Cricoid Pressure Research Articles

Current practice of rapid sequence induction of anaesthesia in the UK - a national survey

BackgroundThe ‘classical’ technique of rapid sequence induction (RSI) of anaesthesia was described in 1970. With the introduction of new drugs and equipment in recent years, a wide variation in this technique has been used. The role of cricoid pressure is controversial because of the lack of scientific evidence. Moreover, gentle mask ventilation has been recommended in situations such as obesity and critically ill patients, to prevent hypoxaemia during the apnoeic period. In identifying multiple techniques, we conducted a national postal survey to establish the current practice of RSI in the UK. MethodsA survey consisting of 17 questions was created and posted to 255 National Health Service (NHS) hospitals in the UK. We included two copies of the questionnaire in each envelope; one to be completed by the airway lead (consultant anaesthetist with responsibility of overseeing the standard of airway training and implementing national airway guidelines and recommendations within their institution) and the other by a trainee in the same department. The difference in responses from consultants and trainees were assessed using the χ2 test and the Fisher's exact test. ResultsIn total we received 272 responses (response rate 53%) of which 266 (58% from consultants and 42% from trainees) were analysed. A majority of the respondents (68%) pre-oxygenated by monitoring end-tidal oxygen concentration and 76% of the respondents use 20–25° head up tilt for all RSIs. Propofol is the most commonly used induction agent (64% of all respondents). Opioid has been used by 80% of respondents and only 18% of respondents use suxamethonium for all patients and others choose rocuronium or suxamethonium based on clinical situation. Although 92% of anaesthetists use cricoid pressure, 83% of them never objectively measure the force used. During the apnoeic period 17% of the respondents use gentle mask ventilation. ConclusionsOur survey demonstrated a persistent variation in the practice of RSI amongst the anaesthetists in the UK. The ‘classical’ technique of RSI is now seldom used. Therefore there is a clear need for developing consistent guidelines for the practice of RSI.

Cricoid pressure: apply - but be ready to release

Cricoid pressure: apply - but be ready to release

Cricoid Pressure Impedes Tracheal Intubation With the Pentax-AWS Airwayscope®

Abstract Background It is unclear how cricoid pressure affects tracheal intubation with the Pentax-AWS Airwayscope® (AWS). We conducted a prospective randomized clinical trial in anaesthetized patients. Methods Sixty patients were allocated to either the cricoid pressure (CP) group (n+30) or the sham group (n+30). We compared the two groups with regard to intubation time, number of attempts required for insertion of the Intlock blade (disposable blade of the AWS) and tracheal intubation, percentage of glottic opening (POGO) score, and subjective difficulty of both laryngoscopy and passage of a tube through the glottis. Results Intubation time was significantly longer in the CP group (median 45[IQR40–59] s) than in the sham group (32[28–45] s) (P+0.003, 95% CI for median difference 5–24 s). The number required for insertion of the Intlock blade did not differ between the groups (P+0.08), but the number for tracheal intubation was significantly higher in the CP group (1 attempt in 14 patients, 2 in 7, 3 in 9) than in the sham group (1 attempt in 24 patients, 2 in 6; P+0.002). POGO score did not differ significantly between the groups (P+0.60), nor did the subjective difficulty of laryngoscopy (P+0.06). The visual analogue scale score for passage of a tube through the glottis was significantly higher in the CP group than in the sham group (P Conclusions Cricoid pressure impedes tracheal intubation using the AWS, and is associated with longer intubation time, which can be attributed to increased difficulty in the passage of a tube through the glottis. Clinical Trial registry number UMI18209.

