text:
(Eriksson) Associate Professor, Department of Anesthesiology, Karolinska Hospital.
(Sundman, Nilsson) Resident, Department of Anesthesiology, Karolinska Hospital.
(Olsson, Witt) Assistant Professor, Department of Diagnostic Radiology, Karolinska Hospital.
(Ekberg) Professor, Department of Diagnostic Radiology, Malmo University Hospital.
(Kuylenstierna) Associate Professor and Chair, Department of Oto-Rhino-Laryngology, Karolinska Hospital.
Received from Karolinska Hospital and Institute, Stockholm, and Malmo University Hospital, Malmo, Sweden. Submitted for publication December 16, 1996. Accepted for publication June 12, 1997. Supported by grants from the Swedish Society of Medicine, the Karolinska Institute, and the Swedish Society of Laryngology, Stockholm, Sweden.
Address reprint requests to Dr. Eriksson: Associate Professor of Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Intensive Care, Karolinska Hospital and Institute, S-171 76 Stockholm, Sweden.
Return to normal function of the pharynx and upper airway is essential for airway control in postoperative patients and in patients cared for in the intensive care unit after tracheal extubation or removal of a tracheostomy. In retrospective surveys, impaired ventilation and oxygenation or failed maintenance of the airway, due to residual effects of anesthetic agents or surgery, are the most frequent cause of complications and death in the postoperative period after general anesthesia and sedation. [1,2 ] In one half of patients admitted to an intensive care unit because of postoperative ventilatory failure, Cooper et al. [2 ] identified residual neuromuscular block as the major reason for ventilatory failure. From studies of nonanesthetized persons we also know that subparalyzing priming doses of atracurium and vecuronium interfere with the electromyogram of pharyngeal muscles and may cause dysphagia and oral discomfort. [3,4 ] In partially paralyzed persons, impaired protection of the airway was demonstrated despite adequate recovery of respiratory muscles after subparalyzing doses of d-tubocurarine. [5 ] On the other hand, as supported by studies by Ali et al., [6 ] a mechanical adductor pollicis train-of-four (TOF) ratio of 0.70 has for many years been regarded as being associated with adequately recovered muscle function, to allow safe extubation and spontaneous ventilation in the postoperative period.
Although routine neuromuscular monitoring during surgery and intensive care mainly are based on mechanical adductor pollicis responses after TOF ulnar nerve stimulation, we have only partial knowledge about the relation between recovery of adductor pollicis TOF responses and return of pharyngeal function and protection of the upper airway. Furthermore, we do not know what mechanisms are involved in pharyngeal dysfunction and aspiration in partially paralyzed persons. Extensive examination of the motility pattern of the pharynx and upper esophagus, including evaluation of airway protection and aspiration after barium contrast swallow, can be assessed using a videoradiographic recording under simultaneous solid-state manometry of the pharynx and upper esophagus; that is, after simultaneous videomanometry. [7–10 ] Functional assessment of the pharynx, upper esophagus, and of the integrity of the upper airway has thus been made in various populations of humans with pharyngeal dysfunction, such as those with dysphagia with or without aspiration. We did this study to evaluate pharyngeal function and airway protection at various degrees of residual adductor pollicis neuromuscular block in awake humans.
The study protocol was approved by the local ethics committee for human research of Karolinska Hospital and Institute, Stockholm, Sweden. All volunteers gave their informed oral consent before being enrolled.
Fourteen healthy volunteers (7 men, 7 women) between the ages of 22 and 44 yr entered the study after 4 h of fasting. They denied neuromuscular, liver, or renal disease and were not taking any medication. None of them had undergone surgery of the pharynx, esophagus, or the upper airway and all denied gastroesophageal reflux disease or dysphagia.
After arrival in the laboratory, an intravenous cannula was placed in a cubital vein in the volunteers' arms that were not going to be used for neuromuscular monitoring, and a continuous infusion of normal saline was given at a rate of 1–2 ml [center dot] kg sup -1 [center dot] h sup -1. ECG, peripheral arterial oxygen saturation, and systemic blood pressure (sphygmomanometry) were all monitored. Apart from the neuromuscular blocking agent, none of the volunteers received additional sedatives or other drugs.
With the volunteer in an upright position, a catheter with four solid-state pressure transducers (Konigsberg Instruments, Pasadena, CA) separated 2 cm apart was inserted through one nostril and forwarded so as to place the distal tip in the cervical esophagus. The volunteers were then placed in a right lateral position on a servo-controlled radiography table, with the head of the table elevated 15 [degree sign] from the horizontal axis. Under fluoroscopic control, correct catheter placement was then achieved by placing the most distal sensor within the upper esophageal sphincter muscle (UES) while the tip of the catheter was in the proximal part of the cervical esophagus. In this position, the most proximal sensor was at the level of the tongue base while the two intermediate sensors were positioned at the level of the pharyngeal constrictor muscle. The position of the transducer probe was confirmed and subsequently recorded using videoradiography. Intermittent fluoroscopy was thereafter used to ensure that the catheter position was maintained unchanged throughout the experimental procedure. The lower pharyngeal constrictor sensor and the UES sensor were recording circumferentially, and the two most proximal sensors recorded pressure in a 180 degree angel. The manometric tracings from the four sensors during normal pharyngeal function is presented in Figure 1(A)(normal swallowing) and during partial paralysis in Figure 1(B)(at a TOF ratio of 0.60).
Figure 1. (A) Manometric tracing from the four solid-state sensors representing normal pharyngeal activity during swallowing of bolus contrast medium. The tracing shows pressure changes during contraction at the upper margin of the tongue base (tracing A), the medial and inferior portion of the pharyngeal constrictor muscle (tracings B and C), and resting tone followed by complete relaxation and peristaltic contraction of the upper esophageal sphincter muscle (tracing D). (B) Manometric tracing from the four solid-state sensors (for description, see Figure 1) in a partially paralyzed awake volunteer at an adductor pollicis train-of-four ratio of 0.60. Please note the marked reduction in resting tone of the upper esophageal sphincter muscle (tracing D).
The compliance of each sensor system was low (7 x 10 sup -6 mm3/mmHg), and the sampling frequency was 64 Hz. All four pressure sensors were pressure and temperature calibrated at the actual barometric pressures before each experiment. The pressure signal was digitized (Polygraph Synectics, Stockholm, Sweden) and stored on the hard disk of a computer. The videoradiographic image was mixed with the manometry recording on a color video screen for on-line visual monitoring of the experiment and subsequently was recorded on a VHS video tape.
