Aspiration Of Stomach Contents Research Articles

A comprehensive guide for managing antibiotic therapy in pediatric pneumonia

Pneumonia is a respiratory infection characterized by inflammation of the alveolar space and interstitial tissue of the lungs. Pneumonia has numerous potential etiologies, the most common of which is infectious and is classified according to several factors. Pneumonia is most transmitted via aspiration of airborne pathogens but may also result from the aspiration of stomach contents. The most likely causal pathogens can be narrowed down based on the patient’s age, immune status, and where the infection was acquired. Pathogens that commonly affect the pediatric population often differ from those seen in adults. Typical pneumonia manifests with, fever, sudden onset of malaise, and a productive cough. On auscultation, crackles and bronchial breath sounds are audible. Atypical pneumonia manifests with the gradual onset of unproductive cough, dyspnea, and extrapulmonary manifestations. Diagnosis is based on history and exam. In some cases, supportive information is obtained through lab investigations and imaging reports. Management consists of empiric antibiotic treatment and supportive measures.

Lung injury caused by aspiration of organophosphorus insecticide and gastric contents in pigs

Introduction Patients who require mechanical ventilation after self-poisoning with ingested organophosphorus (OP) insecticides often die. Aspiration of stomach contents may contribute to lung injury and lethality. This study was designed to assess the severity of direct and indirect pulmonary injury created by pulmonary instillation of mixtures of OP insecticide, solvent (Solv) and porcine gastric juice (GJ) compared to controls. Methods Terminally anaesthetised minipigs (groups n = 5) were exposed to sham bronchoscopy or given mixtures (0.5 mL/kg) of: saline, GJ, OP insecticide and GJ (OP + GJ), or Solv and GJ (Solv + GJ), placed into the right lung, and monitored for 48 h. Lung injury was assessed through analysis of bronchoalveolar lavage fluid (BALF), computed tomography and histopathology. Results OP + GJ created a direct lung injury consisting of neutrophil infiltration, oedema and haemorrhage, as well as indirect injury to the other lung. OP + GJ directly-injured lung parenchyma had increased concentrations of BALF protein, albumin, IL-6, IL-8 and C-reactive protein (CRP) at 24 h (p < 0.05), and BALF protein, albumin and CRP at 48 h (p < 0.05), when compared with controls. Aspiration of GJ produced similar direct effects to OP + GJ but less indirect lung injury. Lung injury was less severe after Solv + GJ, for combined lung histopathology scores (vs. OP + GJ, p < 0.05) and for the proportion of directly-injured lung that was poorly/non-aerated at 48 h. Conclusion Pulmonary instillation of OP + GJ created more lung damage than controls or Solv + GJ. In patients with severe OP insecticide poisoning and reduced consciousness, early airway protection is likely to reduce pulmonary damage.

Ketamine versus propofol for rapid sequence induction in trauma patients: a retrospective study

BackgroundRapid Sequence Induction (RSI) is used for emergency tracheal intubation to minimise the risk of pulmonary aspiration of stomach contents. Ketamine and propofol are two commonly used induction agents for RSI in trauma patients. Yet, no consensus exists on the optimal induction agent for RSI in the trauma population. The aim of this study was to compare 30-day mortality in trauma patients after emergency intubation prehospitally or within 30 min after arrival in the trauma centre using either ketamine or propofol for RSI.MethodsIn this investigator-initiated, retrospective study we included adult trauma patients emergently intubated with ketamine or propofol registered in the local trauma registry at Rigshospitalet, a tertiary university hospital that hosts a level-1 trauma centre. The primary outcome was 30-day mortality. Secondary outcomes included hospital and Intensive Care Unit length of stay as well as duration of mechanical ventilation. We analysed outcomes using multivariable logistic regression models adjusting for age, sex, injury severity score, shock (systolic blood pressure < 90 mmHg) and Glasgow Coma Scale score before intubation and present results as odds ratios (ORs) with 95% confidence intervals.ResultsFrom January 1st, 2015 through December 31st, 2019 we identified a total of 548 eligible patients. A total of 228 and 320 patients received ketamine and propofol, respectively. The 30-day mortality for patients receiving ketamine and propofol was 20.2% and 22.8% (P = 0.46), respectively. Adjusted OR for 30-day mortality was 0.98 [0.58–1.66], P = 0.93. We found no significant association between type of induction agent and hospital length of stay, Intensive Care Unit length of stay or duration of mechanical ventilation.ConclusionsIn this study, trauma patients intubated with ketamine did not have a lower 30-day mortality as compared with propofol.

