.">Blowing hot and cold? Skin counter warming to prevent shivering during therapeutic cooling.</a> Crit Care Med. 37 (6), 2106-2108 (2009).</li><li>Tommasi, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cooling+techniques+in+mild+hypothermia+after+cardiac+arrest.">Cooling techniques in mild hypothermia after cardiac arrest.</a> J Cardiovasc Med. , (2014).</li><li>Diringer, M. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+of+fever+in+the+neurologic+intensive+care+unit+with+a+catheter-based+heat+exchange+system.">Treatment of fever in the neurologic intensive care unit with a catheter-based heat exchange system.</a> Crit Care Med. 32 (2), 559-564 (2004).</li><li>Hegazy, A. F., Lapierre, D. M., Butler, R., Martin, J., Althenayan, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+esophageal+cooling+device:+A+new+temperature+control+tool+in+the+intensivist's+arsenal.">The esophageal cooling device: A new temperature control tool in the intensivist's arsenal.</a> Heart Lung. 46 (3), 143-148 (2017).</li></ol>

作者梅丽莎, 玛利亚灰色, 埃里克 Kulstad 是接通医疗的雇员, 生产的食道温度管理装置描述了这份手稿。作者艾哈迈德 Hegazy, 约瑟夫 Haymore, Neeraj Badjatia 和 Andrej Markota 接受免费设备进行临床评价。

此协议所需的修改和故障排除通常仅限于上面所述的内容, 并涉及在关键护理设置中使用的病人护理的典型监控。在越来越多的临床场景中, 调节核心温度对患者的预后至关重要。这些包括有意诱导低温从常温, 温从无意或故意低温, 并积极保持正常体温 (即, 常温) 的情况下, 在无意中低温常见的, 如在手术室里。作为具体的临床例子, 病人谁遭受缺血再灌注损伤, 如发生在心脏骤停, 受益于降温 (一般温度低于正常体温), 其次是温和的温和发烧预防高达3复苏后的天数28,29,30。新生儿缺氧缺血性脑病得到改善的结果, 如果冷却低于正常体温31。肾脏捐献者在器官移植前的神经死亡后冷却, 已被证明可以降低延迟移植功能的速度32。控制感染性休克患者的发烧可能减少升压的需求, 并有助于降低早期死亡率33。维持常温在外科手术中的病人减少手术伤口感染, 心肌并发症, 失血和输血要求, 同时缩短住院时间和减少死亡的可能性10,11,16。
该技术的局限性包括在管理危重病人方面遇到的挑战。虽然目标温度管理可以促进良好的结果, 但最常见的温度调制技术会给患者带来风险, 给提供者带来后勤挑战 (包括安置困难、血液感染、血栓、皮肤损伤和成本)。食道温度管理是为了克服这些缺点而设计的34,35,36。当适当地管理, 食道温度管理设备不接触与血管 (象血管内温度调节装置) 或皮肤 (象表面温度调制设备), 因此避免血液凝结, 血液感染和皮肤退化。该设备可由各种医疗保健提供商快速放置, 通常在几分钟内21,37。插入技术模仿标准的 orogastric 管放置, 这会使工作流中断最小化, 从而延缓治疗的启动。使用核心的方法也显得比表面的方法更少颤抖的负担27,38,39,40 。这样做的好处是减少镇静剂和 anti-shivering 的药物成本, 从而缩短病人的住院时间, 从较低的镇静程度中更快地觉醒。这些功能, 考虑与上述临床表现, 支持食道温度管理作为一个可行的选择提供者在急诊室, 重症监护病房和手术室。在设备上发布的一组不断增长的数据同样支持此新方法21、22、23、24、27、41。
协议中的关键步骤包括在插入之前在设备内启动流程, 为设备提供足够的润滑, 以确保容易放置, 执行胃吸痰和减压, 以允许最大程度的接触设备和病人, 并解决任何病人颤抖, 可能会发展。遵循这一协议将提供最佳的结果, 并允许高度的性能和安全的照顾这一重要的病人人口。