Volunteers rested in a lateral position with the catheter in place for 15–20 min before the start of recordings. Subsequent control recordings were made in the absence of neuromuscular drugs. The volunteers were given series of five 10-ml iodine contrast boluses separated by approximately 10 s and were ordered to swallow on command (240 mgI/ml Omnipaque; Nycomed A/S, Oslo, Norway). At each of the five swallows, the following manometry and radiography parameters were measured and recorded under simultaneous videoradiography:(1) In the presence or absence of misdirected swallowing (an aspiration episode); that is, if the bolus penetrated into the laryngeal vestibule (laryngeal penetration) or the trachea (tracheal penetration) at one or several of the five swallows. (2) At the pharyngeal constrictor muscle pressure curve; that is, contraction peak amplitude (measured in millimeters of mercury), slope of contraction (mmHg x s sup -1, and duration (in seconds). (3) The UES resting tone (measured in millimeters of mercury); that is, resting pressure before five swallows. From the real-time pressure recording, the following time-related parameters were recorded:(4) Coordination between UES relaxation and pharyngeal constrictor activity; that is, the time (measured in seconds) from the start of UES relaxation until the start of pharyngeal constrictor contraction;(5) bolus transit time (measured in seconds); that is, the time interval between when the bolus head passed the faucial isthmus until passage of the constrictor wave at the UES level. We did not use the tongue base pressure recording for analysis.
All manometric measurements and time-related parameters were calculated as the mean of the series of five consecutive contrast bolus swallows. Besides control recordings, the described experimental sequence was repeated at mechanical adductor pollicis TOF ratios of 0.60, 0.70, 0.80, and after recovery to a TOF ratio > 0.90. Thus a total of 250 ml contrast medium was administered to each volunteer, and the total duration of the experiment was approximately 90 min.
Neuromuscular function was monitored by isometric mechanomyography of the adductor pollicis muscle using a Biometer Myograph 2000 neuromuscular transmission analyzer (Organon Teknika, Turnhout, Belgium).
Vecuronium (5 mg Norcuron [Organon] dissolved in 50 ml normal saline; i.e., 0.1 mg/ml) was administered as a continuous intravenous infusion using a motor syringe (Terumo, Tokyo, Japan). The infusion was given for 20–35 min before a neuromuscular block was established and then adjusted to obtain TOF ratios of 0.60, 0.70, and 0.80, at which time the infusion was stopped and spontaneous recovery to a TOF ratio > 0.90 was anticipated.
The infusion rate was kept constant for 5–10 min before the experiment was started and the vecuronium dose requirement at steady-state neuromuscular block was 23 micro gram [center dot] kg sup -1 [center dot] h sup -1 The TOF values at control and each level of neuromuscular block were calculated as the mean of the five consecutive TOF ratios recorded simultaneously with the five simultaneous barium contrast swallows.
Data are presented as means +/- SD. Pharyngeal function parameters were compared using analysis of variance for multiple measures followed by Fisher's exact test. Probability values < 0.05 were considered significant.
All volunteers participated in the protocol at all levels of partial paralysis. Table 1presents their demographic data and actual TOF ratios and twitch height values at each level of residual paralysis. The duration of vecuronium infusion until a TOF ratio of 0.60 was reached was 23.3 +/- 4.9 min (Table 1).
Volunteers showed misdirected swallowing with episodes of aspiration at TOF ratios of 0.60 (n = 4), 0.70 (n = 3), and 0.80 (n = 1). All episodes showed penetration of the bolus contrast immediately above or to the level of the vocal cords (i.e., laryngeal penetration). In none of the cases did aspiration occur below the vocal cords (tracheal penetration), and none of the volunteers with aspiration coughed or had respiratory discomfort. Aspiration episodes were not detected in any volunteer at a TOF ratio > 0.90 or at any swallow during the control recordings (i.e., during a total of 70 control swallowing sequences). All volunteers had closure of the glottis, as revealed by the change in radiodensity at the level of the vocal folds on the videogram.
The pharyngeal constrictor muscle contraction curve was unchanged during partial paralysis (Figure 2), and there were only minor variations in contraction amplitude, contraction slope, and duration of contraction. In contrast, there was a marked reduction in the UES resting tone at TOF ratios of 0.60, 0.70, and 0.80 (Figure 3). After recovery to an adductor pollicis TOF ratio > 0.90, the UES resting tones were not statistically different from the control recording.
Figure 2. Pharyngeal constrictor muscle function (PHCI) during partial paralysis in 14 awake volunteers. Contraction amplitude (mmHg), duration (ms), and slope (mmHg/s) at vecuronium-induced train-of-four ratios of 0.60, 0.70, 0.80, and after recovery to > 0.90. Data presented as mean +/- SD. There was no significant change in any functional parameter (not significant, analysis of variance).
Figure 3. Upper esophageal sphincter muscle resting tone (mmHg) during partial paralysis in 14 awake volunteers. Mean +/- SD at vecuronium-induced train-of-four ratios of 0.60, 0.70, 0.80, and after recovery to > 0.90. *P < 0.05 (analysis of variance followed by Fischer's exact test).
The coordination between the UES relaxation and initiation of pharyngeal constrictor muscle contraction was impaired with a significantly (P < 0.05) shorter period between the start of relaxation of UES and the start of contraction of the pharyngeal constrictor at a TOF ratio of 0.60 (Figure 4). We also recorded an altered bolus transit time, which was significantly reduced at a TOF ratio of 0.60 (Figure 5).
Figure 4. Coordination (ms) between esophageal sphincter relaxation and pharyngeal constrictor contraction during partial paralysis in 14 awake volunteers. Data presented as mean +/- SD. *P < 0.05 (analysis of variance followed by Fischer's exact test).
Figure 5. Bolus transit time (s) during partial paralysis in 14 awake volunteers. Data presented as mean +/- SD at vecuronium-induced train-of-four ratios of 0.60, 0.70, 0.80, and after recovery to > 0.90. *P < 0.05 (analysis of variance followed by Fischer's exact test).
All volunteers (n = 14) reported diplopia, dysarthria, and subjectively difficult swallowing at TOF ratios of 0.60 and 0.70. However, at a TOF ratio > 0.90, none of them reported swallowing discomfort or residual diplopia.
The main finding of this study was that mechanical TOF ratios of the adductor pollicis muscle of less than 0.90 are associated with pharyngeal dysfunction and reduced resting tonus in the upper esophageal sphincter muscle of awake volunteers. This resulted in impaired airway protection, with laryngeal penetrations occurring at TOF ratios of 0.80 or less.
The protocol focused on five pharyngeal variables and included fluoroscopic detection of laryngeal or tracheal penetration of swallowed bolus contrast medium. We assessed contraction characteristics of the pharyngeal constrictor muscle as an indicator of the initial pharyngeal stage of swallowing, by measuring pressure curves generated at the level of the inferior pharyngeal constrictor muscle. We also recorded the relaxation pattern and resting tone of the UES, responsible for opening the esophageal segment and protection against passive gastroesophageal reflux, regurgitation, and initiating peristaltic activity in the cervical esophagus. We subsequently calculated pharyngeal coordination and transit times, which represent the pharyngeal and esophageal muscle coordination and transport time for the bolus within the pharynx. Finally, an evaluation of the videoradiographic recording was made to evaluate closure of the glottis and to determine whether laryngeal or tracheal penetration occurred, and if so, to what level in the airway the penetrating contrast bolus was aspirated. These variables cover essential aspects of pharyngeal function, as previously described in various patient populations. [8–10,12–14 ] Despite the experimental procedure and the presence of a catheter probe in the pharynx and upper esophagus, aspiration did not occur in any of the volunteers during control recording or at the end of the experiment. Confirming the findings of previous investigators, [8–10,12–14 ] we thus regard the method appropriate to discriminate between normal and abnormal pharyngeal function.