Perioperative management of a morbidly obese pregnant patient undergoing cesarean section under general anesthesia - case report

The increased prevalence of obesity in the general population extends to women of reproductive age. The aim of this study is to report the perioperative management of a morbidly obese pregnant woman, body mass index > 50 kg/m(2), who underwent cesarean section under general anesthesia. Pregnant woman in labor, 35 years of age, body mass index 59.8 kg/m(2). Caesarean section was indicated due to the presumed fetal macrosomia. The patient refused spinal anesthesia. She was placed in the ramp position with cushions from back to head to facilitate tracheal intubation. Another cushion was placed on top of the right gluteus to create an angle of approximately 15° to the operating table. Immediately before induction of anesthesia, asepsis was carried out and sterile surgical fields were placed. Anesthesia was induced in rapid sequence, with Sellick maneuver and administration of remifentanil, propofol, and succinilcolina. Intubation was performed using a gum elastic bougie, and anesthesia was maintained with sevoflurane and remifentanil. The interval between skin incision and fetal extraction was 21 minutes, with the use of a Simpson's forceps scoop to assist in the extraction. The patient gave birth to a newborn weighing 4850 g, with Apgar scores of 2 in the 1(st) minute (received positive pressure ventilation by mask for about 2 minutes) and 8 in the 5(th) minute. The patient was extubated uneventfully. Multimodal analgesia and prophylaxis of nausea and vomiting was performed. Mother and newborn were discharged on the 4(th) postoperative day.

A pilot randomized clinical trial assessing the effect of cricoid pressure on risk of aspiration.

Patients at risk for microaspiration during elective intubation often receive cricoid pressure in the hopes of mitigating such risk. However, there is scarce evidence to either support or reject this practice. The objective of this investigation was to assess the effect of cricoid pressure on microaspiration and to inform the potential feasibility of conducting a larger, more definitive clinical trial. This was a pilot randomized clinical trial set in the operating rooms of a tertiary referral hospital between August and October of 2014. Patients with risk factors for microaspiration (obesity, gastroesophageal reflux disease, or diabetes) were enrolled. The patients were randomized to either cricoid pressure or no cricoid pressure during induction of anesthesia with endotracheal intubation. Immediately after intubation, a sample of lower airway secretions was collected and analyzed for pepsin A. A total of 95 patients were evaluated, randomized and completed the study protocol. 46 were randomized to cricoid pressure and 49 to no cricoid pressure. Seven patients crossed-over treatment arms. A total of 18 (19.6%) patients met the pre-defined criteria for microaspiration. In both the intention-to-treat and per-protocol analyses, there were no statistically significant differences in the rate of microaspiration [OR (95% CI)] = 1.39 (0.49-3.92) and 1.30 (0.44-3.86), respectively. Utilizing pepsin A as a biomarker of aspiration, this pilot clinical trial did not find evidence for a reduced rate of aspiration or adverse clinical events with the administration of cricoid pressure during elective endotracheal intubation of patients with risk factors for microaspiration.

Airway management and training in obstetric anaesthesia.

Airway management and failed intubation in the pregnant woman requires unique considerations, which differ from the nonpregnant patient. Factors that influence airway management in this setting include anatomical and physiological changes in pregnancy, environmental factors as well as training matters. In addition, surgery is often being performed with extreme urgency, which requires rapid decision-making process that takes into account safe outcome of mother and baby. The purpose of this review is to focus on recent developments that address these exceptional airway challenges in obstetrics. The first national UK obstetric difficult airway guidelines that have been recently published, are based around algorithms that deal with induction of general anaesthesia, failed intubation and front-of-the-neck access. As well as emphasising good practice in planning, preparation, and rapid sequence induction (RSI) technique, they outline how to make a provisional plan prior to the induction of general anaesthesia, on whether to awaken or continue general anaesthesia, should failed intubation occur. Current recommendations aim to move away from the traditional and outdated obstetric RSI technique to introduce changes, which are in keeping with anaesthetic practice in the nonpregnant patients. Such changes include the choice of induction agent and muscle relaxant, preoxygenation techniques, and mask ventilation during RSI; and the early release of cricoid pressure should failed intubation occur. Recent advances and recommendations in the management of the obstetric airway should help to bring consistency of clinical practice, reduce adverse events, and standardize teaching by providing a structure for teaching and training on failed tracheal intubation in obstetrics. Opportunities during elective caesarean sections and simulation should be used as teaching tools to improve anaesthetists' and team performance during a crisis.

A human model of restricted upper esophageal sphincter opening and its pharyngeal and UES deglutitive pressure phenomena.