在治疗范围广泛的情况下, 有必要对病人进行体温管理, 包括心跳骤停、顽固性或复发性发热、神经原发热和大手术。在美国, 每年有50万次心脏骤停是在医院 (例如, 在接受一般医疗或外科治疗的病人中)1或出院 (例如, 在家里或在公共场所,然后被带到紧急部门)2。在这两种情况下, 患者的结果是显着改善的, 当积极的温度管理是3和目标温度管理 (TTM) 是一个标准的护理心脏骤停自2005年以来。在美国的4中, 每年有超过500万患者被送往重症监护病房。其中, 发热发展多达45% 的 non-neurologically 受伤患者5和多达70% 的神经受伤患者6。在重症监护病房发烧控制与改善的结果和减少死亡的风险相关, 因为升高的温度增加新陈代谢的需求, 恶化脑缺血, 并且增加神经元损失7。美国每年至少进行1000万次手术, 需要积极的患者加温, 以防止意外的围手术期体温过低8。在手术室, 手术患者应保持体温在36° c 以上, 避免大量的不良反应。在手术前、期间或术后, 未计划的体温下降会增加失血、感染和住院时间, 这使每位患者的住院费增加了7000美元或更多的费用9,10,11 ,12。
尽管临床上有很大的需要, 但最广泛的温度管理协议显示了不充分的表现或给病人带来重大风险。表面设备 (如水毯、传导床垫和强制空气盖) 都很繁琐, 传热能力有限, 必须将其移除, 以使病人能够获得病人的护理和程序。血管内设备是侵入性的, 难以放置, 并容易引起患者感染和血栓。现有的方法, 以防止意外的围手术期低温无法维持常温70% 的时间12,13,14,15,16和回顾性分析post-cardiac 逮捕冷却发现, 总体而言, 30% 的患者未能达到目标温度在6小时17。
食道的病人温度管理方法为现有技术提供了很大的优势18。食道温度管理装置保持胃管的功能, 通常放置在危重护理和外科病人人群。它允许持续的胃吸气和减压的气体和液体, 同时增加能力, 以安全有效地控制病人的体温, 利用良好的热交换环境的食道 (图 1)。通过将食道温度管理装置与使用水作为冷却剂的几种外部热交换器 (也称为冷水机组) 连接, 实现了温度调制。几家供应商生产的兼容热交换器可在医院为现有的温度控制产品 (通常是水毯子) 提供动力。护士, 护士医生, 或医生通常放置一个食道温度管理装置, 但它也可以插入任何提供培训, 以放置一个标准的 orogastric 管。食道温度管理装置不限制病人的接触, 不需要消毒, 避免了在提供者中发生针刺伤的风险, 避免了患者的皮肤并发症、血液感染和血栓的风险。因此, 这种方法的目的是提供一个低风险的替代方法, 控制病人的体温在危重护理和手术室设置。
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/56579/56579fig1.jpg"> 图1。食管温度管理装置放置.设备接近伟大的船只和心脏促进有效的传热在病人的核心。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56579/56579fig1large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>

<table border="0" cellpadding="0" cellspacing="0" width="778">
	<tbody>
		<tr height="63">
			<td height="63" style="height:63px;width:283px;">EnsoETM</td>
			<td style="width:91px;">Attune Medical</td>
			<td style="width:119px;">ECD01</td>
			<td style="width:287px;">Device compatible with Gaymar/Stryker Medi-Therm III and Stryker Altrix Precision Temperature Management System</td>
		</tr>
		<tr height="63">
			<td height="63" style="height:63px;width:283px;">EnsoETM</td>
			<td style="width:91px;">Attune Medical</td>
			<td style="width:119px;">ECD02</td>
			<td style="width:287px;">Device compatible with Cincinnati SubZero Blanketrol II and Cincinnati SubZero Blanketrol III</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:283px;">Gaymar/Stryker Medi-Therm III</td>
			<td style="width:91px;">Stryker</td>
			<td style="width:119px;">n/a</td>
			<td>Compatible heater-cooler with the ECD01</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:283px;">Cincinnati SubZero Blanketrol II</td>
			<td style="width:91px;">Gentherm</td>
			<td style="width:119px;">n/a</td>
			<td>Compatible heater-cooler with the ECD02</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:283px;">Cincinnati SubZero Blanketrol III</td>
			<td style="width:91px;">Gentherm</td>
			<td style="width:119px;">n/a</td>
			<td>Compatible heater-cooler with the ECD02</td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:283px;">Stryker Altrix Precision Temperature Management System</td>
			<td style="width:91px;">Stryker</td>
			<td style="width:119px;">n/a</td>
			<td>Compatible heater-cooler with the ECD01</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:283px;">Water-soluble lubricant</td>
			<td style="width:91px;">Various</td>
			<td style="width:119px;">n/a</td>
			<td>Standard water-soluble lubricant used to ease insertion of tubes, catheters, and digits</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:283px;">Securement device</td>
			<td style="width:91px;">Various</td>
			<td style="width:119px;">n/a</td>
			<td>E.g., Guard360 by PrimeGuard Medical</td>
		</tr>
	</tbody>
</table>

esophageal heat transfer for patient temperature control and targeted temperature management