We could not record any significant effect on the pharyngeal constrictor muscle activity; that is, the contraction amplitude, slope, and duration was nearly unchanged at all levels of partial paralysis. Interestingly, the pharyngeal constrictor muscle showed a very different sensitivity to the neuromuscular blocking agent than the upper esophageal sphincter. Although both muscles are classically striated skeletal muscles, this difference might be explained by the individual pattern of activity. The pharyngeal constrictor muscle is contracting only at each swallow while the upper esophageal sphincter has a continuous resting tension of approximately 90 mmHg. [8–10 ] During swallowing, the UES abruptly relax and the resting tension rapidly decreases to almost zero, before activation of the pharyngeal constrictor muscle, thus allowing safe passage of bolus into the esophageal segment. A contraction phase follows this event before the UES return to its resting tone (see Figure 1(A)). The discrepancy in pattern of activity between the two closely located muscles may partly explain the different response to partial neuromuscular paralysis. The continuously contracting upper esophageal sphincter muscle was more sensitive to neuromuscular block than the intermittently active pharyngeal constrictor muscle. We also found a discoordination within the pharynx with impaired function of the UES and shortened bolus transit times. In some persons (n = 9), the bolus penetrated partially into the larynx and passed down to the level of the vocal cords at mechanical adductor pollicis TOF responses below 0.90. None of the volunteers aspirated bolus contrast below the vocal cords as shown with fluoroscopy control. More important, these events occurred in awake, nonsedated volunteers without residual effects of other anesthetic agents or sedatives. Thus, in patients after anesthesia with a residual adductor pollicis TOF ratio < 0.90, the risk of aspiration may be even higher and must still be described.
Furthermore, the markedly reduced resting tone in the UES may constitute a significant risk for passive regurgitation of gastric contents present in the esophagus. However, the relation between misdirected swallowing, reduction in UES resting tone, and the shortened bolus transit time within the pharynx is unclear. The changes in manometric recording may indicate a more profound impairment of pharyngeal function.
To our knowledge, no studies have been performed in which pharyngeal function and simultaneous mechanical adductor pollicis TOF responses were assessed, including recording of esophageal sphincter function under videoradiographic supervision of aspiration events. This is a comprehensive approach and enabled us quantitatively to study the whole swallowing sequence and pharyngeal function in relation to a gradual recovery of the adductor pollicis muscle. As shown in Figure 3, Figure 4, Figure 5, we found a close association between the adductor pollicis recovery and functional recovery of the esophageal sphincter muscle and coordination parameters. We could not, however, demonstrate impaired pharyngeal constrictor muscle activity. Our findings after vecuronium are somewhat different than those reported in a previous study after pancuronium. [4 ] After bolus dosing, the authors found that the pharyngeal peak contraction pressures were decreased, however, using a different method lacking fluoroscopic catheter supervision or other method to maintain the catheter position within the pharynx or esophagus. Those authors [4 ] also found that the swallowing response to water injected into the pharynx was unaltered during pancuronium-induced partial paralysis, indicating intact neuronal control. In our study, with a carefully controlled catheter position, none of our volunteers showed altered pharyngeal constrictor muscle function (amplitude, slope, or duration) while the UES function was markedly reduced and associated with pharyngeal dysfunction, and these data thus were unequivocal in this matter. There may be, however, a different drug sensitivity of pharyngeal muscles between vecuronium ant pancuronium.
The radiologic evaluation revealed aspiration, bolus transport patterns, and movements of anatomic structures within the pharynx. In addition, manometry as used in this study, measures quantitative pressure phenomenons within the pharynx and the gullet, which reflects mechanical aspects of the muscle function. However, from the functional parameters we analyzed, it is still not clear whether the central control of the swallowing pattern is impaired and if initiation of the swallowing process is also disturbed by the residual neuromuscular block. Further, effects on the integration of respiration during swallowing remain to be assessed. Thus the results encourage further studies of pharyngeal function in association with the residual effect of anesthetic agents.
We conclude that vecuronium-induced partial paralysis causes pharyngeal dysfunction and increased risk for aspiration at mechanical adductor pollicis TOF ratios < 0.90. In humans allowed to recover spontaneously, pharyngeal function is not normalized until an adductor pollicis TOF ratio > 0.90 is reached. The upper esophageal sphincter function is more sensitive to vecuronium than the pharyngeal constrictor muscle function.
Lunn JN, Hunter AR, Scott DB: Anaesthesia-related surgical mortality. Anaesthesia 1983; 38:1090-6.
Cooper AI, Leigh JM, Tring IC: Admission to the intensive care unit after complications of anaesthetic technique over ten years. Anaesthesia 1989; 44:953-8.
D'Honneur G, Gall O, Gerard A, Pimaniol JM, Lambert Y, Duvaldestian P: Priming doses of atracurium and vecuronium depress swallowing in humans. Anesthesiology 1992; 77:1070-3.
Isono S, Ide T, Kochi T, Mizuguchi T, Nishino T: Effect of partial paralysis on the swallowing reflex in conscious humans. Anesthesiology 1991; 75:980-4.
Pavlin EG, Holle RH, Schoene RB: Recovery of airway protection compared with ventilation in humans after partial paralysis with curare. Anesthesiology 1989; 70:381-5.
Ali HH, Wilson RS, Savarese JJ, Kitz RJ: The effect of tubocurarine on indirect elicited train-of-four muscle response and respiratory measurements in humans. Br J Anaesth 1975; 47:570-4.
Castell JA, Castell DO: Modern solid state computerized manometry of the pharyngoesophageal segment. Dysphagia 1993; 8:270-5.
Castell JA, Dalton CB, Castell DO: Pharyngeal and upper esophageal sphincter manometry in humans. Am J Physiol 1990; 258:173-8.
Olsson R, Nilsson H, Ekberg O: Simultaneous videoradiography and pharyngeal solid state manometry (videomanometry) in 25 nondysphagic volunteers. Dysphagia 1995; 10:36-41.
Olsson R, Castell JA, Castell DO, Ekberg O: Solid state computerized manometry improves diagnostic yield in pharyngeal dysphagia: Simultaneous videoradiography and manometry in dysphagic patients with normal barium swallows. Abd Imag 1995; 20:230-5.
Eriksson LI, Lennmarken C, Jensen E, Viby Mogensen J: Twitch tension and train-of-four ratio during prolonged neuromuscular monitoring at different peripheral temperatures. Acta Anaesthesiol Scand 1991; 35:247-52.
Dodds WJ, Kahrilas PJ, Dent J, Hogan WJ: Considerations about pharyngeal manometry. Dysphagia 1989; 1:209-14.