Oropharyngeal dysphagia due to upper esophageal sphincter (UES) dysfunction is commonly encountered in the clinical setting. Selective experimental perturbation of various components of the deglutitive apparatus can provide an opportunity to improve our understanding of the swallowing physiology and pathophysiology. The aim is to characterize the pharyngeal and UES deglutitive pressure phenomena in an experimentally induced restriction of UES opening in humans. We studied 14 volunteers without any dysphagic symptoms (7 men, 66 ± 11 yr) but with various supraesophageal reflux symptoms. To induce UES restriction, we used a handmade device that with adjustment could selectively apply 0, 20, 30, or 40 mmHg pressure perpendicularly to the cricoid cartilage. Deglutitive pharyngeal and UES pressure phenomena were determined during dry and 5- and 10-ml water swallows × 3 for each of the UES perturbations. External cricoid pressure against the UES resulted in a significant increase in hypopharyngeal intrabolus pressure and UES nadir deglutitive relaxation pressure for all tested swallowed volumes (P < 0.05). Application of external cricoid pressure increased the length of the UES high pressure zone from 2.5 ± 0.2 to 3.1 ± 0.2, 3.5 ± 0.1, and 3.7 ± 0.1 cm for 20, 30, and 40 mmHg cricoid pressure, respectively (P < 0.05). External cricoid pressure had no significant effect on pharyngeal peristalsis. On the other hand, irrespective of external cricoid pressure deglutitive velopharyngeal contractile integral progressively increased with increased swallowed volumes (P < 0.05). In conclusion, acute experimental restriction of UES opening by external cricoid pressure manifests the pressure characteristics of increased resistance to UES transsphincteric flow observed clinically without affecting the pharyngeal peristaltic contractile function.

Analysis of cricoid pressure application: anaesthetic trainee doctors vs. nursing anaesthetic assistants

To evaluate the ability of anaesthetic trainee doctors compared to nursing anaesthetic assistants in identifying the cricoid cartilage, applying the appropriate cricoid pressure and producing an adequate laryngeal inlet view. Eighty-five participants, 42 anaesthetic trainee doctors and 43 nursing anaesthetic assistants, were asked to complete a set of questionnaires which included the correct amount of force to be applied to the cricoid cartilage. They were then asked to identify the cricoid cartilage and apply the cricoid pressure on an upper airway manikin placed on a weighing scale, and the pressure was recorded. Subsequently they applied cricoid pressure on actual anaesthetized patients following rapid sequence induction. Details regarding the cricoid pressure application and the Cormack-Lehane classification of the laryngeal view were recorded. The anaesthetic trainee doctors were significantly better than the nursing anaesthetic assistants in identifying the cricoid cartilage (95.2% vs. 55.8%, p=0.001). However, both groups were equally poor in the knowledge about the amount of cricoid pressure force required (11.9% vs. 9.3% respectively) and in the correct application of cricoid pressure (16.7% vs. 20.9% respectively). The three-finger technique was performed by 85.7% of the anaesthetic trainee doctors and 65.1% of the nursing anaesthetic assistants (p=0.03). There were no significant differences in the Cormack-Lehane view between both groups. The anaesthetic trainee doctors were better than the nursing anaesthetic assistants in cricoid cartilage identification but both groups were equally poor in their knowledge and application of cricoid pressure.

Cricoid pressure impedes tracheal intubation with the Pentax-AWS Airwayscope®: a prospective randomized trial

BackgroundIt is unclear how cricoid pressure affects tracheal intubation with the Pentax-AWS Airwayscope® (AWS). We conducted a prospective randomized clinical trial in anaesthetized patients. MethodsSixty patients were allocated to either the cricoid pressure (CP) group (n+30) or the sham group (n+30). We compared the two groups with regard to intubation time, number of attempts required for insertion of the Intlock blade (disposable blade of the AWS) and tracheal intubation, percentage of glottic opening (POGO) score, and subjective difficulty of both laryngoscopy and passage of a tube through the glottis. ResultsIntubation time was significantly longer in the CP group (median 45[IQR40–59] s) than in the sham group (32[28–45] s) (P+0.003, 95% CI for median difference 5–24 s). The number required for insertion of the Intlock blade did not differ between the groups (P+0.08), but the number for tracheal intubation was significantly higher in the CP group (1 attempt in 14 patients, 2 in 7, 3 in 9) than in the sham group (1 attempt in 24 patients, 2 in 6; P+0.002). POGO score did not differ significantly between the groups (P+0.60), nor did the subjective difficulty of laryngoscopy (P+0.06). The visual analogue scale score for passage of a tube through the glottis was significantly higher in the CP group than in the sham group (P<0.001). ConclusionsCricoid pressure impedes tracheal intubation using the AWS, and is associated with longer intubation time, which can be attributed to increased difficulty in the passage of a tube through the glottis. Clinical Trial registry numberUMIN000018209.