控制病人体温对各种临床情况都很重要。冷却到正常或低于正常体温通常是对缺血性侮辱后的神经保护 (如出血性中风, 蛛网膜下腔出血, 心脏骤停, 或其他缺氧性损伤)。从发热状态降温可以治疗发热, 减少热疗对受损神经元的负面影响。患者在手术室内进行加温, 以防止意外的围手术期体温过低, 这是众所周知的导致增加失血, 伤口感染, 和心肌损伤, 同时也延长恢复时间。有许多报告的温度管理方法, 包括重新调整标准用品 (如: 如, 冰, 冷盐水, 风扇, 毛毯) 的简易方法, 但更复杂的技术设计的温度管理通常更成功地提供优化的协议。在过去的十年中, 先进的技术已经开发了大约两种传热方法: 表面设备 (水毯, 强迫空气加热器) 或血管内设备 (不育导管需要血管放置)。最近, 一种新颖的装置被放置在食道, 类似于标准的 orogastric 管, 提供有效的热量传递通过病人的核心。该设备连接到现有的热交换单元, 允许通过伺服机构自动病人温度管理, 使用标准温度传感器 (直肠, 福利, 或其他核心温度传感器) 的病人温度作为输入变量。这种方法消除了血管放置并发症 (深静脉血栓, 中央线相关的血流感染), 减少阻碍病人进入, 并导致较少颤抖时, 与表面的方法。公布的数据也显示了高度的准确性和维护的目标温度使用食道方法的温度管理。因此, 这种方法的目的是提供一种低风险的替代方法, 以控制病人的体温在关键护理设置。