Prospective observational study of the endotracheal intubation complications in Emergency Department

Endotracheal intubation is the gold standard intervention for emergency airway management. Complications related to endotracheal intubation are numerous and frequent. Complications were identified as being related to endotracheal intubation in our study: hypoxia, hypotension, dysrhythmia, cardiac arrest, hypertension, tachycardia, bradycardia, regurgitation and aspiration of stomach contents, endobronchial intubation, and incorrect positioning of the endotracheal tube in either the esophagus or hypopharynx. The study included 186 patients that were over 18 and intubated. The complication rate associated with endotracheal intubation was found to be over 50%. Patients included in our prospective, observational study were all initially evaluated in our ED. A survey was filled out at a time as soon as possible after intubation to record the personnel in charge of intubation, details of the procedure, and hemodynamic changes and complications. Our study found that the following factors were associated with increased rates of complication in intubated patients: history of acute renal failure, history of cancer, GCS &lt; 8, midazolam use during intubation, history of trauma, crash intubation, history of shock, history of cardiac arrest, resident with &lt;1 year of experience carrying out the intubation, residents with 2+ years of experience and specialists carrying out the intubation, history of respiratory failure, and patient age &lt;65. To better understand which patients were likely to be affected by complications associated with intubation, as well as to understand which precautions to take, this study aims to investigate the aggravating factors and complication rates of endotracheal intubation.

A case of fatal multidrug intoxication involving flualprazolam: distribution in body fluids and solid tissues

PurposeDesigner benzodiazepines (DBZDs) increasingly emerged on the novel psychoactive substance (NPS) market in the last few years. They are usually sold as readily available alternatives to prescription benzodiazepines (BZDs) or added to counterfeit medicines. BZDs are generally considered relatively safe drugs due to the low risk of serious acute adverse effects in mono-intoxication, though e.g., alprazolam seems to display an elevated risk of respiratory depression. Here we report on a fatal intoxication involving the novel DBZD flualprazolam.MethodsA complete postmortem examination was performed. General unknown screenings and analysis of drugs of abuse were performed on postmortem samples by immunoassay, gas chromatography–mass spectrometry and liquid chromatography–mass spectrometry. The standard addition method was employed to quantify flualprazolam in postmortem blood and tissues. Finally, a toxicological significance score (TSS) was assigned.ResultsFlualprazolam was detected in heart serum (25.4 ng/mL) and peripheral blood (21.9 ng/mL) as well as in urine, stomach contents, brain, liver and kidney (65.2–323 ng/g). The cause of death was deemed as central nervous system (CNS) and respiratory depression with agonal aspiration of stomach contents, in the setting of a multiple drug intake. Given the concentration levels of the co-consumed CNS depressants, the contribution of flualprazolam to the death was considered likely (TSS of 3).ConclusionsOur results support that highly potent DBZDs like flualprazolam carry an elevated risk for unintended toxicity, especially in association with other CNS depressants. A multidisciplinary evaluation of fatalities remains mandatory, especially when pharmacological/toxicological data on intoxicating compounds are lacking. To our knowledge this is the first report of flualprazolam concentrations in solid tissues in human.