McConnel FMS, Guffin TH, Cerenko D: The effect of asymmetric pharyngoesophageal pressures on manofluorographic measurements. Laryngoscope 1991; 101:510-5.
Olsson R, Ekberg O: Videomanometry of the pharynx in dysphagic patients with a posterior cricopharyngeal indentation. Acad Radiol 1995; 2:597-601.
Lars I. Eriksson, Eva Sundman, Rolf Olsson, Lena Nilsson, Hanne Witt, Olle Ekberg, Richard Kuylenstierna; Functional Assessment of the Pharynx at Rest and during Swallowing in Partially Paralyzed Humans : Simultaneous Videomanometry and Mechanomyography of Awake Human Volunteers. Anesthesiology 1997;87(5):1035-1043.

lowercased:
(eriksson) associate professor, department of anesthesiology, karolinska hospital.
(sundman, nilsson) resident, department of anesthesiology, karolinska hospital.
(olsson, witt) assistant professor, department of diagnostic radiology, karolinska hospital.
(ekberg) professor, department of diagnostic radiology, malmo university hospital.
(kuylenstierna) associate professor and chair, department of oto-rhino-laryngology, karolinska hospital.
received from karolinska hospital and institute, stockholm, and malmo university hospital, malmo, sweden. submitted for publication december 16, 1996. accepted for publication june 12, 1997. supported by grants from the swedish society of medicine, the karolinska institute, and the swedish society of laryngology, stockholm, sweden.
address reprint requests to dr. eriksson: associate professor of anesthesiology and critical care medicine, department of anesthesiology and intensive care, karolinska hospital and institute, s-171 76 stockholm, sweden.
return to normal function of the pharynx and upper airway is essential for airway control in postoperative patients and in patients cared for in the intensive care unit after tracheal extubation or removal of a tracheostomy. in retrospective surveys, impaired ventilation and oxygenation or failed maintenance of the airway, due to residual effects of anesthetic agents or surgery, are the most frequent cause of complications and death in the postoperative period after general anesthesia and sedation. [1,2 ] in one half of patients admitted to an intensive care unit because of postoperative ventilatory failure, cooper et al. [2 ] identified residual neuromuscular block as the major reason for ventilatory failure. from studies of nonanesthetized persons we also know that subparalyzing priming doses of atracurium and vecuronium interfere with the electromyogram of pharyngeal muscles and may cause dysphagia and oral discomfort. [3,4 ] in partially paralyzed persons, impaired protection of the airway was demonstrated despite adequate recovery of respiratory muscles after subparalyzing doses of d-tubocurarine. [5 ] on the other hand, as supported by studies by ali et al., [6 ] a mechanical adductor pollicis train-of-four (tof) ratio of 0.70 has for many years been regarded as being associated with adequately recovered muscle function, to allow safe extubation and spontaneous ventilation in the postoperative period.
although routine neuromuscular monitoring during surgery and intensive care mainly are based on mechanical adductor pollicis responses after tof ulnar nerve stimulation, we have only partial knowledge about the relation between recovery of adductor pollicis tof responses and return of pharyngeal function and protection of the upper airway. furthermore, we do not know what mechanisms are involved in pharyngeal dysfunction and aspiration in partially paralyzed persons. extensive examination of the motility pattern of the pharynx and upper esophagus, including evaluation of airway protection and aspiration after barium contrast swallow, can be assessed using a videoradiographic recording under simultaneous solid-state manometry of the pharynx and upper esophagus; that is, after simultaneous videomanometry. [7–10 ] functional assessment of the pharynx, upper esophagus, and of the integrity of the upper airway has thus been made in various populations of humans with pharyngeal dysfunction, such as those with dysphagia with or without aspiration. we did this study to evaluate pharyngeal function and airway protection at various degrees of residual adductor pollicis neuromuscular block in awake humans.
the study protocol was approved by the local ethics committee for human research of karolinska hospital and institute, stockholm, sweden. all volunteers gave their informed oral consent before being enrolled.
fourteen healthy volunteers (7 men, 7 women) between the ages of 22 and 44 yr entered the study after 4 h of fasting. they denied neuromuscular, liver, or renal disease and were not taking any medication. none of them had undergone surgery of the pharynx, esophagus, or the upper airway and all denied gastroesophageal reflux disease or dysphagia.
after arrival in the laboratory, an intravenous cannula was placed in a cubital vein in the volunteers' arms that were not going to be used for neuromuscular monitoring, and a continuous infusion of normal saline was given at a rate of 1–2 ml [center dot] kg sup -1 [center dot] h sup -1. ecg, peripheral arterial oxygen saturation, and systemic blood pressure (sphygmomanometry) were all monitored. apart from the neuromuscular blocking agent, none of the volunteers received additional sedatives or other drugs.
with the volunteer in an upright position, a catheter with four solid-state pressure transducers (konigsberg instruments, pasadena, ca) separated 2 cm apart was inserted through one nostril and forwarded so as to place the distal tip in the cervical esophagus. the volunteers were then placed in a right lateral position on a servo-controlled radiography table, with the head of the table elevated 15 [degree sign] from the horizontal axis. under fluoroscopic control, correct catheter placement was then achieved by placing the most distal sensor within the upper esophageal sphincter muscle (ues) while the tip of the catheter was in the proximal part of the cervical esophagus. in this position, the most proximal sensor was at the level of the tongue base while the two intermediate sensors were positioned at the level of the pharyngeal constrictor muscle. the position of the transducer probe was confirmed and subsequently recorded using videoradiography. intermittent fluoroscopy was thereafter used to ensure that the catheter position was maintained unchanged throughout the experimental procedure. the lower pharyngeal constrictor sensor and the ues sensor were recording circumferentially, and the two most proximal sensors recorded pressure in a 180 degree angel. the manometric tracings from the four sensors during normal pharyngeal function is presented in figure 1(a)(normal swallowing) and during partial paralysis in figure 1(b)(at a tof ratio of 0.60).
figure 1. (a) manometric tracing from the four solid-state sensors representing normal pharyngeal activity during swallowing of bolus contrast medium. the tracing shows pressure changes during contraction at the upper margin of the tongue base (tracing a), the medial and inferior portion of the pharyngeal constrictor muscle (tracings b and c), and resting tone followed by complete relaxation and peristaltic contraction of the upper esophageal sphincter muscle (tracing d). (b) manometric tracing from the four solid-state sensors (for description, see figure 1) in a partially paralyzed awake volunteer at an adductor pollicis train-of-four ratio of 0.60. please note the marked reduction in resting tone of the upper esophageal sphincter muscle (tracing d).
the compliance of each sensor system was low (7 x 10 sup -6 mm3/mmhg), and the sampling frequency was 64 hz. all four pressure sensors were pressure and temperature calibrated at the actual barometric pressures before each experiment. the pressure signal was digitized (polygraph synectics, stockholm, sweden) and stored on the hard disk of a computer. the videoradiographic image was mixed with the manometry recording on a color video screen for on-line visual monitoring of the experiment and subsequently was recorded on a vhs video tape.
