Cricoid Pressure Research Articles

A novel cricoid pressure sensor device enhances the efficacy of oesophageal occlusion during Sellick's manoeuvre: A randomised controlled trial.

The inability to measure the force applied during cricoid pressure is an important limitation in clinical practice. We developed a novel device to measure this force and provide real-time feedback to the operator. To test the hypothesis of superior oesophageal occlusion during cricoid pressure when guided by the novel device as compared with conventional practice. A prospective randomised controlled trial. Tertiary University Hospital, May to December 2021. Sixty-five ASA I/II adult patients of either sex scheduled for elective surgery under general anaesthesia requiring tracheal intubation. Patients with comorbidities involving the neck, those at risk of pulmonary aspiration, anticipated difficult airway and BMI at least 35 kg m-2 were excluded. Operators applied cricoid pressure with their fingers in both groups. Participants were randomised into 'feedback group' where the operator adjusted this force based on the force measured by the novel device, and 'control group' where the force measured by the device was shielded from the operator. The primary outcome was the rate of occlusion of oesophageal opening assessed by whether a 12 CH orogastric tube could be inserted into the oesophageal entrance during videolaryngoscopy. Secondary outcomes included the magnitudes of force measured during cricoid pressure, oesophageal diameter measured ultrasonographically during cricoid pressure and intubation parameters. Sixty-four patients completed the study. The oesophageal opening was occluded in significantly more patients in the feedback group compared with the control group (94 vs. 6%; P = 0.001). The mean ± SD force (N) applied was significantly better and consistent at all time points in the feedback group compared to the control group (22.65 ± 7.81 vs. 14.57 ± 11.13, P < 0.001). The median [IQR] anteroposterior diameter of the oesophagus during cricoid pressure was less in the feedback group compared to the control group (0.49 [0.36 to 0.56] vs. 0.57 [0.48 to 0.65], P = 0.006). The use of the novel sensor device achieved a significantly high rate of oesophageal occlusion during application of cricoid pressure. Clinical Trial Registry of India (CTRI/2021/05/033484).

Sekwencja szybkiej intubacji. Aktualny stan wiedzy

Rapid sequence intubation is a widely practiced method for handling the airway during anaesthesia induction in patients with gastric problems or those susceptible to regurgitation or aspiration. Preparation involves gathering essential equipment and medications for emergency intubation, including oxygen, suction, bag-valve mask, laryngoscope, endotracheal tubes with stylets, resuscitation gear, and rescue tools. Despite its consistent use for over five decades, debates persist regarding the efficacy of specific elements of the method, such as cricoid pressure and the assessment of fasting in urgent surgical cases. The absence of standardised rapid sequence intubation techniques and universally accepted guidelines has resulted in discrepancies in published data. Cricoid pressure, also known as the Sellick manoeuvre, is a controversial element of rapid sequence intubation that has both supporters and critics. While it has been used for decades and is recommended by many countries to prevent pulmonary aspiration during anaesthesia, recent research has raised questions about its effectiveness. In patients undergoing emergency surgery, ultrasound of the gastric antrum may help evaluate the size of gastric contents in order to minimise the risk of aspiration pneumonia. Techniques and variants of anaesthetic induction in the rapid sequence intubation algorithm should be adapted to a wide range of clinical groups – particularly in children, obese patients and pregnant women. In paediatric anaesthesia and for obese patients, the traditional rapid sequence intubation with apnoea is not commonly used due to their limited respiratory reserve. Despite its numerous side effects, succinylcholine remains the most frequently employed drug for rapid sequence intubation.