Analysis of Cricoid Pressure Force and Technique Among Anesthesiologists, Nurse Anesthetists, and Registered Nurses.

The purpose of this project was to assess the ability of anesthesiologists, nurse anesthetists, and registered nurses to correctly identify anatomic landmarks of cricoid pressure and apply the correct amount of force. The project included an educational intervention with one group pretest-post-test design. Participants demonstrated cricoid pressure on a laryngotracheal model. After an educational intervention video, participants were asked to repeat cricoid pressure on the model. Participants with a nurse anesthesia background applied moreappropriate force pretest than other participants; however, post-test results, while improved, showed no significant difference among providers. Participant identification of the correct anatomy of the cricoid cartilage and application of correct force were significantly improved after education. This study revealed that participants lacked prior knowledge of correct cricoid anatomy and pressure as well as the ability to apply correct force to the laryngotracheal model before an educational intervention. The intervention used in this study proved successful in educating health care providers.

Cricoid Pressure Should Not Be Used with the Pentax Airway Scope

Cricoid pressure has been associated with worsened glottic views and difficult tube placement during conventional laryngoscopy and intubation. It has

Peroral endoscopic myotomy-initial experience with anesthetic management of 24 procedures and systematic review.

Background:Peroral endoscopic myotomy (POEM) is a novel method of treating achalasia of the esophagus. Very little data are available to guide the anesthesia providers caring for these patients. The anesthetic challenges are primarily related to the risk of pulmonary aspiration. There is also a potential risk of pneumomediastinum, pneumoperitoneum, subcutaneous, or submucosal emphysema, as a result of carbon dioxide tracking into the soft tissues surrounding the esophagus and lower esophageal sphincter.Methods:In this retrospective study, electronic charts of 24 patients who underwent POEM over 18 months were reviewed. Demographic data, fasting status, relevant aspiration risks, anesthetic technique, and postoperative care measures were extracted.Results:Fasting times for both solids and liquids were variable. None of the patients underwent preprocedural esophageal emptying. Standard induction and intubation were performed in 16, rapid sequence induction (RSI) with cricoid pressure in seven, and modified rapid sequence without application of cricoid pressure in one of the patients. One of the patients aspirated at induction, and the procedure was aborted. However, the procedure was performed successfully after a few weeks, this time a RSI with cricoid pressure was chosen.Conclusion:As there are no guidelines for the perioperative management of patients presenting for POEM presently, certain recommendations can be made. Preprocedural esophageal emptying should be considered in patients considered as high-risk, although cultural factors might preclude such an approach. Induction and intubation in a semi-reclining position might be useful. Although debatable, use of RSI with cricoid pressure should be strongly considered.

Meconium peritonitis: A rare neonatal surgical emergency.

