JPH0565198B2 - - Google Patents

Description

Tracheostomy tube according to claim 8, characterized in that it includes dilators 72, 74.

10. The tracheostomy tube of claim 9, wherein the dilator further includes a guiding catheter 35.

11 The dilators 72 and 74 are the guide catheter 3
11. The tracheostomy tube of claim 10, including a first dilator of approximately 10 Fr. inserted before insertion of 5 Fr.

12 The dilators 72 and 74 are the guide catheter 3
12. The tracheostomy tube of claim 11, comprising an additional dilator having a diameter intermediate between the diameter of 5 and the diameter of the final dilator.

13. The tracheostomy tube of claim 12, comprising a first syringe 62 for use with an anesthetic injection needle 64 and an additional syringe for use with an insertion needle 66.

[Detailed description of the invention]

(Industrial Field of Application) The present invention relates to a tracheostomy tube, and more particularly to a tracheostomy tube that is inserted percutaneously into the trachea between two adjacent cartilages to assist in breathing.

BACKGROUND OF THE INVENTION Tracheostomy tubes have been used for some time to provide a bypass supply of air or gas mixtures to patients with throat obstruction. The distal end of the tracheostomy tube is inserted into the trachea through an incision in the patient's neck below the area of occlusion, and the proximal end of the tube is left outside the trachea in communication with the surrounding air, which air enters the trachea. allow entry. The proximal end can also be connected to a breathing machine to assist the patient in breathing. The distal end may include an inflatable cuff to form a seal between the tracheostomy tube and the patient's tracheal wall to further facilitate breathing through the breathing apparatus. For a “standard” tracheostomy, approximately 5
Make a longitudinal incision of cm. The cartilage is cut and possibly a portion removed to create a fairly large opening for insertion of a standard tracheostomy tube. Performing this surgical procedure usually requires an operating room, generally employs anesthesia, and takes 45 to 60 minutes. This surgical procedure also requires transportation to and from the operating room and can sometimes involve infectious complications and cosmetic disfigurement due to the surgical opening.

When installing certain tracheostomy devices, the device may be inserted by a technique known as percutaneous insertion. This technique was introduced by Dr. Seldinger into wire-guided conduit catheterization and other techniques including transtracheal oxygen catheter placement, tube nephrotomy, drainage for collection of abnormal fluids, and antiseptic epidural catheterization. Widely applied.

A recently reported application of the Seldinger technique was reported by Dr. P. Ciaglia et al. in Chest Volume 87:715-719, 1985, “Selective Percutaneous Tracheodilation: A New Simple Bedside Technique.” This is for percutaneous tracheostomy described in a preliminary report titled. This approach is quick, technically simple, and presents significantly fewer technical problems. A summary of the main parts of this approach includes: First, a small (approximately 1 cm) incision is made below the lower end of the cricoid cartilage. In combination with local anesthesia, over-the-needle
Insert a syringe with a cannula into the tracheal lumen through the incision. The syringe is then removed and a soft J-wire guide is inserted and extended downward into the trachea. The cannula is then withdrawn, a catheter guide is inserted, and a series of dilators of increasing diameter are inserted to dilate the ostium. The dilators are removed and a standard tracheostomy tube with one of the dilators used as an internal obturator is then guided into the trachea. The obturator and guide are then removed and the tracheostomy tube is secured to the patient. Catheter introduction needle, J-
The various supplies described in the paper by Dr. Ciaglia, including wire guides, dilators, and a series of six dilators of increasing curvature (12 to 32 French) are included in the "Introduction to Percutaneous Tracheostomy." It is packaged as ``Userset'' and sold by Kutsuku Inc. (Bloomington, Ind.) for percutaneous placement of standard tracheostomy tubes. These supplies are in "peel-away" packs that must be opened and then placed on the surgical tray along with standard supplies and the tracheostomy tube, which are not provided.

An emergency cricothyrotomy system has been described by Richard Melker in U.S. Pat. Insert a 2 mm) ventilation catheter (which does not have an inflatable sealing cuff) into the patient.