volunteers rested in a lateral position with the catheter in place for 15–20 min before the start of recordings. subsequent control recordings were made in the absence of neuromuscular drugs. the volunteers were given series of five 10-ml iodine contrast boluses separated by approximately 10 s and were ordered to swallow on command (240 mgi/ml omnipaque; nycomed a/s, oslo, norway). at each of the five swallows, the following manometry and radiography parameters were measured and recorded under simultaneous videoradiography:(1) in the presence or absence of misdirected swallowing (an aspiration episode); that is, if the bolus penetrated into the laryngeal vestibule (laryngeal penetration) or the trachea (tracheal penetration) at one or several of the five swallows. (2) at the pharyngeal constrictor muscle pressure curve; that is, contraction peak amplitude (measured in millimeters of mercury), slope of contraction (mmhg x s sup -1, and duration (in seconds). (3) the ues resting tone (measured in millimeters of mercury); that is, resting pressure before five swallows. from the real-time pressure recording, the following time-related parameters were recorded:(4) coordination between ues relaxation and pharyngeal constrictor activity; that is, the time (measured in seconds) from the start of ues relaxation until the start of pharyngeal constrictor contraction;(5) bolus transit time (measured in seconds); that is, the time interval between when the bolus head passed the faucial isthmus until passage of the constrictor wave at the ues level. we did not use the tongue base pressure recording for analysis.
all manometric measurements and time-related parameters were calculated as the mean of the series of five consecutive contrast bolus swallows. besides control recordings, the described experimental sequence was repeated at mechanical adductor pollicis tof ratios of 0.60, 0.70, 0.80, and after recovery to a tof ratio > 0.90. thus a total of 250 ml contrast medium was administered to each volunteer, and the total duration of the experiment was approximately 90 min.
neuromuscular function was monitored by isometric mechanomyography of the adductor pollicis muscle using a biometer myograph 2000 neuromuscular transmission analyzer (organon teknika, turnhout, belgium).
vecuronium (5 mg norcuron [organon] dissolved in 50 ml normal saline; i.e., 0.1 mg/ml) was administered as a continuous intravenous infusion using a motor syringe (terumo, tokyo, japan). the infusion was given for 20–35 min before a neuromuscular block was established and then adjusted to obtain tof ratios of 0.60, 0.70, and 0.80, at which time the infusion was stopped and spontaneous recovery to a tof ratio > 0.90 was anticipated.
the infusion rate was kept constant for 5–10 min before the experiment was started and the vecuronium dose requirement at steady-state neuromuscular block was 23 micro gram [center dot] kg sup -1 [center dot] h sup -1 the tof values at control and each level of neuromuscular block were calculated as the mean of the five consecutive tof ratios recorded simultaneously with the five simultaneous barium contrast swallows.
data are presented as means +/- sd. pharyngeal function parameters were compared using analysis of variance for multiple measures followed by fisher's exact test. probability values < 0.05 were considered significant.
all volunteers participated in the protocol at all levels of partial paralysis. table 1presents their demographic data and actual tof ratios and twitch height values at each level of residual paralysis. the duration of vecuronium infusion until a tof ratio of 0.60 was reached was 23.3 +/- 4.9 min (table 1).
volunteers showed misdirected swallowing with episodes of aspiration at tof ratios of 0.60 (n = 4), 0.70 (n = 3), and 0.80 (n = 1). all episodes showed penetration of the bolus contrast immediately above or to the level of the vocal cords (i.e., laryngeal penetration). in none of the cases did aspiration occur below the vocal cords (tracheal penetration), and none of the volunteers with aspiration coughed or had respiratory discomfort. aspiration episodes were not detected in any volunteer at a tof ratio > 0.90 or at any swallow during the control recordings (i.e., during a total of 70 control swallowing sequences). all volunteers had closure of the glottis, as revealed by the change in radiodensity at the level of the vocal folds on the videogram.
the pharyngeal constrictor muscle contraction curve was unchanged during partial paralysis (figure 2), and there were only minor variations in contraction amplitude, contraction slope, and duration of contraction. in contrast, there was a marked reduction in the ues resting tone at tof ratios of 0.60, 0.70, and 0.80 (figure 3). after recovery to an adductor pollicis tof ratio > 0.90, the ues resting tones were not statistically different from the control recording.
figure 2. pharyngeal constrictor muscle function (phci) during partial paralysis in 14 awake volunteers. contraction amplitude (mmhg), duration (ms), and slope (mmhg/s) at vecuronium-induced train-of-four ratios of 0.60, 0.70, 0.80, and after recovery to > 0.90. data presented as mean +/- sd. there was no significant change in any functional parameter (not significant, analysis of variance).
figure 3. upper esophageal sphincter muscle resting tone (mmhg) during partial paralysis in 14 awake volunteers. mean +/- sd at vecuronium-induced train-of-four ratios of 0.60, 0.70, 0.80, and after recovery to > 0.90. *p < 0.05 (analysis of variance followed by fischer's exact test).
the coordination between the ues relaxation and initiation of pharyngeal constrictor muscle contraction was impaired with a significantly (p < 0.05) shorter period between the start of relaxation of ues and the start of contraction of the pharyngeal constrictor at a tof ratio of 0.60 (figure 4). we also recorded an altered bolus transit time, which was significantly reduced at a tof ratio of 0.60 (figure 5).
figure 4. coordination (ms) between esophageal sphincter relaxation and pharyngeal constrictor contraction during partial paralysis in 14 awake volunteers. data presented as mean +/- sd. *p < 0.05 (analysis of variance followed by fischer's exact test).
figure 5. bolus transit time (s) during partial paralysis in 14 awake volunteers. data presented as mean +/- sd at vecuronium-induced train-of-four ratios of 0.60, 0.70, 0.80, and after recovery to > 0.90. *p < 0.05 (analysis of variance followed by fischer's exact test).
all volunteers (n = 14) reported diplopia, dysarthria, and subjectively difficult swallowing at tof ratios of 0.60 and 0.70. however, at a tof ratio > 0.90, none of them reported swallowing discomfort or residual diplopia.
the main finding of this study was that mechanical tof ratios of the adductor pollicis muscle of less than 0.90 are associated with pharyngeal dysfunction and reduced resting tonus in the upper esophageal sphincter muscle of awake volunteers. this resulted in impaired airway protection, with laryngeal penetrations occurring at tof ratios of 0.80 or less.