Mortality and morbidity in equine anaesthesia

SummaryEquine peri‐anaesthetic mortality and morbidity are of interest to anaesthetists, practitioners, horse owners and insurance companies. The largest prospective study, ‘The Confidential Enquiry into Perioperative Equine Fatalities’ (CEPEF) was conducted more than 20 years ago. It included over 40,000 horses from multiple centres and reported mortality to be 1.9% that decreased to 0.9% when only elective cases were considered. This is in stark contrast to mortality rates in small animal (dogs: 0.17%, cats: 0.24%) and human anaesthesia (0.04–7/10,000). In spite of developments in understanding the pathophysiology of equine anaesthesia mortality has not decreased in the intervening years. The main contributors to peri‐anaesthetic equine mortality are cardiac arrest, fractures and myopathy or neuropathy. Spinal cord myelopathy and cerebral necrosis are less common. Malignant hyperthermia and hyperkalaemic periodic paralysis are diseases associated with genetic mutations that can be triggered during general anaesthesia and may be fatal if not recognised and treated immediately. Morbidities are reported less frequently, presumably because often they do not cause permanent harm and may resolve within a short period of time. Complications in equine anaesthesia are numerous and include injuries at induction and recovery, damage to the airway associated with orotracheal or nasotracheal intubation, post‐anaesthetic myopathy or neuropathy, regurgitation and aspiration of stomach contents, ocular injuries and complications associated with intravascular cannulation. Hypotension, hypoventilation, hypoxaemia, hypothermia and dysrhythmias may occur both during the maintenance phase of anaesthesia but also in recovery. Airway obstruction during recovery has repeatedly been reported over the years as causing pulmonary oedema, which is often fatal if the airway is not restored extremely quickly. This review summarises the literature on the risk of mortality and morbidity. Information has been gathered from single case reports as well as larger research studies.

Retrospective Observational Study of Organophosphate Poisoning in an Urban Malaysian Hospital

Objectives: The objective of this study is to determine treatment interventions that provided the best outcome for patients. Initial treatment interventions performed in the emergency department such as decontamination, antidote administration and intubation will be analysed. Subsequent management in the intensive care unit with complications related to invasive ventilation will be analysed. The risks of aspiration pneumonia for patients who underwent gastric lavage with or without administration of activated charcoal will also be analysed.Methods: A retrospective observational study was conducted. Study population included all patients presenting to the emergency department of Hospital Tengku Ampuan Rahimah with history of having consumed an organophosphate from the 1st April 2013 to 31st March 2016. The inclusion criteria was all patients with history of ingesting an insecticide containing a suspected organophosphate. The exclusion criteria was patients confirmed not to have ingested an organophosphate from clinical inference and confirmation of actual poison.Results: A total of 84 patients were sampled with 75 patients fulfilling criteria for study inclusion. A total of 22 cases developed complications during their hospital stay with 13 cases of nosocomial infection, 8 cases of aspiration pneumonia, 2 cases with in hospital cardiac arrest and 1 case of atropine toxicity.Malathion and chlorpyrifos were the only two identified organophosphates with the remaining 38 having consumed an unidentified organophosphate. Using chi-square test, there appears to be a significant difference between chlorpyrifos and malathion in terms of need for intubation with a p value of 0.017.Conclusion: Resuscitation of airway, breathing and circulation with close observation for early signs of proximal muscle weakness or paralysis countered with judicious atropine administration is sufficient to ensure good outcome for cases of malathion and chlorpyrifos poisoning which present early to the emergency department.The risk of aspiration pneumonia is high in patients with organophosphate poisoning outweighing the benefits of performing a gastric lavage. Aspiration of stomach contents with a ryle's tube after endotracheal intubation is an acceptable method of gastrointestinal decontamination for patients who have consumed a large quantity of organophosphate.Pralidoxime may be beneficial in reducing the period of respiratory paralysis or weakness for chlorpyrifos poisoning but shows no clear benefit for malathion poisoning. The prolonged muscle paralysis seen in malathion poisoning weighs heavily on intensive care resources. Banning the sale of malathion may help reduce morbidity from prolonged ventilation as well as reduce the burden on intensive care resources.

