Intravascular blood parameter measurement system

Abstract: A parameter of blood is sensed in vivo with a system which includes a catheter and a probe. The catheter has a lumen extending therethrough, a proximal end, a distal end and a distal opening at the distal end. The probe includes one or more sensors at its distal end. A saline solution is introduced into the lumen so that there is an interface adjacent the distal opening of the catheter between the blood and saline solution. The probe is received within the catheter and affixed thereto. The interface is moved back and forth in the lumen to expose the sensors to blood so that they can sense the blood parameters of interest.

Description: This invention relates to intravascular blood parameter measurement. It is often necessary or desirable to measure various parameters of blood, such as temperature and blood constituents, such as blood gases, pH, other electrolytes and glucose. This can be accomplished in real time using fluorescent sensors. For example, this can be accomplished in vivo as disclosed in US-Re-31879. For in vivo sensing, a probe or catheter carrying an appropriate sensor is inserted into a blood vessel of the patient. As another example, there is generally disclosed in US-A-4016866 an assembly for the in vivo measurement of a blood parameter comprising a catheter having a lumen extending therethrough, a proximal end, a distal end and a distal opening at the distal end; a sensor for sensing the blood parameter and providing a signal in response thereto; means for mounting the sensor on the catheter with the sensor being within the lumen; and a conduit for coupling the lumen to a source of fluid whereby the fluid can be supplied to the lumen. In accordance with the invention as claimed, the aforesaid generally disclosed assembly is characterized by a compliant element in communication with the conduit for allowing the volume of the assembly to be expanded and contracted; and by means for changing the extent to which the compliant element allows the volume of the assembly to be expanded and contracted. It is quite surprising that a sensor located within a catheter lumen could adequately sense the parameter of interest in blood. One reason for this is that it is necessary to introduce an anti-clotting solution (comprising the fluid of the invention), such as a heparinized saline solution, into the lumen from a solution-introducing system (which includes the conduit of the invention). The solution may be resident in the lumen, i.e., have no net flow into the vessel, but preferably it flows at a very low rate, such as 3 to 8 milliters per hour, through the lumen and out through the distal opening of the catheter into the blood stream in the vessel. It is surprising that a sensor positioned in the lumen where there is an anti-clotting solution, particularly in the path of the distally flowing anti-clotting solution, would be able to adequately sense the parameters of interest in blood. However, this invention recognizes that there is an interface between the blood and the anti-clotting solution. Theoretically, the interface could be a plane that simply divides the blood from the anti-clotting solution. However, in reality, the interface is a zone which has some axial length and which contains a mixture of the blood and anti-clotting solution. Thus, the interface divides a zone of substantially all blood from a zone containing substantially all anti-clotting solution. Because the anti-clotting solution may be supplied to the catheter such that there is a net flow of solution through the distal opening to the vessel, it would be expected that the interface would be entirely outside of, or at the distal end of, the catheter. However, by moving the interface back and forth in the lumen, the sensor can be exposed to blood for at least a portion of time that the interface is moving. This exposure must be sufficient to enable the sensor to provide an accurate signal related to the blood parameter of interest. The movement of the interface back and forth in the lumen may move the interface over the sensor. However, the sensor, in particular a sensor for sensing oxygen, can tolerate some exposure to the mixture of anti-clotting solution and blood in the interface without providing erroneous readings. For example, it has been found that a mixture consisting of 50% blood by volume and 50% anti-clotting solution by volume yields approximately the same oxygen concentration as the oxygen concentration in a medium consisting essentially of blood. DE-A-3 038 883 discloses an assembly having the features of the preamble of present claim 1. The catheter of this prior art assembly is connected to a roller pump. By a subsequent reversal of pumping direction a movement of the interface is obtained. Movement of the interface to bathe the sensor within the lumen in blood is brought by the assembly of the present invention by the provision of a compliant element. The compliant element can be of virtually any construction and may be, or include for example, a compressible fluid, such as air, a membrane, a bellows, etc. In one embodiment of the invention, the compliant element in the form of a compressible fluid provides the