Point of care ultrasound (POCUS) during Sellick's maneuver of rapid sequence intubation

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Efficacy of Cricoid Pressure Application during Esophagogastroduodenoscopy in Patients with Poor Gastric Wall Extension

Introduction: Esophagogastroduodenoscopy (EGD) requires adequate air infusion. However, cases of poor gastrointestinal wall extension due to frequent eructation have been reported. Sufficient gastrointestinal wall extension can be achieved by applying cricoid pressure during EGD. Herein, we evaluated the frequency of cases with poor gastrointestinal wall extension and the efficacy and safety of applying cricoid pressure during EGD. Methods: This interventional study included patients who underwent EGD between January 2020 and December 2020 at the JA Akita Koseiren Yuri Kumiai General Hospital. Cases wherein folds of the greater curvature of the upper gastric body were not sufficiently extended during EGD were considered to have poor gastrointestinal wall extension. In such cases, air infusion was performed while applying cricoid pressure. This procedure was considered effective when gastric wall extension was achieved. Results: A total of 2,000 patients were enrolled and underwent upper gastrointestinal endoscopy; however, five were excluded because of upper gastrointestinal tract stenosis. Observation of gastric wall extension of the greater curvature in the upper gastric body with normal air insufflation was difficult in 113 (5.7%) cases. Applying cricoid pressure was effective in 93 (82.3%) patients with poor gastric wall extension. Sufficient gastric wall extension was achieved within an average of 12.8 s in cases where cricoid pressure application was effective. No adverse events were associated with cricoid pressure application. Conclusions: Cricoid pressure application for patients with poor gastric wall extension during EGD is useful for ensuring a sufficient field of view during observation of the gastric body.

Non-inferiority randomized controlled trial comparing CricOid pressure and para-laryngeal pressure in parturients undergoing cesarean delivery: NiCOP trial

BackgroundCricoid pressure has been surrounded with controversies regarding its effectiveness. Application of ultrasound-guided para-laryngeal (PL) force has been shown to occlude the esophagus effectively compared with cricoid pressure (CP) in awake patients. We hypothesized that there would be no meaningful difference in the change in antero-posterior esophageal diameter from with application of cricoid or para-laryngeal pressure in parturients undergoing cesarean delivery under general anesthesia. MethodsIn this prospective, randomized, non-inferiority trial, 40 parturients scheduled for elective cesarean delivery under general anesthesia were randomized to receive rapid sequence induction with either cricoid pressure (n = 20) or para-laryngeal pressure (n = 20). The antero-posterior diameter of the esophagus, measured by sonography, was the primary outcome. Visualization of the esophagus, its position in relation to the glottic aperture, esophageal occlusion, percentage of glottic opening (POGO), time to intubation, first pass success rate, overall success rate and adverse events like desaturation or bronchospasm were secondary outcomes. ResultsThe mean change in anterior-posterior diameter in the CP group was 0.17 ±0.1 cm vs. 0.28 ±0.1 cm in the PL group. The mean difference (CP-para-laryngeal pressure) between the groups was -0.11 (95% CI −0.17 to −0.1) cm. As the upper limit of the 95% CI was lower than the prespecified non-inferiority margin (δ = −0.2), non-inferiority was established (P <0.001]. There was no significant difference in the POGO score (P = 0.818), time to intubation (P =0.55), or intubation attempts (P = 0.99). ConclusionsPara-laryngeal pressure was non-inferior to CP in occluding the esophagus in parturients undergoing cesarean delivery under general anesthesia and furthermore, no significant deterioration in intubation parameters was seen.

Comparison of the effects of paratracheal pressure and cricoid pressure on placement of the i-gel® supraglottic airway: a randomized clinical trial