聚合数据 在冷却、维护和升温速率方面, 食道温度管理与其他先进的温度管理技术具有相似的性能。对30例经食管温度管理长达36小时的患者进行分析发现, 平均温度为 2.7 h (SD ±2.8 h), 在维护期间记录的96% 的温度读数在±° c19以内。性能在所有协议中都是一致的, 无论目标温度如何 (图 5、 图 6、 图 7、 图 8)。性能与超过72小时 (图 9和图 10) 的处理时间保持一致。
著名案例 大量案例研究描述了食管温度管理在实践中的应用, 包括治疗心脏骤停缺血再灌注损伤、中枢性发热减少和手术常温的维护20,21,22,23,24,25,26,27. 虽然食道温度管理方法最初是在心脏骤停治疗的背景下构思的, 但以下病例突出了其成功的翻译成其他重要护理和围手术期。
案例 1: 脑膜炎 36名体重为64公斤的 year-old 妇女被承认患有严重的链球菌 pyrogenes 脑膜炎。她的体温从38.2 ° c 增加到40.0 ° c 六小时后;醋氨酚和外部冷却毯证明不成功, 以充分降低温度。
食管温度管理开始于48小时, 病人的体温从39.4 ° c 降至37.8 ° c, 在4时。在接下来的12小时内, 病人的体温继续下降到36.6 ° c, 并在36° c 和37° c 之间维持5天。7天胃镜检查显示, 食道温度管理装置没有任何变化。
案例 2: 严重烧伤和发热逆转 49 year-old 男性体重86公斤被承认与49% 环烧伤, 包括全厚度烧伤双腿, 左臂, 和左躯干。入院后两天后, 病人被带到手术室进行手术, 包括分期切除和移植腿部伤口。在放置食道温度管理装置和启动温度管理, 病人的核心温度保持在常温, 同时允许操作套件的温度被成功地降低到24° c。随后, 在患者的住院日22天, 患者开发了热病由于E。大肠杆菌和对常规冷却方法有抵抗力的念珠菌败血症。食管温度管理再次启动, 减少病人的温度从40° c 到设定点38.5 ° c, 这一温度保持, 尽管限制最低允许水温到12° c。
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/56579/56579fig5.jpg"> 图5。温度曲线为33° c 的协议.17 post-cardiac 拘捕患者被冷却了到33° c 为 24 h, 然后 rewarmed 在 4 h 期间到37° c。然后, 常温又维持了8小时。每个数据点代表单个病人的单一温度测量。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56579/56579fig5large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/56579/56579fig6.jpg"> 图6。温度曲线为35° c 的协议.6 post-cardiac 拘捕患者被冷却了到35° c 为 24 h, 然后 rewarmed 在 4 h 期间到37° c。然后, 常温又维持了8小时。每个数据点代表单个病人的单一温度测量。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56579/56579fig6large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/56579/56579fig7.jpg"> 图7。难治性发热患者的体温曲线.4例顽固性发热患者被冷却到36.5 ° c 或38° c。有关详细信息, 请参见插页图例。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56579/56579fig7large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/56579/56579fig8.jpg"> 图8。围手术期温度曲线常温.3严重烧伤患者 (40-50% 身体表面积) 在手术过程中, 以防止疏忽体温过低。所有患者保持核心温度在36° c 和周围温度在或被维护了在27° c。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56579/56579fig8large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 9" class="xfigimg" src="/files/ftp_upload/56579/56579fig9.jpg"> 图9。延长持续时间食管温度管理在心脏骤停患者.18患者被冷却了到33° c 为 24 h, 然后 rewarmed 在 8 h 期间到36° c。常温然后被维护了到 122 h.<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56579/56579fig9large.jpg" target="_blank">请点击这里查看更大版本的这个数字.</a>
<img alt="Figure 10" class="xfigimg" src="/files/ftp_upload/56579/56579fig10.jpg"> 图10。延长持续时间食管温度管理在顽固性发热患者.18患者根据医院协议冷却了 454 h, 包括目标温度37.5 ° c (绿色三角), 37 ° c (紫色金刚石), 36.7 ° c (红色三角), 36.5 ° c (橙色正方形), 或者36° c (蓝色圈子)。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56579/56579fig10large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>

Watch this Scientific Journal Video about Esophageal Heat Transfer for Patient Temperature Control and Targeted Temperature Management at JoVE.com

Esophageal Heat Transfer for Patient Temperature Control and Targeted Temperature Management

本研究提出了一种新的方法, 以提供有效的病人体温控制降温或变暖患者。一个单一的使用, 三重流明装置被放置到食道, 类似于一个标准的 orogastric 管, 并连接到现有的热交换单位执行自动病人温度管理。

病人体温控制的食管传热及靶温管理

Controlling patient temperature is important for a wide variety of clinical conditions. Cooling to normal or below normal body temperature is often ...

esophageal-heat-transfer-for-patient-temperature-control-targeted

Nanyang Technological University

Research

Education

JoVE Journal

JoVE Core

Nursing

Medicine

Unit 1

Vital Signs: Temperature

Healthcare Delivery Systems

SCIENTISTS IN ACTION

24.1K 次观看.  University of Illinois at Chicago. 本研究提出了一种新的方法, 以提供有效的病人体温控制降温或变暖患者。一个单一的使用, 三重流明装置被放置到食道, 类似于一个标准的 orogastric 管, 并连接到现有的热交换单位执行自动病人温度管理。

视频: Esophageal Heat Transfer for Patient Temperature Control and Targeted Temperature Management