solution-introducing system with some compliance thereby allowing expansion and contraction of the volume of the system by which pressures generated by the patient's heartbeat may move the interface. Consequently, blood is forced to enter the distal opening of the catheter as the blood pressure rises with each beat of the heart. Thus, the interface is caused to flow back and forth in the lumen with the pulsating blood pressure. As a result, the sensor within the lumen is bathed by the back and forth or tidal movement of the blood and can adequately sense and measure the blood parameters of interest. The effect of the compliant element may be enhanced by the natural compliance of the tubing and components of the solution-introducing system to provide the desired degree of elasticity. The compliance of the solution-introducing system may be varied to obtain the results desired. For example, if the compliance of the solution-introducing system is to be used to assist in obtaining the tidal action, the solution-introducing system and the catheter may have a combined total compliance sufficient to provide a volume exchange of at least 10 microliters with a system comprised of a 20-gauge catheter and 0.556 mm (.022 inch) diameter probe. It may be necessary or desirable to take the patient's blood pressure through the lumen of the catheter while the blood parameters are being sensed. The added compliance of the solution-introducing system may be sufficient to undesirably alter the blood pressure readings taken through the lumen of the catheter. Accordingly, the present invention provides, as an option, for selectively nullifying the ability of the compliant element to allow expansion and contraction of the volume of the introducing system. For example, the nullifying means may control expansion or adjustably limit movement of a membrane or bellows or it may selectively switch the compliant element into, and out of, communication with the lumen of the catheter. In this latter event, the compliant element would normally be in communication with the lumen to provide, or assist in providing, the desirable tidal action for sensing of the blood parameters of interest. However, just prior to taking a blood pressure reading, the action of the compliant element can be switched out of the introducing system so that it cannot affect the blood pressure reading taken through the lumen of the catheter. The switching means may take any form that will accomplish this function and may be, for example, a valve. In another embodiment of the invention, movement of the interface to bathe the sensor within the lumen in blood is brought about by providing the solution-introducing system with a volume oscillator which may, for example, take the form of a syringe which, in effect, expands and contracts the volume of the solution-introducing system to move the blood back and forth in the lumen without creating a net or average flow in either direction. One of the most important gases that need to be sensed is oxygen. One problem with in vivo oxygen sensing is that the readings obtained for the concentrations of oxygen tend to vary over an unacceptably wide range when compared with the results obtained using conventional laboratory techniques for measuring the concentration of oxygen. It has been found that this deviation is in many cases unacceptably large so that the reliability of the in vivo measuring system is called into question. We have discovered why unacceptable results were often obtained in the in vivo system. Specifically, we have discovered that the oxygen readings are subject to a "wall effect" in that lower concentration readings are obtained when the oxygen sensor is against the wall of the vessel in which it is placed. One possible reason for the "wall effect" is that the concentration of oxygen in the blood may be different at the vessel wall than at a more central location within the vessel, or the low level of oxygen in the adjacent tissue may cause the oxygen concentration in the vessel wall to be low compared to the concentration in the blood. In addition, there is a "clot effect" which reduces the oxygen readings when a clot forms over the oxygen sensor. The clot may also affect other readings, such as by increasing the reading for the concentration of CO 2 and reducing the reading for the pH value. The "wall effect" and the "clot affect" are independent, but they can exist at the same time, as well as separately. Having recognized these two problems, i.e., the "wall effect" and the "clot effect", a preferred embodiment of this invention solves these problems by keeping the sensors, and in particular, the oxygen sensor from contacting the wall of the vessel in which it is placed, which structure is claimed in our European patent application 88300622.3 (EP-A-0276977) from which the present application is divided. This reduces or eliminates the "wall effect" on the oxygen reading. In addition, it reduces the tendency of the blood to form a clot around the sensors. Accordingly, by keeping the sensors out of contact with the wall of the vessel, these two problems are minimized, and acceptable readings are obtainable. To assure that the sensor will not contact the vessel wall, the sensor