Sir, We present two cases of meconium peritonitis, a rare neonatal surgical emergency. The first baby, 1.8 Kg in weight, born at 32 weeks gestation had Apgar score of 8/10 at 1 min, heart rate (HR) was 164/min, respiratory rate (RR) 54/min and capillary refill time (CRT) 3 s. Abdomen was distended with a hard palpable lump in the supra-umbilical region. There was respiratory distress with intermittent apnoeic episodes for which the baby was intubated. Ultrasonography at 29 weeks showed ascites, bilateral pleural effusion, calcification along the liver surface and an abdominal lump. Abdominal radiograph revealed a centrally located large calcific lesion [Figure 1]. Haemoglobin was 19.2 g %, leucocyte count 17,700/mm3, C-reactive protein (CRP) 192 mg/L (normal <10 mg/L), creatinine 1.3 mg% and electrolytes and blood gases were normal. Diagnosis of meconium peritonitis was made and baby was posted for emergency laparotomy on day 1 of life. Anaesthesia was induced with sevoflurane in oxygen (O2) and maintained on sevoflurane, O2, air (50:50) with fentanyl 2 μg/kg for analgesia. Peripherally inserted central catheter (PICC) (1 Fr G) was inserted through the right cephalic vein. There was an episode of hypotension where blood pressure fell to 42/20 mm Hg for which fluid bolus was given and dopamine infusion started at 10 μg/kg/min. The large calcific deposit was removed, meconium was aspirated and suture of ileal perforation was done. Baby was electively ventilated and extubated on the 4th post-operative day. Figure 1 Chest and abdominal radiograph showing intra-abdominal calcification in the central location The second baby weighing 2 kg was delivered at term by caesarean section. Apgar score was 9/10 at 1 min, HR: 142/min, RR: 48/min and CRT < 3 s. Abdomen was distended. Ultrasound revealed dilated bowel loops with echogenic contents and free fluid suggestive of meconium peritonitis. Haematological investigations were normal. Baby was posted for emergency laparotomy on day 1 of life. Anaesthesia was induced with sevoflurane in O2. Rocuronium 1.2 mg/kg was administered and modified rapid sequence induction was performed with cricoid pressure and gentle ventilation. Exactly 45 s later airway was secured with 3.5 mm ID endotracheal tube. Anaesthesia was maintained on sevoflurane at 1.2 MAC, air, O2 mixture (50:50) and fentanyl 2 μg/kg. Adhesiolysis with excision of meconium pseudocyst in jejunum was performed. PICC (1 Fr G) was inserted through left great saphenous vein. Trachea was extubated on table. Meconium peritonitis is an aseptic chemical peritonitis which results from perforation of the gut in utero.[1] Incidence is 1 in 35,000 live births.[2] Possible causes include mesenteric ischaemia, volvulus, intestinal atresia, meconium plugs, internal hernia and Hirschsprung's disease.[3] Other associations include chromosomal aberrations and cystic fibrosis. Perforation of the intestines in utero results in leakage of meconium into the peritoneal cavity. Inflammatory reaction and chemical peritonitis occurs, which subsequently seals forming intra-abdominal calcifications. Huge abdominal cyst formation and ascites may develop which can cause foetal cardiac insufficiency and cardiorespiratory compromise after birth.[3] Prenatal ultrasound is diagnostic.[4] Management begins at delivery. Fluid resuscitation may be needed if the baby is in shock. Bag-mask ventilation may further aggravate bowel distension. Endotracheal intubation with controlled ventilation is preferable. Initial stabilisation of cardiopulmonary parameters and blood gas analysis, CRP, lactates, haematocrit, blood count, platelets, electrolytes, culture and cross match are done. Inotropes are started early if haemodynamic instability does not respond to fluid boluses. Chest and abdominal radiographs, ultrasound of abdomen and echocardiography are preferable as persistent pulmonary hypertension may complicate the management. These babies are then managed in a staged approach. An abdominal drainage with ultrasound guidance under local anaesthesia is preferred in critical neonates. Exploratory laparotomy with adhesiolysis and enterostomy is done in haemodynamically stable babies. Finally, stoma closure is performed. Prolonged antibiotic administration postoperatively and enteral nutrition may warrant PICC insertion. Complications such as wound infection, intestinal fistula, abdominal abscess, cerebral haemorrhage due to disseminated intra-vascular coagulation, sepsis and multi-organ failure may occur.[3] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Difficult Intubation Factors in Prehospital Rapid Sequence Intubation by an Australian Helicopter Emergency Medical Service