PurposeAnesthesiologists can use supraglottic airway devices as a rescue technique for failed intubation even in patients with an increased risk of gastric regurgitation. In this randomized study, we aimed to evaluate the effects of cricoid pressure and paratracheal pressure on placement of the i-gel® (Intersurgical Ltd., Wokingham, Berkshire, UK).MethodsAfter induction of anesthesia in 76 adult patients, we inserted the i-gel under paratracheal or cricoid pressure, and assessed the success rate of i-gel insertion, resistance during insertion, time required for insertion, accuracy of the insertion location, tidal volumes, and peak inspiratory pressure with or without each maneuver after i-gel insertion.ResultsThe overall success rate of insertion was significantly higher under paratracheal pressure than under cricoid pressure (36/38 [95%] vs 27/38 [71%], respectively; difference, 24%; 95% confidence interval [CI], 8 to 40; P = 0.006]. Resistance during insertion was significantly lower under paratracheal pressure than under cricoid pressure (P < 0.001). The time required for insertion was significantly shorter under paratracheal pressure than under cricoid pressure (median [interquartile range], 18 [15–23] sec vs 28 [22–38] sec, respectively; difference in medians, −10; 95% CI, −18 to −4; P < 0.001). Fibreoptic examination of the anatomical alignment of the i-gel in the larynx revealed no significant difference in the accuracy of the insertion location between the two maneuvers (P = 0.31). The differences in tidal volume and peak inspiratory pressure with or without the maneuvers were significantly lower with paratracheal pressure than with cricoid pressure (P = 0.003, respectively).ConclusionsInsertion of the i-gel supraglottic airway was significantly more successful, easier, and faster while applying paratracheal pressure than cricoid pressure.Study registrationClinicalTrials.gov (NCT05377346); first submitted 11 May 2022.

General anesthesia for maternal surgery during pregnancy: dogmas, myths and evidence, a narrative review

Up to 1% of pregnant women require general anesthesia and maternal non-obstetric surgery during pregnancy, of which urgent abdominal procedures are most commonly indicated. This narrative review summarizes several dogmas and myths on the management of general anesthesia during pregnancy and the corresponding evidence. While historical studies found delayed gastric emptying during pregnancy, recent evidence concluded that gastric emptying remains nearly normal during the entire pregnancy until the onset of labor. To correctly estimate the aspiration risk, gastric ultrasound should be increasingly performed. Based on the available evidence, the application of cricoid pressure should be discouraged during rapid sequence induction of pregnant women. A cuffed endotracheal tube is traditionally recommended, but laryngeal masks have been used in &gt; 9000 patients undergoing cesarean section without observation of aspiration. All material to manage a difficult airway should be available as difficult intubation remains an ongoing concern in obstetrics. Risk factors for difficult intubation are nonobstetric in nature. Due to the lack of evidence for hemodynamic management, it is not possible to make an evidence-based recommendation. We recommend to adhere to the expert opinion of maintaining maternal blood pressure close to the normal physiologic value by using (15°-)30° left lateral tilt position, intravenous fluids and noradrenaline or phenylephrine. Most recent clinical observational studies suggested to consider laparoscopic over open surgery as a standard treatment for abdominal surgery. While animal studies observed impaired fetal brain development after prenatal anesthesia exposure, this could not be confirmed by an observational clinical study.

Enhancing Patient Safety through Education in a Low-to-Middle-Income Country: Training in the Correct Application of Cricoid Pressure.

Cricoid pressure (CP) is applied to occlude the esophagus during endotracheal intubation in patients at an increased risk of aspiration of gastric contents. Evidence shows marked deficiencies in knowledge and skills for CP application among personnel responsible for this task. This study evaluated the effectiveness of CP training in improving knowledge and skills regarding CP application among anesthesiology technicians and critical care nurses and assessed the retention of skills after 2 months. Five workshops were conducted on effective application of CP. Indications, relevant anatomy, physiology, and correct technique were taught using interactive sessions and videos and hands-on practice on a weighing scale, 50-mL syringe, and trainer model. Pre- and postworkshop tests were conducted for knowledge and skill. An assessment was repeated after 2 months to assess skill retention. Five workshops were conducted for 102 participants. Statistically significant improvements were seen in mean scores for knowledge in postworkshop assessments (12.32 ± 2.12 versus 7.12 ± 2.32; P < .01). Similarly, posttraining mean scores for skill assessment were significantly higher than pretraining scores (6.31 ± 0.96 versus 2.72 ± 2.00; P < .0005), indicating an overall 131% improvement. Seventy-four participants appeared for assessment of the retention of skills. A 20% decrement was observed compared with posttraining scores (5.15 ± 1.71 versus 6.45 ± 0.86; P < .0005). A significant improvement was observed in both knowledge and skills immediately following training. However, this does not ensure long-term retention of clinical skills, as a 20% decrement was observed 2 months after the workshops. Formal training and regular practice are recommended to enable clinicians to perform CP effectively.