Other types of tracheostomy devices and methods are shown in Jacob US Pat. Nos. 3,682,166 and 3,788,326. The small flexible curved catheter described therein is attached to a 14 or 16 gauge needle and inserted percutaneously into the cricothyroid membrane at an angle of approximately 45-60°. The needle is withdrawn and the catheter is secured for transtracheal insufflation. This device and method is entitled "Percutaneous Catheter Insufflation: Clinical Experience in 36 Patients" by Dr. Jacobs et al.
Chest, Volume 65, No. 1, January 1974, 36-40
More details are provided in the paper published on p.

Another device somewhat related to this is shown by Engelscher et al. in U.S. Pat. The skin is inserted. The outer tube is described and illustrated as having a distal end with a beveled end toward the back of the tube. The longer inner tube is inserted telescopically into the outer tube to allow removal of secretions from the bronchial passages.

A recurring problem with all known tracheostomy tubes of the prior art is that the distal end of the cannula tends to hit or become lodged in the tracheal cartilage as the tube is introduced into the trachea. Typical tubes on the market are either rounded at the distal tip, flat with a small annular taper or radius, beveled towards the patient's back, or tapered towards the patient's front. form a beveled edge. For percutaneous insertion, none of these configurations consistently avoids bumping the upper or lower cartilage, or both, as they push the distal end of the tracheostomy tube between adjacent cartilages.

(Problems to be Solved by the Invention) An object of the present invention is to provide a percutaneous tracheostomy tube that can be quickly and smoothly inserted into a patient's trachea.

Other objects of the present invention are that the invention is durable and reliable and can be inserted into stomas of minimal dimensions with minimal injury to the stoma and tracheal wall;
Therefore, it is an object of the present invention to provide a percutaneous tracheostomy tube that does not cause complications due to cosmetic deformity or infection due to percutaneous insertion.

SUMMARY OF THE INVENTION The present invention provides a specifically and novelly devised percutaneous incision tube for percutaneous insertion into a patient's trachea between adjacent cartilages through the neck ostium. Solve the problems of the prior art and meet the purpose. The tracheostomy tube of the present invention is inserted as an assembly with the medial obturator using a guidewire, guiding catheter, and dilator in conjunction with the Seldinger technique. The tracheostomy tube includes a tubular cannula with a central longitudinal axis, a distal portion that is inserted into the trachea, and a proximal end that remains outside the trachea. The cannula is made of a relatively soft, pliable plastic material and has a downwardly curved distal portion for placement within the trachea. The assembly includes a removable, semi-rigid, substantially straight, tubular obturator;
It has an inner diameter adjusted to fit tightly over the guiding catheter, an outer diameter adjusted to fit tightly inside the cannula, and a tapered distal end extending beyond the distal end of the cannula. The obturator is easily inserted between adjacent soft tissue over the guiding catheter. The distal end of the cannula is gently tapered to provide a smooth transition between the cannula and the obturator. The distal part of the cannula is beveled on exactly one side of its distal end, so that the distal most tip of the cannula is narrow, beveled, and tapered, introduced by the obturator approximately midway between the adjacent cartilages. be done. Once the narrow tip of the cannula is inserted intact between the adjacent cartilages, the beveled, tapered distal end of the remainder of the cannula can be easily moved between the cartilages without hindrance to insert the assembly. Preferably, the outer cannula includes an inflatable cuff in its distal portion for forming a seal between the cannula and the tracheal wall. It is highly preferred that the inflatable cuff be of a low profile with the distalmost attachment of the cuff everted onto the cannula to facilitate smooth movement into the patient's trachea. The percutaneous tracheostomy tube and preparation and insertion tools are provided in a convenience kit.

While the novel features of the invention are pointed out in the claims, the invention and other features thereof may be better understood from the following detailed description taken in conjunction with the drawings.

FIG. 1 is a bottom front perspective view of the percutaneous tracheostomy tube of the present invention.

FIG. 2 is a partially enlarged right side elevational view of the distal end of the tracheostomy tube of FIG.

FIG. 3 is a partially enlarged left side elevational view of the distal end of the tracheostomy tube of FIG.

FIG. 4 is a partially enlarged right side elevational view of the distal end of the tracheostomy tube with the obturator inserted.

FIG. 5 is a side elevational view including a cross-sectional view of the tracheal cartilage, showing the initial state in which the distal end of the percutaneous tracheostomy tube of the present invention has been inserted into the patient's trachea through the adjacent cartilage. (the obturator is shown in cross section).

Figure 6 is a side elevation view similar to Figure 5, but
The tube is further inserted and the distal end is rotated downwardly.