the protocol focused on five pharyngeal variables and included fluoroscopic detection of laryngeal or tracheal penetration of swallowed bolus contrast medium. we assessed contraction characteristics of the pharyngeal constrictor muscle as an indicator of the initial pharyngeal stage of swallowing, by measuring pressure curves generated at the level of the inferior pharyngeal constrictor muscle. we also recorded the relaxation pattern and resting tone of the ues, responsible for opening the esophageal segment and protection against passive gastroesophageal reflux, regurgitation, and initiating peristaltic activity in the cervical esophagus. we subsequently calculated pharyngeal coordination and transit times, which represent the pharyngeal and esophageal muscle coordination and transport time for the bolus within the pharynx. finally, an evaluation of the videoradiographic recording was made to evaluate closure of the glottis and to determine whether laryngeal or tracheal penetration occurred, and if so, to what level in the airway the penetrating contrast bolus was aspirated. these variables cover essential aspects of pharyngeal function, as previously described in various patient populations. [8–10,12–14 ] despite the experimental procedure and the presence of a catheter probe in the pharynx and upper esophagus, aspiration did not occur in any of the volunteers during control recording or at the end of the experiment. confirming the findings of previous investigators, [8–10,12–14 ] we thus regard the method appropriate to discriminate between normal and abnormal pharyngeal function.
we could not record any significant effect on the pharyngeal constrictor muscle activity; that is, the contraction amplitude, slope, and duration was nearly unchanged at all levels of partial paralysis. interestingly, the pharyngeal constrictor muscle showed a very different sensitivity to the neuromuscular blocking agent than the upper esophageal sphincter. although both muscles are classically striated skeletal muscles, this difference might be explained by the individual pattern of activity. the pharyngeal constrictor muscle is contracting only at each swallow while the upper esophageal sphincter has a continuous resting tension of approximately 90 mmhg. [8–10 ] during swallowing, the ues abruptly relax and the resting tension rapidly decreases to almost zero, before activation of the pharyngeal constrictor muscle, thus allowing safe passage of bolus into the esophageal segment. a contraction phase follows this event before the ues return to its resting tone (see figure 1(a)). the discrepancy in pattern of activity between the two closely located muscles may partly explain the different response to partial neuromuscular paralysis. the continuously contracting upper esophageal sphincter muscle was more sensitive to neuromuscular block than the intermittently active pharyngeal constrictor muscle. we also found a discoordination within the pharynx with impaired function of the ues and shortened bolus transit times. in some persons (n = 9), the bolus penetrated partially into the larynx and passed down to the level of the vocal cords at mechanical adductor pollicis tof responses below 0.90. none of the volunteers aspirated bolus contrast below the vocal cords as shown with fluoroscopy control. more important, these events occurred in awake, nonsedated volunteers without residual effects of other anesthetic agents or sedatives. thus, in patients after anesthesia with a residual adductor pollicis tof ratio < 0.90, the risk of aspiration may be even higher and must still be described.
furthermore, the markedly reduced resting tone in the ues may constitute a significant risk for passive regurgitation of gastric contents present in the esophagus. however, the relation between misdirected swallowing, reduction in ues resting tone, and the shortened bolus transit time within the pharynx is unclear. the changes in manometric recording may indicate a more profound impairment of pharyngeal function.
to our knowledge, no studies have been performed in which pharyngeal function and simultaneous mechanical adductor pollicis tof responses were assessed, including recording of esophageal sphincter function under videoradiographic supervision of aspiration events. this is a comprehensive approach and enabled us quantitatively to study the whole swallowing sequence and pharyngeal function in relation to a gradual recovery of the adductor pollicis muscle. as shown in figure 3, figure 4, figure 5, we found a close association between the adductor pollicis recovery and functional recovery of the esophageal sphincter muscle and coordination parameters. we could not, however, demonstrate impaired pharyngeal constrictor muscle activity. our findings after vecuronium are somewhat different than those reported in a previous study after pancuronium. [4 ] after bolus dosing, the authors found that the pharyngeal peak contraction pressures were decreased, however, using a different method lacking fluoroscopic catheter supervision or other method to maintain the catheter position within the pharynx or esophagus. those authors [4 ] also found that the swallowing response to water injected into the pharynx was unaltered during pancuronium-induced partial paralysis, indicating intact neuronal control. in our study, with a carefully controlled catheter position, none of our volunteers showed altered pharyngeal constrictor muscle function (amplitude, slope, or duration) while the ues function was markedly reduced and associated with pharyngeal dysfunction, and these data thus were unequivocal in this matter. there may be, however, a different drug sensitivity of pharyngeal muscles between vecuronium ant pancuronium.
the radiologic evaluation revealed aspiration, bolus transport patterns, and movements of anatomic structures within the pharynx. in addition, manometry as used in this study, measures quantitative pressure phenomenons within the pharynx and the gullet, which reflects mechanical aspects of the muscle function. however, from the functional parameters we analyzed, it is still not clear whether the central control of the swallowing pattern is impaired and if initiation of the swallowing process is also disturbed by the residual neuromuscular block. further, effects on the integration of respiration during swallowing remain to be assessed. thus the results encourage further studies of pharyngeal function in association with the residual effect of anesthetic agents.
we conclude that vecuronium-induced partial paralysis causes pharyngeal dysfunction and increased risk for aspiration at mechanical adductor pollicis tof ratios < 0.90. in humans allowed to recover spontaneously, pharyngeal function is not normalized until an adductor pollicis tof ratio > 0.90 is reached. the upper esophageal sphincter function is more sensitive to vecuronium than the pharyngeal constrictor muscle function.
lunn jn, hunter ar, scott db: anaesthesia-related surgical mortality. anaesthesia 1983; 38:1090-6.
cooper ai, leigh jm, tring ic: admission to the intensive care unit after complications of anaesthetic technique over ten years. anaesthesia 1989; 44:953-8.
d'honneur g, gall o, gerard a, pimaniol jm, lambert y, duvaldestian p: priming doses of atracurium and vecuronium depress swallowing in humans. anesthesiology 1992; 77:1070-3.
isono s, ide t, kochi t, mizuguchi t, nishino t: effect of partial paralysis on the swallowing reflex in conscious humans. anesthesiology 1991; 75:980-4.
pavlin eg, holle rh, schoene rb: recovery of airway protection compared with ventilation in humans after partial paralysis with curare. anesthesiology 1989; 70:381-5.
ali hh, wilson rs, savarese jj, kitz rj: the effect of tubocurarine on indirect elicited train-of-four muscle response and respiratory measurements in humans. br j anaesth 1975; 47:570-4.
castell ja, castell do: modern solid state computerized manometry of the pharyngoesophageal segment. dysphagia 1993; 8:270-5.
castell ja, dalton cb, castell do: pharyngeal and upper esophageal sphincter manometry in humans. am j physiol 1990; 258:173-8.
olsson r, nilsson h, ekberg o: simultaneous videoradiography and pharyngeal solid state manometry (videomanometry) in 25 nondysphagic volunteers. dysphagia 1995; 10:36-41.
olsson r, castell ja, castell do, ekberg o: solid state computerized manometry improves diagnostic yield in pharyngeal dysphagia: simultaneous videoradiography and manometry in dysphagic patients with normal barium swallows. abd imag 1995; 20:230-5.
eriksson li, lennmarken c, jensen e, viby mogensen j: twitch tension and train-of-four ratio during prolonged neuromuscular monitoring at different peripheral temperatures. acta anaesthesiol scand 1991; 35:247-52.
dodds wj, kahrilas pj, dent j, hogan wj: considerations about pharyngeal manometry. dysphagia 1989; 1:209-14.
mcconnel fms, guffin th, cerenko d: the effect of asymmetric pharyngoesophageal pressures on manofluorographic measurements. laryngoscope 1991; 101:510-5.
olsson r, ekberg o: videomanometry of the pharynx in dysphagic patients with a posterior cricopharyngeal indentation. acad radiol 1995; 2:597-601.
lars i. eriksson, eva sundman, rolf olsson, lena nilsson, hanne witt, olle ekberg, richard kuylenstierna; functional assessment of the pharynx at rest and during swallowing in partially paralyzed humans : simultaneous videomanometry and mechanomyography of awake human volunteers. anesthesiology 1997;87(5):1035-1043.