Effectiveness of the Sellick maneuver for painless gastroscopy in patients with esophageal hiatal hernia: A randomized, self‑control trial.

The Sellick maneuver is used for endotracheal intubation to prevent the occurrence of gastroesophageal reflux. The aim of the present study was to observe the effect of the Sellick maneuver on safety, esophageal closure status, gastric mucosal fold extension status, and positive detection rate of lesions in patients with esophageal hiatal hernia under painless gastroscopy. A total of 40 patients with esophageal hiatal hernia who underwent painless gastroscopy were screened for the use of the Sellick maneuver, in which the operator applied pressure to the cervical cricoid cartilage during the examination. The status of esophageal closure at the are pressed, examination time, gastric mucosal fold extension score, positive rate of lesion detection, and reflux of gastric juice or gastric contents, amongst other parameters were assessed. After using the Sellick maneuver, the state of esophageal closure during gastroscopy was significantly better than the no-Sellick maneuver group (P<0.05), and the extension scores of the greater curvature folds of the gastric body, the lateral folds of the lesser curvature of the gastric body, and the mucosal folds of the fundus were significantly higher than that of the no-Sellick maneuver (all P<0.05). The number of gastric polyps and gastric lesions (gastric ulcers and mucosal hyperplasia, amongst others) examined with the Sellick maneuver was significantly higher than the no-Sellick maneuver group (P<0.01). The Sellick maneuver effectively improved the extension of gastric mucosal folds during gastroscopy in patients with esophageal hiatal hernia, increased the positive detection rate of gastric lesions, and shortened the endoscopy time.

A randomized comparison of the performance of Airtraq videolaryngoscope versus Macintosh laryngoscope in simulated rapid sequence induction of anaesthesia

Application of cricoid pressure during rapid sequence induction (RSI) of anaesthesia leads to difficult airway. No channeled videolaryngoscope (VL) has been compared with the Macintosh laryngoscope for facilitating intubation in RSI. Thus, we compared Airtraq® VL with Macintosh laryngoscope for simulated RSI in patients scheduled for elective surgeries.Following approval from Institutional Ethics Committee-Human Research, this randomized study was conducted. Patients of either sex, aged 18-65yr, ASA grade I/II, scheduled for elective surgeries under GA were included. 'Group DL' underwent direct laryngoscopy (DL) using Macintosh laryngoscope and Group VL with Airtraq® videolaryngoscope. Time taken for intubation, Cormack-Lehane (CL) grade of laryngeal view, number of intubation attempts, and haemodynamic parameters were noted. Student t-test and chi square test were used for statistical analysis.A total of 140 patients with 70 in each group were included. The mean time taken for intubation was significantly higher in VL group (84.70 ± 28.05s) than DL group (23.90 ± 6.67s). The optimal laryngeal view (i.e. CL grade I or II) was significantly improved in VL group than DL group i.e. 97% vs 94%. In group DL, 99% (n=69) were intubated in first attempt; whereas 60% (n=42) in Group VL (p&amp;#60;0.001). Hemodynamics was better in group VL.Airtraq® VL is better than conventional Macintosh laryngoscope for endotracheal intubation during RSI in terms of optimal glottic view, ease of intubation and haemodynamics. On the contrary, the “time taken to intubation” and the first attempt intubation rate were higher with Airtraq® VL.

Efficacy of metoclopramide for prevention of gastric regurgitation during endotracheal intubation in the emergency department: A randomized controlled trial.