FIG. 7 is a top perspective view of the tracheostomy tube kit showing the insertable upper tray disassembled from the lower tray.

Referring first to FIG. 1, there is shown a tracheostomy tube 10 specially designed for percutaneous insertion into a patient's trachea between adjacent cartilages. The percutaneous tracheostomy tube includes a tubular cannula 12 with a distal portion 14 that is inserted into the patient's trachea through an opening formed in the neck, and a proximal end 16 that remains outside the trachea. A typical standard tracheostomy tube is made of semi-rigid polyvinyl chloride (PVC) plastic and shaped into an arcuate shape. The cannula of the present invention is made of relatively flexible soft PVC having a hardness range of about 75 to 100 Shore A hardness, preferably about 80 Shore A hardness. This cannula is arcuate in shape with resilience in the vertical plane and has a central longitudinal axis. The cannula is relatively flexible and elastic, so it easily conforms to the shape of the obturator and adapts its shape when inserted through the stoma during installation and when it comes into contact with the inner wall of the trachea, and any tissue it comes in contact with. It will not cause any significant damage. When the obturator is removed, the canyule returns to its original arcuate shape. Percutaneous tracheostomy tubes are available in a variety of sizes (ie, 6, 7, 8, and 9) to accommodate a range of average patients. For example, size 8 is the inner diameter
8.0mm, external diameter 10.9mm, and length approximately 10cm.

An inflatable cuff 18 (shown in a deflated state) is shown attached to the distal end 14 of the tracheostomy tube, which in the inflated state provides an airtight seal between the tracheostomy tube and the inner wall of the trachea.
Sealing cuffs of this type are described in detail in U.S. Pat. Cuff 18 is inflated by an air syringe (not shown) and pressurizing valve 20. The latter extends from the proximal end 16 and is joined by an inflation tube 22 and a lumen 24 extending from the inflation tube to a location within the cuff of the distal portion 14. Proximal end 16 further includes an integrally molded flexible neck flange 26 which, in combination with an aperture 27 and a suitable strap (not shown),
It is used to pass and secure the tracheostomy tube 10 through the patient's neck. The proximal end 16 further includes:
A standard 15 mm fitting 28 is included that is adapted to easily connect the tracheostomy tube to the breathing system.

2 and 3, distal portion 14 of tracheostomy tube 10 is shown in more detail. Distal portion 14 is considered an important feature of the invention and includes a distal end 30 that is beveled on one side (as opposed to the front or back) relative to the longitudinal axis. The beveled edge is at an angle of about 15-60°, preferably about 45°. The beveled end may be on either the left or right side of the patient, at least for the structural advantage that it allows for percutaneous insertion of the tube. When the tracheostomy tube is subsequently used for breathing, it may be preferable to have the beveled end on the left side (as shown in Figure 1) to facilitate directing air into the left bronchial passageway. . Slanted end 30 has a gentle taper part 3
2, which smoothly connects the inner and outer diameters of cannula 12 at a distance of about 1 cm (at an angle of about 5°).

Referring to FIGS. 4 and 5, a further tubular obturator 34 is shown. The obturator 34 is made of semi-rigid plastic with a Shore D hardness of about 60, has an inner diameter of about 8 French (Fr.), and is adjusted to fit tightly (but still be removable) within the inner diameter of the cannula 12. The obturator is approximately 20 cm long and tapers sharply from its inner diameter to its outer diameter over a section of approximately 2 cm.
A distal portion 36 is provided which forms a smooth transition between the obturator and the guiding catheter 35. The outer diameter of the obturator 34 fits tightly within the distal end 30 of the outer cannula 12, with the tapered portion 32 forming a smooth transition between the obturator 34 and the outer cannula 12, connecting the tracheostomy tube to the adjacent cartilage. For example, it facilitates insertion between 38 and 39. A preferred feature of the obturator is the unique outwardly extending annular flange 37 on the proximal portion. Flange 37 (illustrated as annular, but may have any suitable step or cross-sectional shape) to limit the length that the obturator may be inserted into cannula 12.
It is adjusted to engage the proximal end of the tracheostomy tube (fitting 28). This requires the extended tapered distal end of the obturator 36 and the distal end of the cannula 3 to facilitate insertion of the tube.
This is particularly important to ensure the desired longitudinal alignment with 0. More importantly, flange 37
The sharply tapered, relatively rigid obturator is inserted too far beyond the cannula distal end to prevent possible injury to the patient's posterior tracheal wall. Although the obturator is initially delivered in a substantially straight shape, it can be bent into a desired curved shape as desired or necessary to facilitate insertion into the trachea.