text:
2013 DODGE JOURNEY BLACK EDITION!
If you need a few extra seats, but still like the finer things in life.... THIS BABY IS FOR YOU!!!
Comes with everything you could ever want including: Custom Black Alloy Wheels, Roof Racks, Full Electrics, Tinted Windows, Heaps of Compartment Space, Factory Rear Booster Seats And So Much More!!
SUPER TIDY INSIDE AND OUT, AS YOU WOULD EXPECT WITH THE K'S AND AGE !!!

lowercased:
2013 dodge journey black edition!
if you need a few extra seats, but still like the finer things in life.... this baby is for you!!!
comes with everything you could ever want including: custom black alloy wheels, roof racks, full electrics, tinted windows, heaps of compartment space, factory rear booster seats and so much more!!
super tidy inside and out, as you would expect with the k's and age !!!


text:
The most valuable home improvement projects will guarantee a 97.5% return on investment, so think wisely before investing in that skylight. Improving your garage door is a project that is worth the money and effort.
1. Wood : A wooden garage door can add character to your home and it is practical. There are so many varieties and types of wood and faux woods that can make your home look well cared for.
2. Carriage house style: Makes your home look warm and inviting with a more old-time look.
3. Aluminium : An aluminium garage door will give your home a modern feel.

lowercased:
the most valuable home improvement projects will guarantee a 97.5% return on investment, so think wisely before investing in that skylight. improving your garage door is a project that is worth the money and effort.
1. wood : a wooden garage door can add character to your home and it is practical. there are so many varieties and types of wood and faux woods that can make your home look well cared for.
2. carriage house style: makes your home look warm and inviting with a more old-time look.
3. aluminium : an aluminium garage door will give your home a modern feel.


text:
Get Expert Service To Recover You Precious Mac Data!
Recovery Technology Service – Data Recovery offers the highest success rate when it comes to recovering data from Apple Mac systems. If you are not able to access your data on a Mac system or you cannot see your hard drive on it, you should get in touch with us for expert Mac data recovery services.
We have a section of our experienced data recovery team dedicated to restoring lost data on Mac systems. We work across all the different models and series of Apple Mac Computers so whether you own a Mac Mini, iBook, MacBook Pro, any other latest model or even the Apply I computer, you are welcome at Recovery Technology Service – Data Recovery.
Choose to call us with your data recovery issues instead of trying to fix it yourself. Improper corrective procedures can cause further damage hence you should leave Mac data recovery to us.
If you hear any abnormal sound from the hard drive of your Mac computer, you should shut it down immediately and call us for free diagnosis. Trying to run the computer in such a condition can render the hard drive completely useless.
You can experience the following issues/errors with your Apple computer and should consult us for expert Macintosh data recovery services immediately.
So call us today for Mac data recovery and get back your lost data in a jiffy.
We will provide you with the best possible assistance. Get FREE Data Recovery Diagnosis for your Mac drive now!

lowercased:
get expert service to recover you precious mac data!
recovery technology service – data recovery offers the highest success rate when it comes to recovering data from apple mac systems. if you are not able to access your data on a mac system or you cannot see your hard drive on it, you should get in touch with us for expert mac data recovery services.
we have a section of our experienced data recovery team dedicated to restoring lost data on mac systems. we work across all the different models and series of apple mac computers so whether you own a mac mini, ibook, macbook pro, any other latest model or even the apply i computer, you are welcome at recovery technology service – data recovery.
choose to call us with your data recovery issues instead of trying to fix it yourself. improper corrective procedures can cause further damage hence you should leave mac data recovery to us.
if you hear any abnormal sound from the hard drive of your mac computer, you should shut it down immediately and call us for free diagnosis. trying to run the computer in such a condition can render the hard drive completely useless.
you can experience the following issues/errors with your apple computer and should consult us for expert macintosh data recovery services immediately.
so call us today for mac data recovery and get back your lost data in a jiffy.
we will provide you with the best possible assistance. get free data recovery diagnosis for your mac drive now!


text:
The 2019 season of the SMITE Console League is fast approaching, which means that it’s almost time for qualifiers to begin! We know all our Xbox and PS4 players are excited to test their mettle on the Battleground and see if they have what it takes to make it to the SCL.
In this short guide, we’ll go over everything you need to know about the qualification process for the SMITE Console League and how you can participate. For more information on the league’s structure, check out our recent blog post detailing the SCL format & schedule.
The qualification phase for this season of the SMITE Console League will run from February 9, 2019 until March 3, 2019. We’ll kick things off with an open bracket that runs for several weeks, then move into a closed bracket with the top teams (by region/platform) from the previous weeks of competition.
Teams will earn points based on their performance each week, and those points will determine their seeding for other weeks of the qualifiers. Returning SCL teams will be soft-seeded in the qualifier bracket if they keep at least 3 of the 5 roster members that they qualified with during the 2018 Fall Split placements.
The top 2 teams from each group qualify into the Console League for their console and their region — for a total of 16 qualified teams across Xbox NA, Xbox EU, PS4 NA, and PS4 EU.
If you want to participate in any week of the open bracket for our Console League qualifiers, you’re welcome to sign up for the tournament in your region on your platform. Here’s a step-by-step guide on everything you need to do to get involved.
If you’re planning to compete in the SCL 2019 qualifiers, the first thing you need to do is join the official SMITEPro community Discord channel. This channel will be used for all communications around the qualifiers — including sign-up reminders and chatting with tournament admins.
Below is a more detailed schedule of which days you can participate in the open bracket for your region.
Once the sign-up link has been posted on the dates and times listed above, your team captain will need to fill it out completely and accurately. After the check-in is completed and submitted, you just have to wait for your tournament admin to post the bracket and rules for your games, then give you further direction on when to start matches.
Once your team is checked in, your tournament administrator will use the Discord channel to communicate with all teams and run the qualifiers. They will post a bracket for your team to see your matchup, then give you the rundown on all tournament rules and instructions on how to play your games.
Can I compete in the Console League qualifiers if I’m not a resident of North America or Europe?
No, only players who are legal residents of the NA or EU regions can participate in the SCL qualifiers.