Gastric content regurgitation and aspiration are the dreaded complications of securing the airway. Cricoid pressure hinders intubation and causes lower esophageal sphincter (LES) relaxation. A recent study suggests no added benefit of cricoid pressure in preventing pulmonary aspiration of gastric contents. Metoclopramide increases LES tone, prevents gastroesophageal reflux, and increases antral contractions. Hence, we wanted to study the efficacy of metoclopramide for preventing gastric regurgitation during endotracheal intubation (ETI) in patients presenting to the emergency department (ED). This study was a randomized controlled trial in patients requiring ETI in the ED. The study participants were randomized to receive either metoclopramide (intervention) 10 mg/2 ml intravenous (IV) bolus or a placebo of normal saline (placebo) 2 ml IV bolus 5 min before rapid sequence induction and intubation. The outcome of the study was the visualization of gastric regurgitation at the glottic opening during direct laryngoscopy at the time of intubation. Seventy-four study participants were randomized and allocated to the metoclopramide group (n = 37) or placebo group (n = 37). Gastric regurgitation at the glottis was noted in three study participants (8%) in the metoclopramide group, and six (16%) in the placebo group (odds ratio [OR] - 0.456; 95% confidence interval [CI] of 0.105-1.981; P = 0.295). The study participants who were intubated in the first attempt had less gastric regurgitation compared to ≥2 attempts (OR 0.031; 95% CI of 0.002-0.511; P = 0.015). There was no decrease in regurgitation with metoclopramide as compared to placebo during ETI in study participants presenting to the ED.

Comparing the usefulness of VividTrac and classic Macintosh laryngoscope in intubation in pediatric patients with cleft palate

BackgroundSurgical repair for pediatric patients with cleft palate is performed under general anesthesia requiring endotracheal intubation. However, intubating these cases is usually difficult because of the cleft itself and associated airway abnormalities. VividTrac, a video laryngoscopy that could provide a real-time picture of the glottic area, could be helpful in these cases.MethodsWe conducted the current prospective investigation to compare VividTrac and conventional Macintosh laryngoscope in intubating pediatric patients with cleft palate.ResultsAll patient demographics did not express significant differences between the two groups. The number of trials and the first trial success rate were in favor of group L. The former had mean values of 1.28 and 1.05, while the latter occurred in 81.4% and 97.7% of patients in groups L and V, respectively. Group V showed a significant increase in the time interval passing between mouth opening and connecting the tube with the ventilator.Nonetheless, the difficulty of intubation was increased in group L. The need for cricoid pressure and tube introducer was increased in group L.ConclusionsVividTrac laryngoscope could be a valid and more suitable option for intubation in pediatric patients with cleft palate. Compared to the conventional laryngoscope, it has a higher success rate, lower attempt number, and lower need for assisting maneuvers.

Comparison of Intubation Conditions Between Airtraq, McGrath Video Laryngoscopes, and Macintosh Under Conditions of Simulated Trauma Airway and Rapid Sequence Induction Intubation

BackgroundPatients arriving at the emergency department with a potential cervical spine injury and immobilized in a rigid cervical collar often require emergency airway management and rapid sequence induction intubation (RSII). There have been several advances in airway management with the advent of channeled (AirtraqⓇ; Prodol Meditec) and nonchanneled (McGrathⓇ; Meditronics) video laryngoscopes, which enable intubation without the removal of the cervical collar, but their efficacy and superiority over conventional laryngoscopy (Macintosh) in the presence of a rigid cervical collar and cricoid pressure have not been evaluated. ObjectiveOur aim was to compare the channeled (Airtraq [group A]) and nonchanneled (McGrath [Group M]) video laryngoscopes with a conventional laryngoscope (Macintosh [Group C]) in a simulated trauma airway. MethodsA prospective randomized controlled study was conducted in a tertiary care center. Participants were 300 patients requiring general anesthesia (American Society of Anesthesiologists class I or II), of both sexes, and aged 18–60 years. Airway management was simulated without removal of a rigid cervical collar and using cricoid pressure during intubation. After RSI, patients were intubated with one of the study techniques according to randomization. Intubation time and intubation difficulty scale (IDS) score were noted. ResultsMean intubation time was 42.2 s in group C, 35.7 s in group M, and 21.8 s in group A (p = 0.001). Intubation was easy in group M and group A (median IDS score of 0; interquartile range [IQR] 0–1 for group M and median IDS score of 1; IQR 0–2 for group A and group C; p < 0.001). A higher proportion (95.1%) of patients had an IDS score of < 1 in group A. ConclusionsThe performance of RSII with cricoid pressure in the presence of a cervical collar was easier and more rapid with channeled video laryngoscope than with other techniques.