Repair of late-presenting right Bochdalek hernia in a patient with uncorrected tetralogy of Fallot: Anaesthetic management

Sir, Anaesthesia for patients with isolated tetralogy of Fallot (TOF) or late presenting congenital diaphragmatic hernia (Lp-CDH) can be challenging.[1,2,3] No publications on anaesthetic care of patients with concurrent TOF and Lp-CDH were found on thorough literature search. During pre-anaesthetic evaluation, the patient, a male baby (1-year-old, weighing 7 kg) with TOF was conscious, but irritable and crying, with a regular pulse rate of 150/min, blood pressure (BP) of 90/50 mmHg and peripheral oxygen saturation (SpO2) of 70% on room air. Results of investigations carried out in the pre-operative as well as intra-operative period are shown in Table 1. Table 1 Result of laboratory and imaging studies of the patient On the morning of surgery, prophylaxis against infective endocarditis and scheduled dose of oral propranolol were administered. Premedication was achieved with ketamine 5 mg, glycopyrrolate 70 μg and midazolam 1 mg through the pre-existing 24 G peripheral intravenous (IV) catheter. Mask ventilation and subsequent tracheal intubation were carried out 3 min after administration of ketamine 15 mg, fentanyl 15 μg and vecuronium 1.0 mg IV. End tidal CO2 (ETCO2) was maintained in the range of 27-40 mmHg (tidal volume 60 ml, respiratory rate 22-26/min) with peak airway pressure of 20-24 hPa. A few minutes into the tracheal intubation, his heart rate (HR) increased to 170/min and SpO2 rapidly decreased to 63% and invasive BP (measured at right radial artery) was 100/56 mmHg. At this point of time, ETCO2 was 40 mmHg with normal waveform and auscultation of bilateral lung fields suggested equal ventilation. Isoflurane concentration was increased with not much improvement but subsequent esmolol 3.5 mg IV bolus administration improved SpO2 to 90% and HR settled at 148/min. Anaesthesia was supplemented further with another bolus of fentanyl and regular top up of vecuronium; a nasogastric tube was inserted nasally. Another intra-operative episode of low SpO2 and ETCO2 with tachycardia and normotension did not respond to supplemental dose of fentanyl 15 μg IV. It subsequently responded to RL 70 ml and esmolol 3.5 mg IV bolus administration. The right-sided Bochdalek hernia was repaired through a right subcostal incision and ropivacaine 0.2% (10 ml) was infiltrated in the subcutaneous tissue of the incision site. He was extubated tracheally at the end of surgery. The results of arterial blood gas analysis at different points of time are shown in Table 1. Immediate post-operative period was complicated by another episode of desaturation with tachycardia and normotension that responded to esmolol 3.5 mg and RL 60 ml IV administration. He was discharged in stable condition on the ninth post-operative day, no significant improvement of SpO2 was noted. Peri-operative haemodynamic goals (e.g., maintenance of normovolaemia, avoidance of decrease in systemic vascular resistance and increase in pulmonary vascular resistance) and management of hypercyanotic spell in patients with TOF has been well described.[1,2,3] The first and the last hypercyanotic spell in this case was presumed to be because of increased sympathomimetic activity arising from tracheal intubation and extubation, respectively, leading to right ventricular tract (RVOT) obstruction. As sudden decrease of ETCO2 may be seen in both RVOT obstruction and myocardial depression, we did not increase the concentration of isoflurane during the second hypercyanotic spell. Instead, we administered fluid bolus and supplementary dose of fentanyl. In all the instances, esmolol was used due to persistent tachycardia. Although pre-operative aspiration of stomach contents in patients with Lp-CDH has been recommended, it was not used and we proceeded with gentle mask ventilation, as stomach was intra-abdominal [Figure 1a].[4] Moreover, there was a high chance of precipitating a hypercyanotic spell during its insertion. Use of double lumen endotracheal tube has been suggested, but we proceeded with single lumen endotracheal tube as pre-operative chest X-ray [Figure 1b] showed a comparatively well aerated right lung.[5] Figure 1 (a) Barium upper gastrointestinal tract radiography (1) Stomach at normal intra-abdominal position (red thin arrow), (2) Few segments of small bowel loops are seen in the right hemithorax (green thin arrow), (3) Cardiac shadow (blue thin arrow). (b) Chest ... We hope that description of this unusual clinical situation and our management strategies will help to identify key clinical management issues and serve to compare outcome in patients who may suffer from similar comorbidities. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Pediatric tuberculosis: clinical and epidemiological reflections from a highly endemic setting