I have previously participated in the SCL on Xbox or PS4. Can I participate for 2019 on a different platform?
Yes! Because this is a new season of the Console League, all players who have participated in the past are welcome to switch to a different platform than what they’ve played on previously. However, once you qualify on a specific platform you will be locked in on it for the remainder of the season.
Are there any requirements I need to meet in order to compete in the qualifiers?
There are no level requirements for participating in our SCL qualifiers. However, you must have an account that is in good standing and be on a team of at least 5 members to participate.
I missed the check-in time! Can I still play in the tournament?
If you or your team misses the registration period before matches begin, you cannot participate in that week of the SCL qualifiers. But you are still able to sign up for subsequent weeks if you show up on time!

lowercased:
the 2019 season of the smite console league is fast approaching, which means that it’s almost time for qualifiers to begin! we know all our xbox and ps4 players are excited to test their mettle on the battleground and see if they have what it takes to make it to the scl.
in this short guide, we’ll go over everything you need to know about the qualification process for the smite console league and how you can participate. for more information on the league’s structure, check out our recent blog post detailing the scl format & schedule.
the qualification phase for this season of the smite console league will run from february 9, 2019 until march 3, 2019. we’ll kick things off with an open bracket that runs for several weeks, then move into a closed bracket with the top teams (by region/platform) from the previous weeks of competition.
teams will earn points based on their performance each week, and those points will determine their seeding for other weeks of the qualifiers. returning scl teams will be soft-seeded in the qualifier bracket if they keep at least 3 of the 5 roster members that they qualified with during the 2018 fall split placements.
the top 2 teams from each group qualify into the console league for their console and their region — for a total of 16 qualified teams across xbox na, xbox eu, ps4 na, and ps4 eu.
if you want to participate in any week of the open bracket for our console league qualifiers, you’re welcome to sign up for the tournament in your region on your platform. here’s a step-by-step guide on everything you need to do to get involved.
if you’re planning to compete in the scl 2019 qualifiers, the first thing you need to do is join the official smitepro community discord channel. this channel will be used for all communications around the qualifiers — including sign-up reminders and chatting with tournament admins.
below is a more detailed schedule of which days you can participate in the open bracket for your region.
once the sign-up link has been posted on the dates and times listed above, your team captain will need to fill it out completely and accurately. after the check-in is completed and submitted, you just have to wait for your tournament admin to post the bracket and rules for your games, then give you further direction on when to start matches.
once your team is checked in, your tournament administrator will use the discord channel to communicate with all teams and run the qualifiers. they will post a bracket for your team to see your matchup, then give you the rundown on all tournament rules and instructions on how to play your games.
can i compete in the console league qualifiers if i’m not a resident of north america or europe?
no, only players who are legal residents of the na or eu regions can participate in the scl qualifiers.
i have previously participated in the scl on xbox or ps4. can i participate for 2019 on a different platform?
yes! because this is a new season of the console league, all players who have participated in the past are welcome to switch to a different platform than what they’ve played on previously. however, once you qualify on a specific platform you will be locked in on it for the remainder of the season.
are there any requirements i need to meet in order to compete in the qualifiers?
there are no level requirements for participating in our scl qualifiers. however, you must have an account that is in good standing and be on a team of at least 5 members to participate.
i missed the check-in time! can i still play in the tournament?
if you or your team misses the registration period before matches begin, you cannot participate in that week of the scl qualifiers. but you are still able to sign up for subsequent weeks if you show up on time!


text: Losing your vision can be one of the most devastating experiences in your lifetime, but learning how to maximize use of your remaining vision can be one of the most rewarding. Our doctors will spend the time to fully understand your visual goals and set you up with glasses and other optical devices to help you return to doing the things you love. Should we find that you may benefit from a specific device in your home, we will contact one of our associates to bring different devices to you so that you can trial them in the comfort of your own home, as well as receive training specific to that device and how you plan on using it.

lowercased: losing your vision can be one of the most devastating experiences in your lifetime, but learning how to maximize use of your remaining vision can be one of the most rewarding. our doctors will spend the time to fully understand your visual goals and set you up with glasses and other optical devices to help you return to doing the things you love. should we find that you may benefit from a specific device in your home, we will contact one of our associates to bring different devices to you so that you can trial them in the comfort of your own home, as well as receive training specific to that device and how you plan on using it.


text:
HOW DO I PROTECT MY RIGHTS AFTER AN ACCIDENT?
Never admit fault, even if you believe you are at fault. You could have been entirely in the right but if you admitted you were at fault to the other driver, their insurance company can use that against you down the road and it can make collecting compensation more difficult.
Don’t accept cash from the other driver in lieu of filing a police report and an insurance claim because your medical expenses and property damage could ultimately wind up being far more than your deductible.
Don’t let the other driver get away without obtaining their identifying information such as their license plate number, driver’s license number, contact information, insurance information and address. If you let them get away without exchanging identifying information, your chances of filing an insurance claim with their insurance carrier are non-existent.
Be sure to call the police to the scene and have them fill out an accident report. Having an accident report generally ensures that the claims process goes faster.
Never leave the scene of an accident without checking for injuries, calling an ambulance when needed, and exchanging identifying information with the other driver. If you leave the scene of an accident you are essentially breaking the law and face criminal prosecution.
After seeking medical help for any injuries, contact a Hartford car accident attorney from McCoy & McCoy right away. Having a personal injury attorney by your side from the onset is the best insurance you can have. With our help we can ensure that your legal rights are protected and we will fight aggressively to pursue maximum financial compensation from the at-fault driver’s auto insurance carrier or in the case of an uninsured/underinsured motorist claim, we will fight for maximum compensation under your own auto insurance policy.

lowercased:
how do i protect my rights after an accident?
never admit fault, even if you believe you are at fault. you could have been entirely in the right but if you admitted you were at fault to the other driver, their insurance company can use that against you down the road and it can make collecting compensation more difficult.
don’t accept cash from the other driver in lieu of filing a police report and an insurance claim because your medical expenses and property damage could ultimately wind up being far more than your deductible.
don’t let the other driver get away without obtaining their identifying information such as their license plate number, driver’s license number, contact information, insurance information and address. if you let them get away without exchanging identifying information, your chances of filing an insurance claim with their insurance carrier are non-existent.
be sure to call the police to the scene and have them fill out an accident report. having an accident report generally ensures that the claims process goes faster.
never leave the scene of an accident without checking for injuries, calling an ambulance when needed, and exchanging identifying information with the other driver. if you leave the scene of an accident you are essentially breaking the law and face criminal prosecution.
after seeking medical help for any injuries, contact a hartford car accident attorney from mccoy & mccoy right away. having a personal injury attorney by your side from the onset is the best insurance you can have. with our help we can ensure that your legal rights are protected and we will fight aggressively to pursue maximum financial compensation from the at-fault driver’s auto insurance carrier or in the case of an uninsured/underinsured motorist claim, we will fight for maximum compensation under your own auto insurance policy.