Does Cricoid Pressure Increase the Laryngoscopy Force During Rapid Sequence Induction?-A Randomized Study.

Cricoid pressure, a manoeuver used to prevent pulmonary aspiration during rapid sequence induction, can result in deterioration of laryngeal view and increased haemodynamic changes. Its effect on laryngoscopy force remains unevaluated. The study aimed to assess the impact of cricoid pressure on laryngoscopy force and intubation characteristics during rapid sequence induction. Seventy American Society of Anaesthesiologists I/II patients, both sexes, aged 16-65, having non-obstetric emergency surgery were randomly assigned to the cricoid group, which received 30 N cricoid pressure during rapid sequence induction, and the sham group, which received 0 N pressure. Propofol, fentanyl, and succinylcholine were used to produce general anaesthesia. The primary outcome was the peak force of laryngoscopy. Secondary outcomes were the laryngoscopic view, time to execute endotracheal intubation, and intubation success rate. With the application of cricoid pressure, the peak forces of laryngoscopy increased significantly, with a mean difference (95% CI) of 15.5 (13.8-17.2) N. With and without CP, the mean peak forces were 40.758 (4.2) and 25.2 (2.6) N, respectively, P < .001. Without cricoid pressure, the intubation success rate was 100%, compared to 85.7% with cricoid pressure, P = .025. The proportions of CL1/2A/2B patients with and without cricoid pressure were 5/23/7 and 17/15/3, respectively, with P = .005. With cricoid pressure, there was a considerable increase in intubation duration, with a mean difference (95% CI) of 24.4 (2.2-19.9) seconds. Cricoid pressure increases peak forces during laryngoscopy, resulting in worse intubation characteristics. This demonstrates the need of exercising care while performing this manoeuver.

Another simple technique for nasogastric tube insertion in anaesthetised, intubated patients.

