Cricoid Pressure Research Articles

Do Not Use Cricoid Pressure with the i-gel Airway Device

To determine whether cricoid pressure affects placement or effectiveness of ventilation with the i-gel supraglottic airway device, researchers

The loneliest doctor.

The loneliest doctor.

Prevention of esophagopharyngeal reflux by augmenting the upper esophageal sphincter pressure barrier

Incompetence of the upper esophageal sphincter (UES) is fundamental to the occurrence of esophagopharyngeal reflux (EPR), and development of supraesophageal manifestations of reflux disease (SERD). However, therapeutic approaches to SERD have not been directed to strengthening of the UES barrier function. Our aims were to demonstrate that EPR events can be experimentally induced in SERD patients and not in healthy controls, and ascertain if these events can be prevented by application of a modest external cricoid pressure. Individual case control study. We studied 14 SERD patients (57 ± 13 years, 8 females) and 12 healthy controls (26 ± 3 years, 7 females) by concurrent intraesophageal slow infusion and pharyngoscopic and manometric technique without and with the application of a sustained predetermined cricoid pressure to induce, detect, and prevent EPR, respectively. Slow esophageal infusion (1 mL/s) of 60 mL of HCl resulted in a total of 16 objectively confirmed EPR events in none patients and none in healthy controls. All patients developed subjective sensation of regurgitation. Sustained cricoid pressure resulted in a significant UES pressure augmentation in all participants. During application of sustained cricoid pressure, slow intraesophageal infusion resulted in only one EPR event (P < .01). Slow esophageal liquid infusion unmasks UES incompetence evidenced as the occurrence of EPR. Application of 20 to 30 mm Hg cricoid pressure significantly increases the UES intraluminal pressure and prevents pharyngeal reflux induced by esophageal slow liquid infusion. These techniques can be useful in diagnosis and management of UES incompetence in patients suffering from supraesophageal manifestations of reflux disease.

Do not know where to press? Cricoid pressure in the very young

Do not know where to press? Cricoid pressure in the very young

Rapid sequence induction: its place in modern anaesthesia

In 1958, aspiration was credited as the largest cause of anaesthesia-related death by Snow and Nunn. Surprisingly, this remains the case in 2011. The Royal College of Anaesthetists National Audit Project (NAP4) calculated the incidence of fatal aspiration during general anaesthesia as one in 340 000, but acknowledging that as a probable underestimate, reported that it may be as common as one in 45 000. The risk of aspiration itself is estimated at one in 2–3000 during elective surgery and one in 6–800 during emergency surgery. Potential consequences of aspiration include chemical pneumonitis, bacterial aspiration pneumonia, acute respiratory distress syndrome, and death. While recognizing the lack of a clear definition, NAP4 recommended that, in those patients at risk of regurgitation and subsequent aspiration, a rapid sequence induction (RSI) with cricoid pressure should be the technique of choice to induce anaesthesia. However, RSI as a practice is not without risk, particularly in the critically ill population. Risks include hypoxia, failed intubation, oesophageal trauma, cardiovascular compromise, and awareness. We will describe how modern practice has deviated from the traditional, standardized RSI to an approach where management of the patient at increased risk of aspiration involves an assessment of all risks to identify suitable techniques designed to minimize those risks for that individual.

Effect of cricoid pressure on placement of the I-gel™ : a randomised study.

We studied 40 adult patients to see if cricoid pressure affected placement of the I-gel(™). In a randomised crossover design, the i-gel was placed with and without cricoid pressure, and we compared the success rate of adequate ventilation through the i-gel, time to placement and the rate of optimal position of the device between the two circumstances. Cricoid pressure significantly decreased the success rate of adequate ventilation through the i-gel (40 vs 34 patients) (p = 0.041, 95% CI for difference 4-26%), and significantly decreased the rate of the optimal position (39 vs 17 patients) (p < 0.001). The time to achieve adequate ventilation was significantly longer (p < 0.001) with cricoid pressure than without (median difference 8 s; 95% CI for median difference 3-12 s). Cricoid pressure significantly decreases the success rate of ventilation through the i-gel, but the success rate of ventilation through the i-gel is reasonably high.