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is respect for patient's values, preferences, and expressed needs. Yet specific approaches to gaining this understanding and translating it to quality care in the clinical setting are lacking. From a patient perspective quality is not a simple concept but is best understood in terms of five dimensions: technical outcomes; decision-making efficiency; amenities and convenience; information and emotional support; and overall patient satisfaction. Failure to consider quality from this five-pronged perspective results in a focus on medical outcomes, without considering the processes central to quality from the patient's perspective and vital to achieving good outcomes. In this paper, we argue for applying the concept of fair process in clinical settings. Fair process involves using a collaborative approach to exploring diagnostic issues and treatments with patients, explaining the rationale for decisions, setting expectations about roles and responsibilities, and implementing a core plan and ongoing evaluation. Fair process opens the door to bringing patient expertise into the clinical setting and the work of developing health care goals and strategies. This paper provides a step by step illustration of an innovative visual approach, called photovoice or photo-elicitation, to achieve fair process in clinical work with acquired brain injury survivors and others living with chronic health conditions. Applying this visual tool and methodology in the clinical setting will enhance patient-provider communication; engage patients as partners in identifying challenges, strengths, goals, and strategies; and support evaluation of progress over time. Asking patients to bring visuals of their lives into the clinical interaction can help to illuminate gaps in clinical knowledge, forge better therapeutic relationships with patients living with chronic conditions such as brain injury, and identify patient-centered goals and possibilities for healing. The process illustrated here can be used by clinicians, (primary care physicians, rehabilitation therapists, neurologists, neuropsychologists, psychologists, and others) working with people living with chronic conditions such as acquired brain injury, mental illness, physical disabilities, HIV/AIDS, substance abuse, or post-traumatic stress, and by leaders of support groups for the types of patients described above and their family members or caregivers.

This paper illustrates an innovative visual approach (photovoice or photo-elicitation) to achieve fair process in clinical care for patients living with chronic health conditions, illuminate gaps in clinical knowledge, forge better therapeutic relationships, and identify patient-centered goals and possibilities for healing.

利用视觉和叙事方法，以实现公平的进程中，在临床护理

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is ...

科研

医学

Implantation of Radiotelemetry Transmitters Yielding Data on ECG, Heart Rate, Core Body Temperature and Activity in Free-moving Laboratory Mice

The laboratory mouse is the animal species of choice for most biomedical research, in both the academic sphere and the pharmaceutical industry. Mice are a manageable size and relatively easy to house. These factors, together with the availability of a wealth of spontaneous and experimentally induced mutants, make laboratory mice ideally suited to a wide variety of research areas.
In cardiovascular, pharmacological and toxicological research, accurate measurement of parameters relating to the circulatory system of laboratory animals is often required. Determination of heart rate, heart rate variability, and duration of PQ and QT intervals are based on electrocardiogram (ECG) recordings. However, obtaining reliable ECG curves as well as physiological data such as core body temperature in mice can be difficult using conventional measurement techniques, which require connecting sensors and lead wires to a restrained, tethered, or even anaesthetized animal. Data obtained in this fashion must be interpreted with caution, as it is well known that restraining and anesthesia can have a major artifactual influence on physiological parameters1, 2.
Radiotelemetry enables data to be collected from conscious and untethered animals. Measurements can be conducted even in freely moving animals, and without requiring the investigator to be in the proximity of the animal. Thus, known sources of artifacts are avoided, and accurate and reliable measurements are assured. This methodology also reduces interanimal variability, thus reducing the number of animals used, rendering this technology the most humane method of monitoring physiological parameters in laboratory animals3, 4. Constant advancements in data acquisition technology and implant miniaturization mean that it is now possible to record physiological parameters and locomotor activity continuously and in realtime over longer periods such as hours, days or even weeks3, 5.
Here, we describe a surgical technique for implantation of a commercially available telemetry transmitter used for continuous measurements of core body temperature, locomotor activity and biopotential (i.e. onelead ECG), from which heart rate, heart rate variability, and PQ and QT intervals can be established in freeroaming, untethered mice. We also present pre-operative procedures and protocols for post-operative intensive care and pain treatment that improve recovery, well-being and survival rates in implanted mice5, 6.

A surgical technique for implantation of commercially available telemetry transmitters used for continuous measurement of biopotential (one-lead ECG), heart rate, core body temperature and locomotor activity in freely moving mice is shown. Recommendations and protocols for post-operative care and pain relief, improving recovery, well being and survival rate are also presented.

植入的无线电遥测发射器产生心电图，心率，身体核心温度和自由移动的实验室小鼠的活动上的数据

The laboratory mouse is the animal species of choice for most biomedical research, in both the academic sphere and the pharmaceutical industry. Mice are a ...