Dear Editor, Insertion of a nasogastric tube (NGT) in an anaesthetised, intubated patient can become challenging. The conventional method of blind NGT insertion has a success rate of approximately 40–58%.[1] After obtaining patients’ consent and ethical clearance, we selected 20 anaesthetised, intubated patients posted for surgery (1st to 31st January 2022). Patients who needed general anesthesia with intubation and NGT placement (laparoscopic surgery, gastrointestinal surgery, etc.) were included in our study. Patients with skull base fracture, coagulopathy, nasopharyngeal and oesophageal pathology, and head and neck radiotherapy were excluded. Size 16 French, 105 cm NGT was used. NGT insertion was performed by a single anaesthesiologist. After intubation, the head was kept in a neutral position using an intubation pillow (8–10 cm height soft pad placed under the occiput). NGT length was estimated by measuring the distance from the xiphoid process to the nostril via the earlobe. The proximal end of the NGT was lubricated with water-based jelly and inserted through the larger nostril. Once NGT entered the nasopharynx, it was gently inserted further and simultaneously rotated in a clockwise direction continuously using the right hand. The remaining length of the NGT was straightened with its distal end held with the left hand and rotated continuously in the same direction so that the NGT rotates in toto. If any resistance was faced, the NGT was withdrawn a little and reinserted with continuous clockwise rotational movements. Correct placement of NGT was confirmed with epigastric auscultation. Time taken for NGT insertion was noted. A laryngoscopy was done to look for kinking of NGT or bleeding in the oral cavity. If the first attempt failed, NGT was cleaned and reinserted by a similar technique. Time taken for the second attempt of NGT insertion was noted. It was considered as failed, after the failed second attempt. NGT insertion was then guided by laryngoscope and Magill forceps. Demographic characteristics and procedural parameters are summarized in Table 1. Eleven patients were of normal weight, six were overweight and three were obese. NGT insertion was successful in the first attempt in 19/20 patients and in the second attempt in 1/20 patients. In one patient where the first attempt of NGT insertion was unsuccessful, both bleeding and full coiling were noted. The shortest and longest time taken for the procedure was 14 and 55 seconds respectively. Fourteen patients (70%) NGT was inserted in ≤30 seconds and six patients (30%) in >30 seconds. Two patients had right nasal intubation because of carcinoma tongue. In both these patients, NGT was inserted through the left nostril successfully in the first attempt. Three patients had developed a single coil of NGT in the oropharynx because of over-insertion. Common sites of NGT misplacement are piriform sinus, arytenoid cartilage, oesophagus, and lungs.[2] Several techniques like neck flexion, lateral neck pressure, and reverse sellick maneuver had been tried with different success rates (85% vs 85% vs 80%, respectively).[3] Strengthening the distal portion of NGT by freezing (85% success)[4] or threading guide wire (96% success)[3] improves the ease of insertion. Despite GlideScope or Macintosh laryngoscope-guided NGT insertion being successful, it can limit the space for manipulation of Magill forceps. NGT insertion by SORT (Sniffing position, orientation of NGT, contralateral Rotation, Twisting) technique has also shown good results (97%).[2] However, with rotational movement alone, we had successful NGT insertion in all the patients. Thus, we hypothesize that if the NGT tip faces any resistance during insertion, the continuous rotational movement will deflect the tip from resistance. The tip will then find the path of least resistance to the oesophagus. This is a very simple technique that nurses can perform easily. As the neck position is not altered, this technique can be helpful in anesthetized cervical spine fracture patients. Also, this technique may be convenient in anesthetized patients with facial bone fractures or intra-oral lesions, as there is no necessity for devices like laryngoscope or Magill forceps.Table 1: Patient demographics and procedural parametersFinancial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Factors predicting difficulty in insertion of real-time-three-dimensional transesophageal echocardiography probe in adult patients undergoing cardiac surgery.

Transesophageal echocardiography (TEE) probe insertion may be associated with many complications. Demographic factors and airway conditions such as high Mallampati scores (MMC) and Cormack-Lehane grades (MCLG) are likely to have an impact on its ease of insertion. The primary aim of this study was to identify the predictive factors for difficult real-time-three-dimensional TEE probe insertion. A total of 153 adult patients undergoing cardiac surgery were prospectively evaluated. The upper airway manipulations required for TEE probe placement were jaw thrust, reverse Sellick's maneuver, and laryngoscopy. All the patients who required airway manipulations were grouped under difficult TEE probe placement group. We evaluated the patients' predictive factors such as demographic characteristics and factors related to difficult intubation. Out of 153 patients, 123 were males and 30 were females. Overall, 27.5% (n = 42) patients had difficulty in probe placement. About 31.7% (n = 39) males had difficulty in TEE probe placement against 13% (n = 4) females (P-value 0.045). Difficulty in TEE probe placement was found in 72.7% (n = 16) of obese patients (body mass index [BMI] > 30), compared to 18.6% (n = 17) in the patients with BMI less than 25 (P-value < 0.001). Probe insertion was significantly more difficult in the presence of MMC III and IV (50%, n = 18) compared to class I (19.2%, n = 10) (P-value 0.001) and MCLG III (73.3%, n = 22) compared to grade I (11.1%, n = 7) (P-value 0.001). Male gender, obesity, higher grades of MMC and MCLG were found to be the risk factors for difficult TEE probe placement in anesthetized patients.