ObjectivePrehospital rapid sequence intubation (RSI) of critically ill trauma patients is a high-risk procedure that may be associated with an increased rate of severe complications such as failed intubation, failure of oxygenation, hypoxia, hypotension, or need for surgical airway. The objective of this study was to describe the factors associated with difficult intubation in prehospital RSI as defined by more than a single look at laryngoscopy to achieve tracheal intubation. MethodsThis is an observational study using prospectively collected data. ResultsFour hundred forty-three RSIs were performed. Paramedics were the initial laryngoscopist in 290 (65.5%). First-look laryngoscopy resulted in successful tracheal intubation (TI) in 372 (84.0%) (95% confidence interval, 80.3%-87.1%). Intubation was achieved on second look at laryngoscopy in 58 (13.1%). “First-pass” TI was achieved in 394 (88.9%). Overall, successful TI was achieved in 438 (98.9%) (95% confidence interval, 97.4%-99.5%). Complications occurred in 116 (26.2%), with desaturation the commonest in 77 (17.4%). ConclusionFactors associated with more than 1 look at laryngoscopy before TI included paramedic laryngoscopist and the presence of at least 1 of the following indicators: blood/vomitus in the airway, limited mouth opening, and limited neck movement. Trauma to face/neck, obese body habitus, C-spine precautions, cricoid pressure, midline stabilization, and intubation on the ground did not influence the level of difficulty encountered.

Large gastric wood bezoar: Anesthesia implications.

Sir, Bezoars are collections or concretions of indigestible foreign material that accumulate and coalesce in the gastrointestinal tract, most commonly in the stomach. Gastric bezoar formation occurs in patients with altered gastric physiology, impaired gastric emptying and other co-existing illness affecting gastrointestinal motility. It is also commonly seen in patients with psychiatric illnesses and history of pica. In the pediatric population, common types of bezoar seen are lactobezoars, phytobezoars, and trichobezoars.[1] We report the case of a 7-year-old child with a large gastric wood bezoar. A 7-year-old male child weighing 20 kg presented with a history of pica, mostly wooden scrapings since 2½ years, pain in abdomen and vomiting. Upper gastrointestinal (UGI) endoscopy revealed a large gastric bezoar. The patient underwent endoscopy twice during which general endotracheal anesthesia was given but the attempts to remove the bezoar piecemeal were unsuccessful. Five days following the third endoscopy, the patient developed constipation, abdominal tenderness and guarding, and was scheduled for a laparotomy. The biochemical investigations of the patient were normal, except for hemoglobin level of 92 g%. Preoperative optimization of fluid status was done. Rapid sequence induction (RSI) was done using 40 mg of propofol and 20 mg of rocuronium intravenously, and the patient was intubated using 5.5 mm ID cuffed endotracheal tube. A 24 G lumbar epidural catheter was inserted postinduction for analgesia. Gastric perforation was seen on laparotomy caused either by the bezoar itself or the attempted endoscopic removal. After extending the incision, a phytobezoar measuring 13 cm × 11 cm (200 g) was removed, and the gastric perforation was closed [Figure 1]. Anesthesia was reversed, and recovery was uneventful.Figure 1: Wood bezoarThe anesthesiologist must be aware of the perioperative complications of a large gastric bezoar. The complication rate of endoscopy is 0.1% for UGI procedures with cardiopulmonary events predominating (50%) which include dysrhythmias, hypoxemia from respiratory depression, and cardiac arrest. Bleeding, aspiration, and perforation are other complications.[2] There is a reported case of respiratory arrest due to airway obstruction following the endoscopic removal of trichobezoar.[2] Certain co-morbid conditions such as cystic fibrosis, diabetes mellitus, hypothyroidism, Guillain–Barre syndrome, and renal failure, etc., have been associated with an increased risk of bezoar formation.[3] Bezoars are also associated with failure to thrive and iron deficiency anemia. Patients with protracted obstructive symptoms and vomiting are likely to be hypovolemic and have electrolyte disturbances. Preprocedure resuscitation may be required. RSI is indicated as these patients are at high risk of aspiration.[4] In pediatric patients, the cricoid pressure given during RSI can distort the airway and interfere with smooth induction. Furthermore, there are more chances of hypoxemia in the period between induction and reestablishment of ventilation.[5] Hence, we avoided the “classic” RSI and used gentle pressure limited mask ventilation with 100% oxygen following induction. The close psychiatric follow-up is recommended to diminish the chances of recurrence.[1] Laparoscopic removal of gastric bezoar is associated with less postoperative morbidity and pain but is technically challenging.[3] Our patient had borderline hemoglobin with a picture of iron deficiency anemia with normal electrolytes. The risk of aspiration was present as the patient had developed obstructive symptoms. Due to the large size of bezoar and risk of aspiration, RSI was done. As the patient was clinically stable, propofol was used for induction, and epidural anesthesia was also given. The patient was referred for psychiatric evaluation postoperatively. To conclude, the anesthetic plan to manage a gastric bezoar should include complications associated with preoperative fluid and electrolyte imbalance, the need for RSI and intubation, and issues associated with the procedure or surgery itself. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Developments in the management of diabetic ketoacidosis in adults: implications for anaesthetists