Breathing-controlled Electrical Stimulation (BreEStim) for Management of Neuropathic Pain and Spasticity

Electrical stimulation (EStim) refers to the application of electrical current to muscles or nerves in order to achieve functional and therapeutic goals. It has been extensively used in various clinical settings. Based upon recent discoveries related to the systemic effects of voluntary breathing and intrinsic physiological interactions among systems during voluntary breathing, a new EStim protocol, Breathing-controlled Electrical Stimulation (BreEStim), has been developed to augment the effects of electrical stimulation. In BreEStim, a single-pulse electrical stimulus is triggered and delivered to the target area when the airflow rate of an isolated voluntary inspiration reaches the threshold. BreEStim integrates intrinsic physiological interactions that are activated during voluntary breathing and has demonstrated excellent clinical efficacy. Two representative applications of BreEStim are reported with detailed protocols: management of post-stroke finger flexor spasticity and neuropathic pain in spinal cord injury.

Breathing-controlled Electrical Stimulation BreEStim for Management of Neuropathic Pain and Spasticity

The purpose is to present a new method, breathing-control electrical stimulation (BreEStim) for management of neuropathic pain and spasticity.

呼吸控制电气的刺激（BreEStim）的神经性疼痛和痉挛的管理

Electrical stimulation (EStim) refers to the application of electrical current to muscles or nerves in order to achieve functional and therapeutic goals. ...

Patient Derived Cell Culture and Isolation of CD133+ Putative Cancer Stem Cells from Melanoma

Despite improved treatments options for melanoma available today, patients with advanced malignant melanoma still have a poor prognosis for progression-free and overall survival. Therefore, translational research needs to provide further molecular evidence to improve targeted therapies for malignant melanomas. In the past, oncogenic mechanisms related to melanoma were extensively studied in established cell lines. On the way to more personalized treatment regimens based on individual genetic profiles, we propose to use patient-derived cell lines instead of generic cell lines. Together with high quality clinical data, especially on patient follow-up, these cells will be instrumental to better understand the molecular mechanisms behind melanoma progression.
Here, we report the establishment of primary melanoma cultures from dissected fresh tumor tissue. This procedure includes mincing and dissociation of the tissue into single cells, removal of contaminations with erythrocytes and fibroblasts as well as primary culture and reliable verification of the cells' melanoma origin.
Recent reports revealed that melanomas, like the majority of tumors, harbor a small subpopulation of cancer stem cells (CSCs), which seem to exclusively fuel tumor initiation and progression towards the metastatic state. One of the key markers for CSC identification and isolation in melanoma is CD133. To isolate CD133+ CSCs from primary melanoma cultures, we have modified and optimized the Magnetic-Activated Cell Sorting (MACS) procedure from Miltenyi resulting in high sorting purity and viability of CD133+ CSCs and CD133- bulk, which can be cultivated and functionally analyzed thereafter.

Patient Derived Cell Culture and Isolation of CD133+ Putative Cancer Stem Cells from Melanoma

This article describes the preparation of freshly obtained melanoma tissue into primary cell cultures, and how to remove contaminations of erythrocytes and fibroblasts from the tumor cells. Finally, we describe how CD133+ putative melanoma stem cells are sorted from the CD133- bulk using Magnetic Activated Cell Sorting (MACS).

来自患者的细胞培养和分离的CD133<sup&gt; +</sup&gt;假定的肿瘤干细胞的恶性黑色素瘤

Despite improved treatments options for melanoma available today, patients with advanced malignant melanoma still have a poor prognosis for ...

Using an Ingestible Telemetric Temperature Pill to Assess Gastrointestinal Temperature During Exercise

Exercise results in an increase in core body temperature (Tc), which may reduce exercise performance and eventually can lead to the development of heat-related disorders. Therefore, accurate measurement of Tc during exercise is of great importance, especially in athletes who have to perform in challenging ambient conditions. In the current literature a number of methods have been described to measure the Tc (esophageal, external tympanic membrane, mouth or rectum). However, these methods are suboptimal to measure Tc during exercise since they are invasive, have a slow response or are influenced by environmental conditions. Studies described the use of an ingestible telemetric temperature pill as a reliable and valid method to assess gastrointestinal temperature (Tgi), which is a representative measurement of Tc. Therefore, the goal of this study was to provide a detailed description of the measurement of Tgi using an ingestible telemetric temperature pill. This study addresses important methodological factors that must be taken into account for an accurate measurement. It is recommended to read the instructions carefully in order to ensure that the ingestible telemetric temperature pill is a reliable method to assess Tgi at rest and during exercise.

This study describes an accurate, reliable and non-invasive technique to continuously measure gastrointestinal temperature during exercise. The ingestible telemetric temperature pill is suitable to measure gastrointestinal temperature in laboratory settings as well as in field based settings.