725 A Multi-Center Prospective Study of the Upper Esophageal Sphincter (UES) Assist Device for the Treatment of Extraesophageal Reflux

Background: Extra-esophageal reflux (EER) is a heterogeneous disorder,caused by reflux of gastroduodenal contents resulting in symptoms such as chronic cough, hoarseness, throat clearing and globus. The cost of caring for EER exceeds $50 billion due predominately to over utilization of proton pump inhibitors (PPI's) which are often not effective. The Upper Esophageal Sphincter (UES) Assist Device is a novel medical device designed to eliminate the reflux of gastric contents into the laryngopharynx. In this multicenter prospective study we aimed to assess efficacy and safety of this device in patients with suspected EER. Methods: Patients with extraesophageal presentations and reflux symptom index (RSI) > 13 were invited to participate in this multicenter study. Predominant presenting symptoms included chronic cough, choking, aspiration, chronic post nasal drip, globus, sore throat, throat clearing. The UES assist device, worn at bed-time, was fitted individually and a deviceapplied external cricoid pressure adjusted to above 20 mmHg. Applied cricoid pressure was monitored by external sensors in all subjects to ensure readings above 20 mmHg for study duration. RSI, SF-36, patient and physician satisfaction scores and Functional Outcomes of Sleep Questionnaire (FOSQ) were measured at 2and 4-weeks post enrollment. The study primary effectiveness endpoint was reduction in RSI at 4-weeks from baseline. Intend to treat (ITT) analysis conducted post intervention. Safety was based on reported adverse reactions. Results: 51 patients consented and 47 patients (ITT) completed study protocol in four centers [mean (SD) age=50 (+/-14.2); median (IQR) BMI= 25.8 (23-29); 72% female, 86% Caucasian]. Most common troublesome symptoms included chronic cough (28%), excess mucus/post nasal drip (19%), throat clearing (11%) and hoarseness (11%). There was a significant (p< 0.0001) reduction in median (IQR) RSI at 2and 4-weeks post therapy [14.0 (8.0-20) and 12.0 (7.0-19), respectively] compared to pre-therapy values (27 (21-32) (Figure). Eighty-six percent (86%) of patients reported improvement greater than 25%, The mean (+/-SD) improvement from baseline was 54% (+/-28.1%) with 30% of patients having an improvement of 75% or more. SF36 and FOSQ were unchanged; however, 75% of patients and 92% of providers reported satisfaction with the device. The adverse events reported during the course of the study were generally mild [device technical issues 14% and mild skin irritation (8%)] and there were no study withdrawal due to adverse events. Conclusion: The UES assist device is a safe and effective non-invasive method for the treatment of extraesophageal symptoms. Given poor response to PPI therapy in many such patients this device by serve as a potential alternative for this difficult to treat group of patients.

337 Pharyngeal Electrical Stimulation (PES) Expedites Swallowing Recovery in Dysphagia Post-Acute Stroke: a Phase II Double-Blinded Randomised Controlled Trial