With particular reference to FIGS. 1, 5, and 6, another feature of the present invention, briefly described above as inflatable cuff 18, is illustrated. The inflatable cuff is generally described as a cylindrical elastic membrane material attached to the distal portion of the outer cannula at the most distal annular attachment 40 and the more proximal annular attachment 42. In many tracheostomy tubes, attachments 40 and 42 are made by everting the ends of the tube-like material into the cuff for various manufacturing, functional, and cosmetic purposes. In the case of the present invention, the distal annular attachment 40 presents only a single material thickness and is therefore specially secured in an everted position to form a lower profile cuff, which facilitates insertion of the tube into the trachea. make it easier,
A smoother cuff 18 is obtained. Although the attachment at 42 is preferably everted to reduce the vertical space required by the cuff, this attachment is considered optional.

With particular reference now to Figures 4, 5 and 6,
Operations and procedures for placement of percutaneous tracheostomy tubes of the present invention are described. The operating method is described in a paper by the inventors, namely Dr. Patrick.
B. Hazard et al., “Percutaneous tracheostomy at the bedside: Experience with the procedure in 55 selected cases,” Ann. Thorac. Surg., Vol. 45, 1988.
This is detailed in a report published in May 2016 (an advance copy of which is presented here). A summary of its operation is as follows. First, raise the patient's head in bed approximately 30 degrees and place the patient's head in a hyperextended neck position. Cover the front of the neck with a sterile cloth in the usual manner.
Identify the subcricoid cartilage, and the intertracheal annular space. The tracheostomy site 46 is chosen based on ease of identification and access, but generally the subchondral space of the second trachea is preferred. Appropriately remove the upper skin 1
Anesthetize with ~2 ml of 2% lidocaine solution. Stabilize the cricoid cartilage between the thumb and index finger of the surgeon's left hand and insert a 14-gauge needle (not shown) into the
6 into the tracheal lumen through the midline puncture site. Immediately air is drawn into the syringe and lidocaine solution 3
~4ml is injected into the trachea. The syringe is then removed from the needle and the appropriate guidewire 44, eg, diameter. A 13 cm J-tip guidewire is introduced through the needle and into the tracheal lumen. The needle is then withdrawn leaving the wire in place. A 1 cm midline vertical incision is made at the guide wire entry site 46 using a No. 11 scalpel.
A guide catheter 35 - suitably an 8 Fr. tapered Teflon dilator - is then passed over guide wire 44 into the trachea. Approximately 20 Fr. sharp tapered dilator, such as Obtrator 3
4 into the trachea following the guide catheter,
Expand further into smaller portions. Replace this with a larger dilator (approximately 30Fr.). This corresponds to at least the diameter of the outer cannula of the tracheostomy tube 10. The obturator 34 is then inserted into the tracheostomy tube 10 and its distal end portion 36 is extended a predetermined distance beyond the distal end 30 of the cannula. Once the proper edge is formed,
The larger dilator is removed and the percutaneous tracheal tube 10 and obturator 34 assembly is advanced along the guide catheter 35 into the trachea. In particular, as shown in FIG. 5, the sharply tapered distal portion 36 of the obturator is
It is easily inserted between two adjacent tracheal cartilages 38 and 39. However, as the obturator assembly is advanced, it increases in diameter and essentially becomes a wedge fit as the distal end 30 of the tracheostomy tube enters the intercartilage space. As is clear from FIG. 5, the abrupt transition between the obturator and the tracheostomy tube will certainly damage the cartilage 38 or 39. This has been the previous experience using standard tracheostomy tubes. Dull, rounded, annularly tapered tubes have difficulty passing between the cartilages; tubes with dorsally facing beveled ends also tend to impinge on the lower cartilage; The tube also tends to collide with the upper cartilage, creating resistance to insertion into the trachea. As shown, the beveled distal end of the present invention is narrow, beveled, and tapered with the distalmost tip essentially on one side, approximately midway between adjacent cartilages 38 and 39 by an obturator. , so that the distal end 30 is initially placed comfortably between the cartilages. Once the distal end 30 is placed intact between the cartilages, the tapered, beveled remainder of the distal end easily moves between the cartilages and into the trachea. Further insertion is obturator 34
This is done by rotating the distal end 36 of the distal end 36 downwardly. FIG. 6 further shows that the obturators are preferably given a downward curvature. Similarly, as shown in FIG. 6, the smooth transition to and from the low profile cuff attachment 40 provides a smooth transition and facilitates movement between adjacent cartilages. When the distal end of the inflatable cuff is inserted between the cartilages, the cartilage is further expanded by the rest of the cuff as the cuff is inserted, and since the cartilage was not cut, there are no rough cartilage edges to tear the cuff.
The obturator 34, guide catheter 35 and guide wire 44 are then withdrawn from the tracheostomy tube 10, and the tracheostomy tube is fully inserted into the trachea and secured to the patient's neck by a strap passed through the neck flange 26. canyule 12
The arcuate curvature of the tube (see FIG. 1) elastically returns to the tracheostomy tube, thus placing the tube in position within the trachea. The cuff can then be inflated and the tube connected to the breathing system.