Pediatric TB provides unique opportunities to study TB disease epidemiology. Improved diagnostics are of key importance in order to address many of the challenges posed by TB in children. In the Western Cape Province in South Africa, the TB notification rate was more than 600 out of 100,000 for children aged 0-14 years in 2007; the maternal HIV prevalence was 15%, with a good vertical preventative program. The HIV transmission rate was 4-5%; 99% of neonates routinely receive BCG vaccination at birth. Isoniazid prophylaxis, shown to be effective in the prevention of TB in young children, is seldom initiated and many missed opportunities for preventive therapy exist. In children admitted to hospital, mycobacterial culture is routinely done for TB in children less than five years of age through gastric aspiration of stomach contents in this setting; the culture yield is 30-40% in children with clinically suspected TB. In a recent study of infants admitted to the three Cape Town hospitals over a three-year period, 55% of children born to HIV positive mothers had a household contact with TB, indicating a high level of TB exposure. A high risk of serious BCG vaccine complications exists in HIV-positive infants in the form of disseminated BCG disease, with an incidence of 992 per 100 000 (95% CI: 567-1495). More research is needed to determine if BCG vaccination protects against TB in infants born to HIV-infected women based on the high risk in the excessively high TB incidence (more than 20-fold higher) in HIV-infected infants. Because scientists have improved techniques for isolating Mycobacterium tuberculosis in children and increasing the yield, it is possible to identify the strains from infected children, which can impact diagnosis and treatment. Our team has developed a protein-enriched broth that increases yield and decreases the time to detection. Pediatric TB also offers an opportunity to look at the emergence of drug resistant TB strains. In three DST surveys conducted in Cape Town (1997 through 2007) results indicated a significant increase in both drug and multi-drug resistant cases of TB in children. Examination of genotypes in 400 culture positive children showed the most prevalent form to be the Beijing strain, thought to have the greatest probability of progressing from TB infection to disease and with distinct disease forms. Programs to prevent TB and TB/HIV co-infection in children and adults must be improved; and safer vaccines, better diagnostics and shorter treatment regimens developed targeting children.

Part 14: Pediatric Advanced Life Support

In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1 Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2,–,9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see “Sudden Unexplained Deaths,” below). Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15,–,17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9 It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units …

Anaesthesia for Caesarean section and acid aspiration prophylaxis

Anaesthesia for Caesarean section and acid aspiration prophylaxis

To BURP or Not to BURP

Application of cricoid pressure during rapid sequence intubation (RSI) to prevent regurgitation and aspiration of stomach contents was proposed by in 1961. Despite a lack of solid evidence of its efficacy and concern that it sometimes worsens glottic view, the Sellick has become a standard of care. The BURP maneuver (backward, upward, and rightward pressure on the larynx), introduced by Knill in 1993, has …