preferably does not protrude beyond the distal openings of the catheter. It is desirable to have the sensor located proximal to the distal opening of the catheter to provide added insurance against contact with the wall of the vessel. Similarly, the sensor should not be located so far proximal to the distal opening that it cannot adequately sense the parameter of interest. Thus, the sensor should not be so far proximal that it cannot be adequately bathed by the blood. This distance will vary depending on how far the blood is drawn into the lumen. Although the specific distances can vary, for example, placing the sensor between .12 mm (.005 inch) proximal to the distal opening and 3.17 mm (.125 inch) proximal to the distal opening has been found satisfactory. The .12 mm (.005 inch) dimension is usually sufficient to provide for tolerance variations that, if added together, might cause the sensor to protrude from the lumen. The probe may carry one or more sensors depending upon the number of parameters of interest. These sensors can be of any type, such as electrochemical, that is suitable for sensing the parameter of interest; however, optical sensors are preferred, and fluorescent sensors are considered optimum. Although multiple sensors could be provided to sense the same blood parameter, preferably, each sensor senses a different blood parameter. In a preferred construction, the transmission means includes an optical fibre for each of the sensors, with the sensor being located on the distal end of the associated optical fibre. The sensors provide signals related to the associated blood parameters of interest, and such signals may be used or processed continuously, intermittently or on demand to provide readings indicative of the blood parameters of interest. A conventional catheter usable with this invention has a standard lead-in taper, i.e., the cross-sectional area of the lumen reduces toward the distal opening in a zone closely adjacent the distal opening. The presence of the probe in this tapered zone tends to reduce the remaining open area of the lumen to the extent that the monitoring of blood pressure through the lumen is adversely affected. To address this problem, in the case of multiple sensors, the sensors may be positioned at different longitudinal locations along the distal portion of the transmission means. In the specific case of utilizing an optical fibre for each sensor, the optical fibres terminate distally at staggered locations. Consequently, not all of the sensors are located in the tapered zone, and a larger open area of the tapered zone remains for pressure sensing. In order that the invention may be well understood there will now be described some embodiments thereof, given by way of example, reference being made to the accompanying drawings, in which: Fig. 1 is a schematic view of an assembly for the in vivo measurement of blood parameters of interest; Fig. 2 is a perspective view of one form of valve usable in the assembly of Fig. 1; Fig. 3 is an axial sectional view through the valve with the compliant element being in communication with the conduit leading to the lumen of the catheter; Fig. 4 is an elevational view partially in section and similar to Fig. 3 with the compliant element being out of communication with the conduit; Fig. 5 is an enlarged fragmentary sectional view of the distal region of one form of probe and catheter usable in the assembly of Fig. 1; Fig. 6 is an enlarged sectional view taken generally along line 6-6 of Fig. 5; Fig. 7 is a longitudinal sectional view through the probe-catheter assembly; Fig. 8 is a sectional view similar to Fig. 5 showing an alternative construction of the distal region of the probe; and Fig. 9 is a schematic view similar to Fig. 1 showing another assembly for the in vivo measurement of blood parameters of interest. Referring first to Fig. 1, there is shown an assembly 11 for the in vivo measurement of various blood parameters, and particularly the pH value and the concentrations of oxygen and carbon dioxide. Although the assembly 11 can be of different constructions, in this embodiment it includes a solution introducing system 13 and a probe-catheter assembly 15. The assembly 11 may also include an instrument 17 for providing a readout of the blood parameters of interest. Generally, the solution introducing system 13 introduces an appropriate anti-clotting solution, such as a heparinized saline solution, through the probe-catheter assembly 15 to the patient to keep the line leading to the patient patent. Although this can be accomplished in different ways, in the embodiment shown schematically in Fig. 1, the system 13 includes a pressurized source 19 of heparinized saline solution, a conduit 21 leading from the source to the probe-catheter assembly 15, a flow restrictor 23 to reduce the rate of flow through the conduit 21 to the desired drop rate, a flush valve 25 in a bypass 27 around the restrictor 23, a stop cock 28, a four-way valve 29, a blood withdrawal site 30 and a pressure transducer 31. All of the components of the system 13 may be conventional, and the system 13 may include other components, if desired. In the illustrated embodiment, solution from the pressurized source 19 flows