Anesthesia Management of Sectio Caesarian Patients with Eisenmenger Syndrome and Fetal Distress

Brief overview: 27 year old woman, G2P1A0 gravida 35-36 weeks with congenital heart disease (ventricular septal defect) that progresses to Eisenmenger syndrome, respiratory failure and fetal distress underwent an emergency caesarean section. Management: Anesthesia management was performed under general anesthesia with post-operative care in ICU. Prior to induction, pre-oxygenated with 100% O2 was performed, followed by Rapid Sequence Induction with Ketamine 70 mg, and Rocuronium 50 mg. After the patient had fallen asleep the Sellick maneuver was performed, intubated with ETT no. 6.5. Anesthesia maintenance with Sevoflurane 1 vol%, and 100% oxygen. Fentanyl 50 μg was given after the baby was born. Outcome: In this patient, general anesthetic technique was preferred over regional anesthetic technique for better maternal and fetal outcomes because this patient had already experienced respiratory failure and fetal distress, so a caesarean section was decided as soon as possible. The operation lasted for two hours, with SpO2 during the operation reaching 85% and a live baby boy was born with APGAR scores at the 1st ,3rd and 5th minute 6. Postoperatively, the patient remained intubated and was transferred to the intensive care unit with vital signs blood pressure 122/80 mmHg, pulse 96 beats per minute, SpO2 82-85%.

Comparison between gum elastic bougie and malleable stylet as aids to intubation during application of cricoid pressure: a prospective randomised controlled study

Background: Rapid sequence intubation with application of cricoid pressure is widely practiced in all emergency situations to prevent aspiration of gastric contents. Stylet or gum elastic bougie is used as intubation aid for rapidly securing the airway. Aim: To compare gum elastic bougie and malleable stylet as aids for endotracheal intubation during application of cricoid pressure. Results: Endotracheal intubation was successful in the first attempt in all of the 60 patients enrolled in the study. Time taken for laryngoscopy and intubation was clinically similar in both the groups of patients. However, in the stylet group, successful ET intubation was achieved in about 7 sec less when compared to the bougie group (p&lt; 0.05). Ease of intubation as compared using the Visual Analogue Scale (VAS) Score was similar in both groups. Laryngeal view improved in 22 patients of 60 patients (36.66%) after application of cricoid pressure, while it remained the same as before in 22. Overall, the grade remained the same or improved after cricoid pressure in 73.3% of patients. The laryngeal view worsened in 16 patients (27.7%). Conclusion: Gum elastic bougie and stylet are equally effective intubation aids during rapid sequence intubation. Intubation aided by bougie takes more time than that of a stylet, even though it is clinically trivial. Cricoid pressure does not affect the laryngoscopic visualisation of glottis in majority of patients

Rapid sequence induction-intubation and cricoid pressure – facts and fallacies

Rapid sequence induction-intubation (RSII) is ‘the standard of care’ practice since decades while anaesthetising a full stomach patient or during emergency airway management. Cricoid pressure (CP), an important manoeuvre, labelled as the ‘linchpin of rapid sequence induction-intubation’, when not performed properly can lead to catastrophic results. The purpose of this review of literature is to discuss if rapid sequence induction and application of cricoid pressure is a safe and effective technique in managing a full stomach patient. Literature from multiple sources was searched for key words, subject headings and text entries on rapid sequence induction, rapid sequence induction and intubation, and cricoid pressure. Outcomes such as prevention of aspiration and prevention of other airway complications such as airway trauma could not be evaluated based on the literature available at present. There is lack of clear cut evidence from randomised controlled trials on the safety and effectiveness of rapid sequence induction-intubation and cricoid pressure. Despite wide acceptance of RSII, its role in emergency airway management is still debated. CP as an essential skill, lacks in its uniformity among clinicians, technicians and nurses, and simulation based training hold promise in this regard.

Cricoid pressure revisited

Cricoid pressure revisited