The use of muscle relaxants for routine induction of anesthesia in Germany

The aim of this study was to evaluate the use of muscle relaxants during induction of anesthesia in patients without risk of aspiration of stomach contents. Of the 2,996 questionnaires sent out, 2,054 (68.6%) could be analysed and the results show that succinylcholine is used regularly in 13.6% of anesthesia departments. The next most commonly used muscle relaxants are atracurium, vecuronium and mivacurium, followed by cis-atracrium, rocuronium and pancuronium. Alcuronium is the least frequently used muscle relaxant. During induction of an elective anesthesia procedure, a priming technique is used by 19% of anesthesiologists, 22% utilize precurarization, and a timing technique is performed in 7.1%. The use of muscle relaxants for on-going relaxation follows the same pattern as for induction of neuromuscular blockade and succinylcholine is used in 1.4% if further relaxation is needed. The desire for specific qualities of muscle relaxants is correlated with higher use of the specific substance: short onset time for rocuronium, good controllability with mivacurium, no side-effects with cisatracurium and economical aspects with alcuronium. Of the participants 76.6% voiced the desire for a non-depolarizing replacement for succinylcholine.Private practices use mivacurium more often than hospitals, level one hospitals use rocuronium and cisatracurium more often. This survey could not show a definite standard of use in terms of muscle relaxants for an elective case.Precurarization, priming and timing are used frequently in patients not at risk of aspiration. This should be reduced by on-going teaching.

Nasogastric Tube Knotting Over the Epiglottis: A Cause of Respiratory Distress

Nasogastric tube placement in the stomach is required for enteral nutrition, for medication in critically ill patients, and for evacuation of stomach content to prevent aspiration pneumonitis. Nasogastric tube placement is associated with mechanical complications such as ulceration and bleeding from the nose, pharynx, esophagus, and stomach (1). Accidental insertion of the nasogastric tube into the tracheopulmonary system during placement is associated with significant morbidity such as pneumothorax, hemothorax, or even death (2–4). We report a case of knotting of the nasogastric tube over the epiglottis leading to life-threatening respiratory distress in a spontaneously breathing postoperative patient having received a living related liver transplant. Case Report A 36-yr-old woman weighing 48 kg diagnosed with hepatitis C virus-related liver cirrhosis with portal hypertension was scheduled to undergo a living related liver transplant. Anesthesia and surgery were uneventful. Total duration of surgery was 18 h. After induction of anesthesia and endotracheal intubation, an 18F nasogastric (NG) tube was placed through the right nostril into the stomach in the first attempt without difficulty. Proper placement of the NG tube was checked by auscultation over the stomach while injecting 10 mL air with a disposable syringe into the NG tube and also by aspiration of stomach contents. Postoperatively the patient was shifted to the surgical intensive care unit for elective ventilation and monitoring. On the second postoperative day the patient was conscious, obeying commands, hemodynamically stable, had good respiratory efforts with satisfactory blood gases, and was thus tracheally extubated. Thereafter, the patient breathed 40% oxygen through a Ventimask. Her arterial blood gases were well maintained and pulse oximeter displayed a saturation of more than 98% throughout the case. Eight hours after extubation, the patient had a sudden bout of coughing after which she complained of choking, respiratory discomfort, tachypnea, dyspnea, and cyanosis. Therefore emergency reintubation was attempted. During laryngoscopy for intubation, the NG tube was observed to be coiling around the epiglottis. On withdrawing the NG tube for relieving the coiling, it formed a knot over the epiglottis. We therefore proceeded with the emergency intubation by directly lifting the epiglottis via the laryngoscope blade and the patient was connected to the ventilator. No part of the NG tube was seen passing through the vocal cords. Subsequently, the knot over the epiglottis was released with the help of the Magill’s forceps. The patient was given 100 mg hydrocortisone for any edema of the epiglottis. She died on the seventh postoperative day of fungal infection, septicemia and renal failure. Discussion Over the last two decades, the narrow bore enteral feeding tube has gained widespread acceptance as compared to the rigid large-bore type. The narrow tube is softer, made from polyvinyl chloride/silastic and generally provides greater patient comfort and fewer complications (such as ulceration and bleeding from the nose, pharynx, larynx, esophagus, and stomach) than the stiffer large-bore tube. Inadvertent placement of the NG tube into the tracheopulmonary system has been reported in 2% of cases (2,5). NG tube placement results in pneumothorax/hemothorax in 0.2%–0.7% of the patients (2,5–7). Mortality associated with NG tube insertion is approximately 0.3%(2–4). Fluoroscopy, laryngoscopy, and endoscopically guided insertion of the NG tube have been advised to circumvent these complications (3,4,7). However, all these techniques increase the cost of the treatment as well as the time taken for insertion and require the availability of a specialist. Chest radiography is recommended before initiation of feeding in all cases after NG tube placement in high-risk unconscious patients or those with tracheotomies. Pushing or pulling of the NG tube after it has been successfully placed into the stomach either by an operator or spontaneously via neck movement or deglutition/coughing may lead to formation of a loop in the pharynx. This loop may encircle the pharyngeal structures like the epiglottis in which case pulling the NG tube will further tighten its grip around the encircled structure. If the NG tube rotates in the pharynx it may form a knot around that particular structure. We report knotting of the NG tube over the epiglottis leading to respiratory distress in a spontaneously breathing patient. Though this is a rare occurrence it is a dangerous one. The possibility of NG tube knotting should be kept in mind with regard to any patients who have an NG tube in place and subsequently develop respiratory distress of sudden onset.