Introduction: Human disease models can help to better understand the pathophysiology and systematically characterize its consequences. Upper esophageal sphincter (UES) dysphagia is a common sequela of a number of disorders including CVA, reflux disease and aging. Intrinsic disorders of the UES such as fibrosis and inflammation can result in its diminished distensibility and restrict its opening causing dysphagia. Aim: To characterize the pharyngeal and UES deglutitive pressure phenomena in an experimentally induced restricted UES model in humans. Methods: We studied 15 patients (8 male, age 65±11 years) with various supraesophageal reflux symptoms. To induce UES restriction, we used a handmade simple device comprised of two components that could be comfortably worn around the neck: an elastic band and a cushion (5 X 3 X 2.5 CM). The cushion was placed horizontally at the center of the cricoid cartilage. By adjusting the elastic band, we selectively applied 0, 20, 30, 40 mmHg pressure perpendicular to the cricoid laryngeal structure inducing equivalent resistance against UES opening. In this model, the UES, in addition to relaxation, has to overcome the externally imparted pressure to open. Deglutitive pharyngeal and UES pressure phenomena were determined using high-resolution manometry, which recorded from entire pharynx, UES and proximal esophagus. We tested dry, 5 and 10ml swallows x 3. Results: Application of the external pressure band increased the length of the UES high pressure zone from 2.5 cm without the band to 3.1, 3.5 and 3.7 cm for 20, 30, 40mmHg cricoid restrictive pressure, respectively (p<0.05). Increased restrictive pressure against UES resulted in a significant increase in hypopharyngeal intra-bolus pressure (IBP) during all swallowed volumes (figure). Similarly, increased UES restrictive pressure resulted in increased UES nadir deglutitive relaxation pressure for all swallowed volumes (table, p<0.05). Swallowed volume had no effect on pharyngeal peak pressure, duration or velocity. None of these were affected by restrictive external UES pressures. Deglutitive velopharygeal pressure progressively increased with increased swallowed volume (p<0.05). These pressures were also not affected by UES restrictive external pressure. Conclusions: Acute experimental restriction of UES opening by external cricoid pressure in humans manifests the pressure characteristics of increased resistance to UES trans-sphincteric flow observed in disorders that are accompanied by reduced UES opening. These pressure characteristics include increased hypopharyngeal intra-bolus as well as nadir deglutitive UES relaxation pressures. This model can potentially be helpful in better understanding of UES pathophysiology. The effect of external cricoid (UES restrictive) pressure on UES nadir pressure

338 Maturation and Stimulus-Volumes Modulate Pharyngeal Provocation Induced Pharyngeal Rhythms in Human Premature Infants

Introduction: Human disease models can help to better understand the pathophysiology and systematically characterize its consequences. Upper esophageal sphincter (UES) dysphagia is a common sequela of a number of disorders including CVA, reflux disease and aging. Intrinsic disorders of the UES such as fibrosis and inflammation can result in its diminished distensibility and restrict its opening causing dysphagia. Aim: To characterize the pharyngeal and UES deglutitive pressure phenomena in an experimentally induced restricted UES model in humans. Methods: We studied 15 patients (8 male, age 65±11 years) with various supraesophageal reflux symptoms. To induce UES restriction, we used a handmade simple device comprised of two components that could be comfortably worn around the neck: an elastic band and a cushion (5 X 3 X 2.5 CM). The cushion was placed horizontally at the center of the cricoid cartilage. By adjusting the elastic band, we selectively applied 0, 20, 30, 40 mmHg pressure perpendicular to the cricoid laryngeal structure inducing equivalent resistance against UES opening. In this model, the UES, in addition to relaxation, has to overcome the externally imparted pressure to open. Deglutitive pharyngeal and UES pressure phenomena were determined using high-resolution manometry, which recorded from entire pharynx, UES and proximal esophagus. We tested dry, 5 and 10ml swallows x 3. Results: Application of the external pressure band increased the length of the UES high pressure zone from 2.5 cm without the band to 3.1, 3.5 and 3.7 cm for 20, 30, 40mmHg cricoid restrictive pressure, respectively (p<0.05). Increased restrictive pressure against UES resulted in a significant increase in hypopharyngeal intra-bolus pressure (IBP) during all swallowed volumes (figure). Similarly, increased UES restrictive pressure resulted in increased UES nadir deglutitive relaxation pressure for all swallowed volumes (table, p<0.05). Swallowed volume had no effect on pharyngeal peak pressure, duration or velocity. None of these were affected by restrictive external UES pressures. Deglutitive velopharygeal pressure progressively increased with increased swallowed volume (p<0.05). These pressures were also not affected by UES restrictive external pressure. Conclusions: Acute experimental restriction of UES opening by external cricoid pressure in humans manifests the pressure characteristics of increased resistance to UES trans-sphincteric flow observed in disorders that are accompanied by reduced UES opening. These pressure characteristics include increased hypopharyngeal intra-bolus as well as nadir deglutitive UES relaxation pressures. This model can potentially be helpful in better understanding of UES pathophysiology. The effect of external cricoid (UES restrictive) pressure on UES nadir pressure