使用可摄取遥测温度丸，以评估胃肠道温度在练习

Exercise results in an increase in core body temperature (Tc), which may reduce exercise performance and eventually can lead to the development of ...

Contractions of Human-iPSC-derived Cardiomyocyte Syncytia Measured with a Ca-sensitive Fluorescent Dye in Temperature-controlled 384-well Plates

Spontaneously contracting syncytia of cardiomyocytes derived from human-induced pluripotent stem cells (hiPSC-CM) are a useful model of human cardiac physiology and pharmacology. Various methods have been proposed to record this spontaneous activity and to evaluate drug effects, but many of these methods suffer from limited throughput and/or physiological relevance. We developed a high-throughput screening system to quantify the effects of exogenous compounds on hiPSC-CM's beating frequency, using a Ca-sensitive fluorescent dye and a temperature-controlled imaging multi-well plate reader. We describe how to prepare the cell plates and the compound plates and how to run the automated assay to achieve high sensitivity and reproducibility. We also describe how to transform and analyze the fluorescence data to provide reliable measures of drug effects on spontaneous rhythm. This assay can be used in drug discovery programs to guide chemical optimization away from, or toward, compounds affecting human cardiac function.

Spontaneously contracting syncytia of cardiomyocytes derived from human-induced pluripotent stem cells are useful models of human cardiac physiology and pharmacology. Here we present a high-throughput screening system to quantify the effects of exogenous compounds on beating frequency, using a Ca-sensitive fluorescent dye and a temperature-controlled imaging multi-well plate reader.

温度控制384孔板中用 Ca 敏感荧光染料测定人 iPSC 的心肌细胞较多的收缩

Spontaneously contracting syncytia of cardiomyocytes derived from human-induced pluripotent stem cells (hiPSC-CM) are a useful model of human cardiac ...

Simultaneous Laryngopharyngeal and Conventional Esophageal pH Monitoring

In addition to typical reflux symptoms, many patients with gastroesophageal reflux disease (GERD) present with extraesophageal symptoms such as cough, hoarseness or asthma, which can be caused by laryngopharyngeal reflux (LPR). Due to their multifactorial origin, those symptoms can be a great diagnostic and therapeutic challenge. Esophageal pH-monitoring is commonly used to determine abnormal esophageal acid exposure and confirm the diagnosis of GERD. However, for better evaluation of acid exposure above the upper esophageal sphincter, a new laryngopharyngeal pH measurement system is now available and may lead to more reliable results in patients with predominantly extraesophageal symptoms. This article aims to present a standardized protocol for simultaneous pH measurement using esophageal and laryngopharyngeal pH probes in order to obtain acid exposure scores from both measurements.

Laryngopharyngeal pH monitoring has been specifically designed to measure acid exposure above the upper esophageal sphincter and complements diagnostic evaluation in patients that present with mainly extraesophageal reflux symptoms. Patients with suspected laryngopharyngeal reflux (LPR) were evaluated using distal esophageal and laryngopharyngeal pH testing simultaneously.

同时监测喉咽和常规食管 pH 值

In addition to typical reflux symptoms, many patients with gastroesophageal reflux disease (GERD) present with extraesophageal symptoms such as cough, ...

Evaluation of Capnography Sampling Line Compatibility and Accuracy when Used with a Portable Capnography Monitor

Capnography is commonly used to monitor patient&#8217;s ventilatory status. While sidestream capnography has been shown to provide a reliable assessment of end-tidal CO2 (ETCO2), its accuracy is commonly validated using commercial kits composed of a capnography monitor and its matching disposable nasal cannula sampling lines. The purpose of this study was to assess the compatibility and accuracy of cross-paired capnography sampling lines with a single portable bedside capnography monitor. A series of 4 bench tests were performed to evaluate the tensile strength, rise time, ETCO2 accuracy as a function of respiratory rate, and ETCO2 accuracy in the presence of supplemental O2. Each bench test was performed using specialized, validated equipment to allow for a full evaluation of sampling line performance. The 4 bench tests successfully differentiated between sampling lines from different commercial sources and suggested that due to increased rise time and decreased ETCO2 accuracy, not all nasal cannula sampling lines provide reliable clinical data when cross-paired with a commercial capnography monitor. Care should be taken to ensure that any cross-pairing of capnography monitors and disposable sampling lines is fully validated for use across respiratory rates and supplemental O2 flow rates commonly encountered in clinical settings.