The percutaneous tracheostomy tube of the present invention
Incorporated (Irvin, Calif.) and is conveniently packaged as a percutaneous tracheostomy kit as shown in FIG. The kit includes an upper tray 50 containing patient preparation supplies, which comprises a lower tray 50 containing tracheostomy procedure supplies.
It is housed in the upper part of 2. The trays are stacked and sealed within a suitable peel-off Tyvek lid material (not shown). Peeling off the lid exposes an upper tray 50 with vacuum formed compartments for separating and housing preparation supplies. This includes suitable drapes 54, including a U-shaped neck drape 30" x 30" and a face drape 54.
30″ x 12″; pair of gloves 56, i.e. size 8 latex; pack 5 of saturated antiseptic swabstacks.
8; and appropriate gauze cloth 60 (approximately 5 pieces of 4" x 4"). After preparing the patient,
The upper tray is removed to expose the lower tray 52. The lower tray includes vacuum-formed compartments for separating and housing treatment supplies. Each compartment contains the following: At least one syringe 62 is required and preferably used with an anesthetic needle 64 and an insertion needle 66, or two syringes are provided for each individual injection; a vial of anesthetic agent 68; i.e., one or two 10 c.c. 2% lidocaine solutions; scalpel 70, i.e., No. 11 blade with plastic handle; guide wire 44, shown in a coiled state; first short tubular dilatation; Vessel 7
2, approximately 10 Fr.; guiding catheter 35; a pair of tube-like sharply tapered dilators 74, approximately 20 cm in length, with diameters varying in relation to the size of the tracheostomy tube (i.e. No. 7 tube has a 10 Fr. .
25 Fr. and 30 Fr. dilators in addition to the first dilator 72 and a 17 Fr. guide catheter 35 common to all sizes of tracheostomy kits);
Finally, the kit includes a tracheostomy tube 10 with a neck strap and an obturator 34 (which can also be used as an intermediate dilator if desired).

The novel configuration of the tracheostomy tube 10 and obturator 34 of the present invention makes the entire procedure technically simple and generally requires only a few minutes to perform. 2 superimposed
The novel packaging of the supplies in tray-type disposable kits contributes to the speed and cleanliness of preparation and treatment, thus greatly reducing the probability of complications. The virtual absence of complications due to infection is particularly advantageous. Furthermore, the procedure can be performed at the bedside, without the need to risk transporting the patient outside the intensive care unit. Finally, the cosmetic deformity after extubation is minimal. Additionally, the absence of tracheal rupture and infection associated with percutaneous techniques appears to reduce the risk of subsequent stenosis.

Although the invention has been illustrated and described herein, it will be appreciated that modifications and changes will occur to those skilled in the art. It is therefore intended that the appended claims encompass all such modifications and changes as fall within the true spirit and scope of the invention.