336 A Human Model of Restricted UES Opening and Its Characteristic Pharyngeal and UES Deglutitive Pressure Phenomena

Introduction: Human disease models can help to better understand the pathophysiology and systematically characterize its consequences. Upper esophageal sphincter (UES) dysphagia is a common sequela of a number of disorders including CVA, reflux disease and aging. Intrinsic disorders of the UES such as fibrosis and inflammation can result in its diminished distensibility and restrict its opening causing dysphagia. Aim: To characterize the pharyngeal and UES deglutitive pressure phenomena in an experimentally induced restricted UES model in humans. Methods: We studied 15 patients (8 male, age 65±11 years) with various supraesophageal reflux symptoms. To induce UES restriction, we used a handmade simple device comprised of two components that could be comfortably worn around the neck: an elastic band and a cushion (5 X 3 X 2.5 CM). The cushion was placed horizontally at the center of the cricoid cartilage. By adjusting the elastic band, we selectively applied 0, 20, 30, 40 mmHg pressure perpendicular to the cricoid laryngeal structure inducing equivalent resistance against UES opening. In this model, the UES, in addition to relaxation, has to overcome the externally imparted pressure to open. Deglutitive pharyngeal and UES pressure phenomena were determined using high-resolution manometry, which recorded from entire pharynx, UES and proximal esophagus. We tested dry, 5 and 10ml swallows x 3. Results: Application of the external pressure band increased the length of the UES high pressure zone from 2.5 cm without the band to 3.1, 3.5 and 3.7 cm for 20, 30, 40mmHg cricoid restrictive pressure, respectively (p<0.05). Increased restrictive pressure against UES resulted in a significant increase in hypopharyngeal intra-bolus pressure (IBP) during all swallowed volumes (figure). Similarly, increased UES restrictive pressure resulted in increased UES nadir deglutitive relaxation pressure for all swallowed volumes (table, p<0.05). Swallowed volume had no effect on pharyngeal peak pressure, duration or velocity. None of these were affected by restrictive external UES pressures. Deglutitive velopharygeal pressure progressively increased with increased swallowed volume (p<0.05). These pressures were also not affected by UES restrictive external pressure. Conclusions: Acute experimental restriction of UES opening by external cricoid pressure in humans manifests the pressure characteristics of increased resistance to UES trans-sphincteric flow observed in disorders that are accompanied by reduced UES opening. These pressure characteristics include increased hypopharyngeal intra-bolus as well as nadir deglutitive UES relaxation pressures. This model can potentially be helpful in better understanding of UES pathophysiology. The effect of external cricoid (UES restrictive) pressure on UES nadir pressure

Tu1855 Correlation of Externally Applied Cricoid Pressure With Luminal Upper Esophageal Sphincter Pressure Augmentation; Effect of Posture and Technique

Tu1855 Correlation of Externally Applied Cricoid Pressure With Luminal Upper Esophageal Sphincter Pressure Augmentation; Effect of Posture and Technique

More Evidence on Cricoid Pressure to Prevent Regurgitation

The effectiveness of cricoid pressure in occluding the esophageal entrance remains a topic of debate, partly because the maneuver can make intubation

Randomised controlled trials of videolaryngoscopy vs direct laryngoscopy on intensive care are needed