through the restrictor 23 at a relatively slow rate, such as 5 ml/hour. The solution flows through the valve 29 and the probe-catheter assembly 15 to the patient. If a more rapid flow rate from the source 19 is desired, as for example during priming, the flush valve 25 can be manually opened to provide a relatively high-rate flow path around the restrictor 23 in a conventional manner. The four-way valve 29 may also be of conventional construction. As shown in Fig. 3, the valve 29 includes a valve body 33 having a passage 35 extending therethrough and forming a portion of the conduit 21, a rotatable valve element 37 in the passage 35 and a handle 39 (Fig. 2) for manually rotating the valve element 37. The valve body 33 has a leg 41, and a closure cap 43 is attached to the leg 41 to define, along with the leg, a chamber 45 in which a compliant element in the form of air is located. The valve element 37 has ports 47 and 49 for communicating with the conduit 21, and a port 51 which can communicate with the chamber 45 as shown in Fig. 3 or which can be sealed and out of communication with the conduit 21 and the chamber 45 as shown in Fig. 4. In this manner, the compliant element can be switched into, or out of, the system 13. The pressure transducer 31 communicates with the conduit 21 and can measure the pressure therein. Accordingly, with the probe-catheter assembly 15 inserted into the vascular system of a patient, the pressure transducer 31 can provide blood pressure readings. By rotating the valve element 37 to the position of Fig. 4, the compliance of the air within the chamber 45 cannot affect the blood pressure readings provided by the transducer 31. The blood withdrawal site 30 is used for taking blood samples from the patient through the probe-catheter assembly 15. Preferably for this kind of compliant element, the stop cock 28 is located between the valve 29 and the site 30 so that, by closing the stop cock 28, the air in the chamber 45 cannot be withdrawn during a blood withdrawal procedure. The probe-catheter assembly 15 includes a catheter 53 and a probe 55 (Fig. 7). The catheter 53 may be a conventional arterial catheter. As such, the catheter 53 may include a proximal end 57, a distal end 59, a lumen 61 extending axially, completely through the catheter and opening at a distal opening 63 at the distal end. The catheter 53 has a standard lead-in taper, i.e., a tapered zone 65, which extends from a reference plane 66 along the outer periphery of the catheter 53 to the distal end 59. The diameter of the lumen 61 also decreases distally throughout the tapered zone 65 as shown in Fig. 5. The tapered zone 65 may extend about 2.277 mm (.090 inch) proximally of the distal end 59. The catheter 53 has an externally threaded coupling 67 at its proximal end. The probe 55 may be of various different constructions, and in the embodiment illustrated, includes an oxygen sensor 69, a carbon dioxide sensor 71 and a pH sensor 73, with each of the sensors affixed to the distal ends of single optical fibers 75, 77, and 79, respectively, (Fig. 6). In this embodiment, the sensors 69, 71 and 73 are fluorescent optical sensors, and they respond to the concentration of oxygen, the concentration of carbon dioxide and the pH value, respectively, to provide continuous optical signals indicative of the condition sensed. The optical fibres 75, 77 and 79 serve as transmission means for transmitting the signals from the associated sensors proximally. The probe 55 is of very small cross-sectional area so that it fits within the lumen 61 with an ample radial clearance 81 as shown in Fig. 5. The particular design of the probe 55 forms no part of this invention because this invention is applicable to probes of various different constructions. Briefly, however, the sensors 69, 71 and 73 are attached to the distal ends of the associated optical fibres 75, 77 and 79 in any suitable manner, and each of the sensors and the associated fibre is separately encased in an inner overcoat 83 which, among other things, may assist in retaining the sensor on the end of the associated fibre. The overcoat 83 is, of course, permeable to the relevant blood parameters so that such parameter, or one related to it, can be sensed by the sensors. An outer overcoat 85 covers the inner overcoats 83 and a length of the fibres just proximally of the overcoats 83. Proximally of the overcoat 85, the optical fibres 75, 77 and 79 and a temperature-sensitive element, such as a thermocouple 86 (Fig. 6), are suitably encased within an appropriate sheath 87. The probe 55 includes a "Y" fitting 93 at its proximal end as shown in Fig. 7. The optical fibres 75, 77 and 79 extend within the sheath 87 completely through one leg 95 of the "Y" fitting 93 to the instrument 17 as shown in Fig. 1. Another leg 97 of the fitting 93 has a passage 99 which communicates with the lumen 61, and more particularly, with the clearance 81 around the probe 55. The leg 97 is coupled to the conduit 21 of the system 13 as shown in Fig. 1. A third leg 101 of the "Y" fitting 93 carries a rotatable internally threaded coupling 103 for attaching the "Y" fitting of the probe 55 to the proximal end of the catheter 53 outside the cardiovascular system of the