Small patients may have big problems: Complications of pediatric anesthesia

Surveys of mortality associated with anesthesia performed 40 to 50 years ago, reported an increased risk of cardiac arrest and death in children. 1-3 The risk was considered especially great for those younger than 1 year of age, and was even higher for the newborn infant. The most common contributing factors in anesthesia-related death were respiratory: failure to ventilate, aspiration of stomach contents, and drug-induced ventilatory depression. Slightly less common factors involved the cardiovascular system: inadequate volume replacement, myocardial depression, and electrolyte disturbances. In one study that provided specific data, cardiac arrest due to anesthesia occurred during 1 in 719 anesthetics involving infants younger than 1 year, and during 1 in 2,326 anesthetics in children 1 to 12 years old? Of those children who had a cardiac arrest, only 16% made a complete recovery, 16% made a partial recovery, and 68% died. During the years since these studies, many advances have been made, both in our understanding of the physiology and pharmacology of pediatric anesthesia and in the techniques which we apply to anesthetize and monitor infants and children. It might therefore be anticipated that the rate of anesthesia-related cardiac arrest and mortality should have been progressively reduced. Comparisons, however, are difficult; although anesthesia care certainly should have improved, surgical procedures have also become more complex and are attempted in the more acutely ill patient. A retrospective study 4 of 12,712 anesthetics administered to children younger than 12 years of age during the years from 1969 until 1983 documented an incidence of anesthesia-related cardiac arrest of 1 in 2,128 cases. The principal cause in 5 of 6 cases was absolute overdose of halothane, and failure to ventilate was the cause of one arrest. Fully successful rescusitation was achieved in 50% of the patients who had a cardiac arrest. A multicenter prospective study of 40,240 pediatric patients conducted in France s during the years from 1978 to 1982 reports an incidence of anesthesia-related cardiac arrest of 1 in 5,000 for children 1 to 14 years of age and 1 in 526 for infants under 1 year of age. Only 1 child died, producing an overall anesthesia-related mortality rate of 1:40,000. Most of the patients who suffered cardiac arrest were successfully resuscitated. The incidence of major complications was increased in those with higher American Society of Anesthesiologists (ASA) risk classification, multiple coexisting diseases, and emergency surgery. Complications in infants occurred most commonly during maintenance of anesthesia and were usually the result of failure to maintain ventilation. Complications in children were equally divided between induction, maintenance, and recovery stages, and circulatory failure was associated as frequently as ventilatory failure. The anesthesia-related factors responsible for complications were airway mismanagement, intubation complications, aspiration, postoperative respiratory depression, halothane overdose, acute volume overload, and anaphylaxis af ter drugs (A1thesin, succinylchotine). A retrospective study of the years from 1983