Dear Editor, We read with great interest the editorial by Larsson and Dhonneur [1] regarding the role of videolaryngoscopy in airway management on intensive care units (ICUs). We have had a dedicated MacIntosh-style videolaryngoscope (VL) on our ICU for 4 years, and believe that this has significantly contributed to safer airway management. Airway-related complications are both more common in the ICU environment and more likely to result in harm than elsewhere in hospitals [2, 3]. Many factors can explain this: airway management in ICU may often be a true emergency, with less preparation time and increased risk of aspiration; ICU trainees (and consultants) are increasingly from nonanaesthetic backgrounds; ICU nurses have less airway management training than anaesthetic nurses or operating department practitioners; airway equipment may be less readily available than in theatre; and airway complications occur more commonly out of hours when senior clinicians are unavailable [4]. Since its introduction, use of the VL has rapidly become routine practice for all intubations on our ICU. Advantages of videolaryngoscopy as compared to direct laryngoscopy include training junior doctors (the separate VL screen enables a supervising doctor to see the intubating doctor’s view of the larynx, provide practical advice to assist intubation and often enables the completion of intubation by the junior when this would not be possible without a VL); training ICU nurses (the separate VL screen provides real-time monitoring of the effect of cricoid pressure and allows adjustment as needed); improved management of the unanticipated difficult airway (as a VL is immediately to hand) [5]. Perhaps the greatest impact has been on improved human factors and team working, owing to all staff involved being able to watch the intubation and anticipate the next steps. An important advantage of VLs based on a MacIntosh blade is that the same skills as are used for direct laryngoscopy can be used, with less need for dedicated VL training. We teach our trainees to use the VL blade in the same way as a standard MacIntosh laryngoscope, initially without access to the VL screen (which is used by the trainer): if the view at direct laryngoscopy is difficult the trainee is given access to the VL screen to assist in completing the intubation. A ‘difficult airway VL blade’ is immediately available when intubation is not easy. We support Drs. Larsson and Dhonneur’s call for more randomised controlled trials (RCTs) of videolaryngscopy vs direct laryngoscopy on ICU. We hope such trials will be performed soon, before widespread uptake of these popular devices makes this practically difficult. We would suggest that such RCTs would ideally aim to capture not only procedural aspects of the intubation but also broader non-technical safety aspects of the team process (e.g. situation awareness, team working, learning curves) and the impact on trainees’ skill acquisition and success. Such human factors are difficult to quantify, but in a similar way that central venous catheter placement under ultrasound guidance has advantages for training and team working, we believe that VL-guided intubation has human factor-related advantages that should not be ignored.

The Effectiveness of Cricoid Pressure for Occluding the Esophageal Entrance in Anesthetized and Paralyzed Patients

In the last 2 decades, the effectiveness of cricoid pressure (CP) in occluding the esophageal entrance has been questioned. Recent magnetic resonance imaging studies yielded conflicting conclusions. We used real-time visual and mechanical means to assess the patency of the esophageal entrance with and without CP in anesthetized and paralyzed adult patients. One hundred seven, nonobese ASA physical status I and II patients were recruited for the study. A cricoid force of 30 N was used. This force was standardized by using a weighing scale before application of CP in each patient. After oxygen administration, anesthetic induction, neuromuscular blockade, and establishment of manual ventilation with FIO2 = 1.0, the view of the glottis and esophageal entrance was visualized, and video recordings were obtained by using a Glidescope video laryngoscope. Attempts to insert 2 gastric tubes (GTs), size 12 and 20 F, into the esophagus were made by a "blinded" operator without and with CP, the timing of which was randomized. A successful insertion of a GT in the presence of CP was considered evidence of a patent esophageal entrance (ineffective CP), whereas an unsuccessful insertion of a GT was considered evidence of an occluded esophageal entrance (effective CP). After the attempts to insert the GTs were completed, tracheal intubation was performed while CP was applied. The position of the esophageal entrance in relation to the glottis (midline versus lateral) was assessed from the video recordings, with and without CP. We stopped the study when 79 patients (41 men and 38 women) qualified for and completed the study (2-sided Clopper-Pearson confidence interval (CI) 95% to 100%, n = 72). Advancement of either size GT into the esophagus could not be accomplished during CP in any patient but was easily done in all subjects when CP was not applied. This occurred whether the esophageal entrance was in a midline position or in a left or right lateral position relative to the glottis. Esophageal patency was visually observed in the absence of CP, whereas occlusion of the esophageal entrance was observed during CP in all patients. Without CP, the esophageal entrance was in a left lateral position in relation to the glottis in 57% ([95 % CI, 45%-68%)] of patients, at midline in 32% (CI, 22%-43%), and in a right lateral position in 11% (CI, 5%-21%). The position did not change with CP. The current study provides additional visual and mechanical evidence supporting a success rate of at least 95% by using a cricoid force of 30 N to occlude the esophageal entrance in anesthetized and paralyzed normal adult patients. The efficacy of the maneuver was independent of the position of the esophageal entrance relative to the glottis, whether midline or lateral.