patient. Although the details of the fitting 93 form no part of this invention, the sheath 87 may be guided in the leg 95 by a sleeve 105 and retained in position by potting 107. The sheath 87 extends within a flexible tube 109 suitably attached to the leg 95, and shrink tubing 111 is provided over the adjacent end portions of the fitting and the tube for strain relief. With the proximal end of the catheter 53 coupled to the probe 55 by the coupling 103, the probe 55 is within the lumen 61, and the sensors 69, 71 and 73 are within the lumen adjacent the distal opening 63 as shown in Fig. 5. Accordingly, with the catheter within the cardiovascular system of the patient, such as in a radial artery, the catheter 53 keeps the sensors from contacting the wall of the artery to thereby reduce or eliminate the wall effect and the clot effect on the signals provided by the sensors. In use of the assembly 11, the catheter 53 is first inserted into the radial artery using conventional techniques. Next, the probe 55 is inserted into the lumen 61 and attached to the proximal end of the catheter 53 with the coupling 103. This properly positions the sensors 69, 71 and 73 within the lumen 61 to within 3.17 mm (.125 inch) of the distal end 59. In priming the solution introducing system 13 prior to insertion of the catheter into the artery, a small quantity of air is trapped in the chamber 45. This can be accomplished, for example, with the valve element 37 in the position of Fig. 4, by filling the conduit 21 with solution from the source 19 with the closure cap 43 removed from the valve 29, and without allowing the solution to flow into the leg 41. The closure cap 43 is then affixed to the leg 41 to trap the air in the chamber 45, and then the rotatable valve element 37 is turned to the position shown in Fig. 3. The conduit 21 can then be connected to the probe 55. When in use, the solution from the source 19 completely fills the lumen 61 around the probe 55. The solution is provided under a pressure such that there is a slow flow of solution from the lumen 61 into the patient's artery. This introduction of the solution through the lumen and into the artery results in an interface 113 adjacent the distal opening 63 which has some axial length and which includes both blood and the solution from the source 19. The interface 113 is a partition between essentially all blood distally of the interface and essentially all anti-clotting solution proximally of the interface. The interface washes axially back and forth in a tidal action as a result of the rising and falling of the patient's blood pressure with each heartbeat. If the solution introducing system 13 were perfectly rigid, it would not be possible for the blood to force the solution proximally within the lumen 61 because the solution is essentially incompressible. However, the conduit 21 is typically in the form of flexible plastic tubing, which has some elasticity or compliance to allow some of this tidal action to occur. In addition, the illustrated embodiment of the invention provides a compliant element in the form of air within the chamber 45 which adds additional elasticity or compliance to the system 13. Consequently, the interface can flow back and forth to bathe the sensors 69, 71 and 73 in blood. With this embodiment of the invention, the back and forth travel of the interface 113 is a function of the magnitude of the patient's blood pressure, the compliance of the solution-introducing system 13 and the delivery pressure of the anti-clotting solution. However, assuming that there is some net flow of the anti-clotting solution out of the distal opening 63, it would be necessary for at least the distal region of the interface 113 to travel distally as far as the distal opening, unless it is possible for some of the solution to migrate through the blood and through the distal opening. Because the flow rate of anti-clotting solution into the bloodstream is extremely low, the precise manner in which the solution enters the patient's bloodstream and the exact extent of travel of the interface 113 is not known. However, utilizing the tidal action of the interface, it is possible to bathe the sensors 69, 71 and 73 in blood sufficiently so that accurate readings are obtained, and it is believed that the sensors are in essentially all blood for a majority of the time. Fig. 8 shows another embodiment of this invention which is identical to the embodiment of Figs. 1-7 in all respects not shown or described herein. Portions of the embodiment of Fig. 8 corresponding to portions of the embodiment of Figs. 1-7 are designated by corresponding reference numerals followed by the letter "a." The primary differences between the embodiment of Fig. 8 and Figs. 1-7 is that the sensors 69a, 71a, and 73a are at different longitudinal positions within the lumen 61a, the sensors 71a and 73a project farther from the overcoat 85a, and there are a plurality of radial apertures 121 in the catheter 53a leading from the lumen 61a adjacent the distal opening 63a of the catheter. In this embodiment, each of the three sensors terminates at a different axial position within the lumen 61a, and with this construction, the total cross-sectional area of the probe 55a