Le contentieux en rapport avec l'anesthésie à l'Assistance publique — Hôpitaux de Paris

To evaluate the number and the reason of anaesthesia-related malpractice claims in university hospitals of Paris. Retrospective study. From December 1977 to December 1994, 1,185 claims, originating from all departments, dental trauma excluded, were reviewed and classified by one medical expert. They were analyzed with regard to type of activity responsible for the damage. Out of the 789 claims resulting from surgical activity, 41 were directly anaesthesia-related. The most frequent problems were the neurological complications of spinal or epidural anaesthesia (n = 10), and the consequences of difficult intubation or aspiration of stomach contents (n = 5). A series of 19 damages due to posture was difficult to classify as surgery- or anaesthesia-related. In the 41 anaesthesia-related claims, an indemnification was alloted to seven (5.2%). This rate was similar to that for surgical activity-related claims. However, the amount of the anaesthesia-related malpractice compensations was equivalent to 26% of those alloted to the surgery-related claims and to two-thirds of the indemnifications equal to or above 2,000,000 FF. There are few anaesthesia-related claims in the Paris university hospitals. Only few claims result in a compensation. By contrast, when a indemnification is alloted, its amount is very high. Locoregional anaesthesia seems to be at a higher risk for malpractice claims.

The Aspiration of Stomach Contents into The Lungs During Obstetric Anesthesia

The Aspiration of Stomach Contents into The Lungs During Obstetric Anesthesia

Pyloric stenosis in full term babies. A postal survey of the management by paediatric anaesthetists

SummaryWe report the results of a postal survey of the management of full term babies with pyloric stenosis by specialist paediatric anaesthetists. The conclusions from the survey are that the most likely anaesthetic techniques used are: rehydration and at least partial correction of electrolyte and acid‐base abnormalities before surgery; aspiration of stomach contents before induction of anaesthesia; a rapid sequence induction; extubation of the trachea with the baby awake and on its side; and infiltration of the wound at the end of surgery with local anaesthetic.

The laryngeal mask airway

The laryngeal mask airway (LMA) is a new concept in airway management. A miniature inflatable mask is positioned in the hypopharynx, forming a low-pressure seal around the laryngeal inlet. The mask is attached via a tube to the breathing circuit. It is inserted after induction of anesthesia without the need for muscle relaxants or laryngoscopy. The LMA can be used to facilitate both spontaneous and controlled ventilation in adults and children. The LMA has been used for a wide variety, of surgical procedures but is probably best suited to short procedures, especially if a light general anesthetic is used in combination with a regional technique. It may be particularly useful in outpatient anesthesia, as it avoids the need for intubation or muscle relaxants. It can be used as an alternative to mask anesthesia or when (in endotracheal tube would have been inserted to allow surgical access. It has been used successfully in cases of difficult or failed intubation, although its role here needs further appraisal. It does not protect against aspiration of stomach contents and should not be used when aspiration is a risk. Controversy exists regarding its use to facilitate positive-pressure ventilation (PPV) due to concern that gases under pressure may be forced into the stomach and predispose the patient to regurgitation. It may be more difficult to use in children. It is now widely used in the United Kingdom; however, it is not yet available for sale in the U.S. It has already had a major effect on practice in Britain and has the potential to do the same in the United States.

Immobilisation of southern elephant seals and leopard seals with cyclohexamine anaesthetics and xylazine

Ketamine and xylazine were given to 55 southern elephant seals (Mirounga leonina) for stomach lavaging, and to three leopard seals (Hydrurga leptonyx). The elephant seals showed prolonged apnoea and two of them died owing to aspiration of stomach contents. Two of the leopard seals died from unknown causes. Tiletamine and zolazepam were given to five elephant seals and one leopard seal. Two of the elephant seals and the leopard seal died from unknown causes. Xylazine alone was administered to 34 leopard seals. Sedation was poor at low dose rates (less than 1.7 mg/kg) but four of the seals given higher dose rates died owing to the aspiration of stomach contents.