The goal of this study was to evaluate the accuracy of capnography sampling lines used in conjunction with a portable bedside capnography monitor. Sampling lines from 7 manufacturers were evaluated for tensile strength, rise time, and ETCO2 accuracy as a function of respiratory rate or supplemental oxygen flow rate.

与便携式刻度学监视器一起使用时，评估卡光采样线兼容性和准确性

Capnography is commonly used to monitor patient&#8217;s ventilatory status. While sidestream capnography has been shown to provide a reliable assessment ...

Reduced Procedure Time and Variability with Active Esophageal Cooling During Radiofrequency Ablation for Atrial Fibrillation

Various methods are utilized during radiofrequency (RF) pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) to protect the esophagus from inadvertent thermal injury. Active esophageal cooling is increasingly being used over traditional luminal esophageal temperature (LET) monitoring, and each approach may influence procedure times and the variability around those times. The objective of this study is to measure the effects on procedure time and variability in procedure time of two different esophageal protection strategies utilizing advanced informatics techniques to facilitate data extraction. Trained clinical informaticists first performed a contextual inquiry in the catheterization laboratory to determine laboratory workflows and observe the documentation of procedural data within the electronic health record (EHR). These EHR data structures were then identified in the electronic health record reporting database, facilitating data extraction from the EHR. A manual chart review using a REDCap database created for the study was then performed to identify additional data elements, including the type of esophageal protection used. Procedure duration was then compared using summary statistics and standard measures of dispersion.&#160;A total of 164 patients underwent radiofrequency PVI over the study timeframe; 63 patients (38%) were treated with LET monitoring, and 101 patients (62%) were treated with active esophageal cooling. The mean procedure time was 176 min (SD of 52 min) in the LET monitoring group compared to 156 min (SD of 40 min) in the esophageal cooling group (P = 0.012). Thus, active esophageal cooling during PVI is associated with reduced procedure time and reduced variation in procedure time when compared to traditional LET monitoring.

This study utilized advanced informatics techniques to compare procedure duration in patients undergoing radiofrequency atrial ablation treated with active esophageal cooling to those treated with traditional luminal esophageal temperature monitoring. Contextual inquiry, workflow analysis, and data mapping were utilized. The findings demonstrated reduced procedure time and variability with active cooling.

通过主动食管冷却减少心房颤动射频消融术的手术时间和可变性

Various methods are utilized during radiofrequency (RF) pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) to protect the ...

Lumican Extraction from Amniotic Membrane and Determination of its Storage Temperature

Lumican is a small leucine-rich proteoglycan in the human amniotic membrane (AM) that promotes corneal epithelialization and the organization of collagen fibers, maintaining corneal transparency. In the present work, a method for protein extraction from AM to obtain lumican is proposed. Additionally, the stability of lumican in the AM extract (AME) stored at different temperatures and time periods is evaluated. 100 mg of AM were thawed and mechanical de-epithelialized. The de-epithelialized AM was frozen and crushed until a fine powder was obtained, which was solubilized with 2.5 mL of saline buffer with protease inhibitors and centrifuged for protein extraction. The supernatant was collected and stored at -20 &#176;C, 4 &#176;C, and room temperature (RT) for 6, 12, 20, and 32 days. Afterward, lumican was quantified in each AME. This technique allows an accessible and acquirable protocol for lumican extraction from AM. Lumican concentration was affected by storage time and temperature conditions. Lumican in the AME of 12 days stored at -20 &#176;C and 4 &#176;C was significantly higher than other AME. This lumican extraction could be useful for developing treatments and pharmaceutical solutions. Further studies are needed to determine the uses of AME lumican in re-epithelialization and wound healing process.

The present protocol describes the extraction of lumican from the amniotic membrane (AM) and their storing conditions as AM extract (AME) at -20 &#176;C, 4 &#176;C, and room temperature (RT) for 6, 12, 20, and 32 days to quantify its proteins and lumican concentration.

从羊膜中提取Lumican及其储存温度的测定

Lumican is a small leucine-rich proteoglycan in the human amniotic membrane (AM) that promotes corneal epithelialization and the organization of collagen ...