The “Other Tube” in the Airway

The “Other Tube” in the Airway

Gastric Tubes and Airway Management in Patients at Risk of Aspiration

Rapid sequence induction and intubation (RSII) and awake tracheal intubation are commonly used anesthetic techniques in patients at risk of pulmonary aspiration of gastric or esophageal contents. Some of these patients may have a gastric tube (GT) placed preoperatively. Currently, there are no guidelines regarding which patient should have a GT placed before anesthetic induction. Furthermore, clinicians are not in agreement as to whether to keep a GT in situ, or to partially or completely withdraw it before anesthetic induction. In this review we provide a historical perspective of the use of GTs during anesthetic induction in patients at risk of pulmonary aspiration. Before the introduction of cricoid pressure (CP) in 1961, various techniques were used including RSII combined with a head-up tilt. Sellick initially recommended the withdrawal of the GT before anesthetic induction. He hypothesized that a GT increases the risk of regurgitation and interferes with the compression of the upper esophagus during CP. He later modified his view and emphasized the safety of CP in the presence of a GT. Despite subsequent studies supporting the effectiveness of CP in occluding the esophagus around a GT, Sellick's early view has been perpetuated by investigators who recommend partial or complete withdrawal of the GT. On the basis of available information, we have formulated an algorithm for airway management in patients at risk of aspiration of gastric or esophageal contents. The approach in an individual patient depends on: the procedure; type and severity of the underlying pathology; state of consciousness; likelihood of difficult airway; whether or not the GT is in place; contraindications to the use of RSII or CP. The algorithm calls for the preanesthetic use of a large-bore GT to remove undigested food particles and awake intubation in patients with achalasia, and emptying the pouch by external pressure and avoidance of a GT in patients with Zenker diverticulum. It also stipulates that in patients with gastric distension without predictable airway difficulties, a clinical and imaging assessment will determine the need for a GT and in severe cases an attempt to insert a GT should be made. In the latter cases, the success of placement will indicate whether to use RSII or awake intubation. The GT should not be withdrawn and should be connected to suction during induction. Airway management and the use of GTs in the surgical correction of certain gastrointestinal anomalies in infants and children are discussed.

Rapid-sequence intubation and cricoid pressure.

Airway management is the most important clinical skill for anesthesiologist, emergency physician, and other providers who are involved in oxygenation and ventilation of the lungs. Rapid-sequence intubation is the preferred method to secure airway in patients who are at risk for aspiration because it results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis). Application of cricoid pressure (CP) for patients undergoing rapid-sequence intubation is controversial. Multiple specialty societies have recommended that CP is not effective in preventing aspiration; rather it may worsen laryngoscopic view and impair bag-valve mask ventilation. Some experts think that CP should be applied in trauma and patients at risk for aspiration; however CP, if necessary, should be altered or removed to facilitate intubation.

An evaluation of knowledge and skill on cricoid pressure among emergency personnel.