reduces in step-wise fashion from the distal end of the sensor 71a proximally. Consequently, not all of the sensors are in the tapered zone 65a, and a larger cross-sectional area of the tapered zone remains open for pressure sensing via the pressure transducer 31 shown in Fig. 1. In the construction of Fig. 8, preferably the carbon dioxide sensor 71a is the most distal sensor, and the oxygen sensor 69a is the most proximal. The reason for this is that carbon dioxide is the most sensitive to being even partially out of the blood, and the oxygen sensor can provide acceptable oxygen readings even in a fifty-fifty mixture of the blood and the anti-clotting solution. The sensitivity of the pH sensor 73a is intermediate the sensitivity of the carbon dioxide sensor 71a and the oxygen sensor 73a and so is preferably located intermediate these sensors. The radial apertures 121 are preferably located proximally of the sensor 73a for the purpose of allowing blood and solution from the lumen 61a to flow out of the apertures. One or more of these apertures may be provided, and in the embodiment of Fig. 8, two of the apertures are shown. Of course, the apertures 121 may be distributed in axially spaced relationship, as well as circumferentially spaced relationship, along the catheter 53a. The apertures 121 may also be used in the embodiment of Figs. 1-7, if desired. Fig. 9 shows another embodiment of this invention which is identical to the embodiment of Figs. 1-7 in all respects not shown or described herein. Portions of the embodiment of Fig. 9 corresponding to portions of the embodiment of Figs. 1-7 are designated by corresponding reference numerals followed by the letter "b." The only difference between the embodiment of Fig. 9 and Figs. 1-7 is that the valve 29 has been replaced with a volume oscillator 131. Although the volume oscillator 131 can take different forms, including that of a conventional syringe, in this embodiment, it is illustrated schematically as including a cylinder 133 in communication with the conduit 21, a piston 135 slidable in the cylinder and a motor 137 for reciprocating the piston 135 through an appropriate reciprocating drive (not shown), such as a cam shaft. When the piston 135 is moved upwardly as viewed in Fig. 9, a chamber 139 below the piston is enlarged to expand the volume of the introducing system 13b. Conversely, when the piston 135 moves downwardly, the volume of the chamber 139 is decreased to thereby contract the volume of the introducing system. Of course, expansion of the introducing system 13b pulls the interface 113 (Fig. 5) proximally. Contraction of the introducing system moves the interface distally, with the amount of such movement being a function of the degree to which the volume oscillator 131 expands and contracts the volume of the introducing system. The motor 137 can be operated continuously, intermittently or upon demand to create the tidal action. There is no net or average flow of fluid in either direction as a result of reciprocation of the piston 135. Of course, the volume oscillator 131 can also be used with the embodiment of Fig. 8.

Claims: An assembly for the in vivo measurement of a blood parameter comprising: a catheter (53) having a lumen (61) extending therethrough, a proximal end (57), a distal end (59) and a distal opening (63) at the distal end; a sensor (69; 71; 73) for sensing the blood parameter and providing a signal in response thereto; means (103) for mounting the sensor on the catheter with the sensor being within the lumen; and a conduit (21) for coupling the lumen to a source of fluid whereby the fluid can be supplied to the lumen; characterized by a compliant element (133) in communication with the conduit (21) for allowing the volume of the assembly to be expanded and contracted; and means (29; 135 ) for changing the extent to which the compliant element (133) allows the volume of the assembly to be expanded and contracted. An assembly as claimed in claim 1, wherein the changing means (29) includes means (29) for selectively switching the compliant element into and out of communication with the conduit (21). An assembly as claimed in claim 1, wherein the switching means (29) includes a valve (29). An assembly as claimed in claim 1, wherein the compliant element (133) comprises a cylinder (133) in communication with the conduit (21) and the changing means (135) comprises a piston (135) slidable in the cylinder (133). An assembly as claimed in claim 4, wherein the changing means (135) includes a motor (137) for moving the piston (135). An assembly as claimed in claim 1, wherein the changing means (29) includes means (29) for selectively nullifying the ability of the compliant element to allow the volume of the assembly to be expanded and contracted. An assembly as claimed in any preceding claim, including means (33, 43) coupled to the conduit (21) and defining a chamber (45) for receiving the compliant element. An assembly as claimed in any of claims 1, 2, 3, 6 and 7, wherein the compliant element includes a gas.

Inventors: MAXWELL THOMAS P, MAXWELL, THOMAS P.
Applicants: MINNESOTA MINING & MFG, MINNESOTA MINING AND MANUFACTURING COMPANY
Application year: 1988
Main classification: A61B5
IPC codes: A61B5