[Brief explanation of the drawing]

FIG. 1 is a front perspective view of a percutaneous tracheostomy tube of the present invention. 2 and 3 are partially enlarged right and left side elevational views, respectively, of the distal end of the tracheostomy tube of FIG. FIG. 4 is a partially enlarged right side elevational view of the distal end of the tracheostomy tube with the obturator inserted. FIG. 5 is a side elevational view including a cross-sectional view of the tracheal cartilage, showing the initial state in which the distal end of the percutaneous tracheostomy tube of the present invention has been inserted into the patient's trachea through the adjacent cartilage. FIG. 6 shows the tube further inserted and the distal end rotated downwardly. FIG. 7 is a top perspective view of the tracheostomy tube kit showing the insertable tray disassembled from the lower tray. In each figure, the numbers mean the following: 10... tracheostomy tube, 12... cannula, 14... distal part of 12, 16... proximal part of 12, 18... inflatable cuff, 20... pressurization valve, 22... inflation tube, 24...
... lumen of 22, 26... neck flange, 27...
...26 openings, 28...fittings, 30...12 distal ends, 32...30 tapered portions, 34...
obturator, 35...guiding catheter,
36...distal part of 34, 37...flange, 3
8, 39... cartilage, 40, 42... attachment of 18, 44... guide wire, 46... entry site, 50... upper tray, 52... lower tray, 54
... Drape, 56 ... Gloves, 58 ... Antiseptic swab stick, 60 ... Gauze cloth, 62 ... Syringe, 64, 66 ... Needle (for injection, insertion), 68
...Anesthetic vial, 70...Small knife, 72,7
4...Extender.

Claims (1)

Claims: 1. Consists of a tubular cannula 12 having a central longitudinal axis, a distal portion 14 for percutaneous insertion into the trachea, and a proximal end 16 that remains extratracheally; material, with the distal portion curved downward for placement within the trachea; adjacent cartilage 3 to assist in breathing.
A tracheostomy tube 10 for use with an obtrator 34 and a guide wire 44 for percutaneous insertion into a patient's trachea through an ostium between 8 and 39; the distal end portion having a smooth transition with the obtrator; is gently tapered 32 to form a bevel, and has a beveled end on one side relative to the longitudinal axis, such that the distalmost tip 30 of this bevel is narrow, beveled, and tapered. attached,
A tracheostomy tube, characterized in that it is introduced approximately centrally between adjacent cartilages, and that the remainder of the obliquely tapered distal end can easily move between the cartilages without hindrance to facilitate insertion of the tube. 2. The tracheostomy tube of claim 1, further comprising a ventilation fitting 28 at the proximal end and an inflatable cuff 18 at the distal end for forming a seal with the tracheal wall. 3. The cannula 12 is made of flexible polyvinyl chloride having a Shore A hardness of approximately 75-100;
A tracheostomy tube according to claim 2. 4. The tracheostomy tube of claim 2, wherein the distal end 30 is beveled to direct air to the left side of the patient's trachea. 5 further comprising an obturator 34 having a tubular shaft adjusted to fit tightly within the tracheostomy tube 10 and having a distal portion 36 inserted into the tracheostomy tube and a proximal portion remaining outside the tracheostomy tube. the distal portion 36 has a sharply tapered distal end extending beyond the distal end 30 of the tracheostomy tube, and the proximal portion is adjusted to engage the proximal end 16 of the tracheostomy tube. Annular flange 3 extending to
Tracheostomy tube according to claim 2, characterized in that it has a tracheostomy tube of 7, thereby limiting the length of the portion by which the distal part of the obturator can extend beyond the distal end of the tracheostomy tube. 6 the most distal attachment 4 with the cuff 18 everted onto the cannula 12 to facilitate insertion;
4. The cuff and cannula have a low profile shape with a smooth transition between the cuff and the cannula.
Tracheostomy tube as described in. 7. Obturator 34 is substantially straight and made of a semi-rigid plastic material;
A tracheostomy tube according to claim 4. 8 Additionally, an upper tray 5 containing patient preparation supplies.
0, the upper tray is assembled to the upper part of the lower tray containing the percutaneous tracheostomy treatment equipment 10, 34, and the upper tray and the lower tray are enclosed in a removable cover,
6. The tracheostomy tube of claim 5 packaged as a kit. 9 The upper tray 50 further includes a drape 54, a surgical glove 56, an antiseptic 58, a gauze cloth 60, and the lower tray 52 further includes the tracheostomy tube 10, the obturator 34, a scalpel 70, a syringe 62, and an injection. needle 64, insertion needle 66, anesthetic solution 68, guidewire 44, and