Cricoid pressure (CP) is a step during rapid sequence induction. Previous studies showed a poor clinical application of CP despite a reasonable theoretical knowledge of CP. This study aims to evaluate the proficiency and knowledge retention on CP among the emergency staff in the Emergency Department, Universiti Kebangsaan Malaysia Medical Centre. This is questionnaire-based observational comparative study. Once the questionnaire is filled, the application of CP is tested on an airway model and competency level is documented. An education hand out is passed to all participants after the procedure. The improvement and knowledge retention were assess after 2 month. A total of 81 completed surveys were returned comprises of of 34 medical officers, 23 staff nurses and 24 assistant medical officers. 75.3% subjects have work experience more than a year but only 59.3% of them were trained in CP application. A total of 69.1% participants passed the pre educational handout test and 100% passed the post educational handout test. However, for pre educational handout phase, 81.5% participants passed the theory part while only 42% passed the practical component. In post educational handout phase, the number of respondents who passed both components was 97.5% and 63% respectively. There are positive correlation between designation and working experience with overall passes in this study. The theoretical knowledge of CP is satisfactory but clinical application is poor especially in the pre educational handout phase. The educational handout is proved to improve the knowledge transfer and retention with regards to CP.

Techniques of rapid sequence induction and intubation at a university teaching hospital.

Rapid sequence induction and intubation (RSII) is a medical procedure involving a prompt induction of general anesthesia by using cricoid pressure that prevents regurgitation of gastric contents. The factors affecting RSII are prophylaxis for aspiration, preoxygenation, drug and equipment preparation for RSII, ventilation after induction till intubation and patient condition. We sometimes saw difficulties with the practice of this technique in our hospital operation theatres. The aim of this study was to assess the techniques of rapid sequence induction and intubation. Hospital based observational study was conducted with a standardized checklist. All patients who were operated upon under general anesthesia during the study period were included. The techniques of RSII were observed during the induction of anesthesia by trained anesthetists. Altogether 140 patients were included in this study with a response rate of 95.2%. Prophylaxis was not given to 130 patients (92.2%), and appropriate drugs were not used for RSII in 73 patients (52.1%), equipments for difficult intubation in 21 (15%), suction machines with catheter not connected and turned on in 122 (87.1%), ventilation for patients after induction and before intubation in 41 (29.3%), cricoid pressure released before cuff inflation in 12 (12.1%), and difficult intubation in 8 (5.7%), respectively. RSII with cricoid pressure was applied appropriately in 94 (67.1%) patients, but cricoid pressure was not used in 46 (32.9%) patients. The techniques of rapid sequence induction and intubation was low. Training should be given for anesthetists about the techniques of RSII.

Comparison of four techniques of nasogastric tube insertion in anaesthetised, intubated patients: A randomized controlled trial.

Background and Aims:Insertion of nasogastric tubes (NGTs) in anaesthetised, intubated patients with a conventional method is sometimes difficult. Different techniques of NGT insertion have been tried with varying degree of success. The aim of this prospective, randomised, open-label study was to evaluate three modified techniques of NGT insertion comparing with the conventional method in respect of success rate, time taken for insertion and the adverse events.Methods:In the operation theatre of general surgery, the patients were randomly allocated into four groups: Group C (control group, n = 54), Group W (ureteral guide wire group, n = 54), Group F (neck flexion with lateral pressure, n = 54) and Group R (reverse Sellick's manoeuvre, n = 54). The number of attempts for successful NGT insertion, time taken for insertion and adverse events were noted.Results:All the three modified techniques were found more successful than the conventional method on the first attempt. The least time taken for insertion was noted in the reverse Sellick's method. However, on intergroup analysis, neck flexion and reverse Sellick's methods were comparable but significantly faster than the other two methods with respect to time taken for insertion.Conclusion:Reverse Sellick's manoeuver, neck flexion with lateral neck pressure and guide wire-assisted techniques are all better alternatives to the conventional method for successful, quick and reliable NGT insertion with permissible adverse events in anaesthetised, intubated adult patients. Further studies after eliminating major limitations of the present study are warranted to establish the superiority of any one of these modified techniques.