### Key points Diabetic ketoacidosis (DKA) is a medical emergency. The diagnostic triad is: 1. Ketonaemia ≥3.0 mmol litre−1 or significant ketonuria (more than 2+ on urine sticks) 2. Blood glucose >11.0 mmol litre−1 or known diabetes mellitus 3. Bicarbonate <15.0 mmol litre−1, venous pH <7.3, or both. DKA can occur in both type 1 and type 2 diabetes mellitus and, although preventable, it remains a frequent and life-threatening complication. Errors in the management of DKA are not uncommon and are associated with significant morbidity and mortality. The majority of mortality and morbidity in DKA are attributable to delays in presentation and initiation of treatment. Rapid recognition and treatment of DKA is critical. To overcome these concerns and to highlight current management strategies, the Joint British Diabetes Societies (JBDS) published guidelines in 2010. This was updated in consultation with the Intensive Care Society in September 2013.1 This article will review the pathophysiology of DKA and highlight the modern management of DKA that is relevant for anaesthetists. A summary of the JBDS guidelines pertinent to intensivists has been published.2 In England in 2010, there were 14 375 admissions to …

All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in obstetrics.

The various physiological changes in pregnancy make the parturient vulnerable for early and rapid desaturation. Severe hypoxaemia during intubation can potentially compromise two lives (mother and foetus). Thus tracheal intubation in the pregnant patient poses unique challenges, and necessitates meticulous planning, ready availability of equipment and expertise to ensure maternal and foetal safety. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for the safe management of the airway in obstetric patients. These guidelines have been developed based on available evidence; wherever robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists (ISA). Modified rapid sequence induction using gentle intermittent positive pressure ventilation with pressure limited to ≤20 cm H2O is acceptable. Partial or complete release of cricoid pressure is recommended when face mask ventilation, placement of supraglottic airway device (SAD) or tracheal intubation prove difficult. One should call for early expert assistance. Maternal SpO2 should be maintained ≥95%. Apnoeic oxygenation with nasal insufflation of 15 L/min oxygen during apnoea should be performed in all patients. If tracheal intubation fails, a second- generation SAD should be inserted. The decision to continue anaesthesia and surgery via the SAD, or perform fibreoptic-guided intubation via the SAD or wake up the patient depends on the urgency of surgery, foeto-maternal status and availability of resources and expertise. Emergency cricothyroidotomy must be performed if complete ventilation failure occurs.

A survey of a population of anaesthesiologists from South India regarding practices for rapid sequence intubation in patients with head injury.

Background and Aims:Evidence and utility of the individual steps of the rapid sequence induction and tracheal intubation protocols have been debated, especially in the setting of traumatic brain injury. The purpose of this survey was to determine preferences in the current approach to rapid sequence intubation (RSI) in head injury patients among a population of anaesthesiologists from South India.Methods:A questionnaire was E-mailed to all the members of the Indian Society of Anaesthesiologists’ South Zone Chapter to ascertain their preferences, experience and comfort level with regard to their use of rapid sequence intubation techniques in adult patients with head injury. Participants were requested to indicate their practices for RSI technique for a head-injured patient upon arrival at the Emergency Medical Services department of their hospital.Results:The total response rate was 56.9% (530/932). Of the total respondents, 35% of the clinicians used cricoid pressure routinely, most respondents (68%) stated that they pre-oxygenate the patients for about 3 min prior to RSI, thiopentone (61%) and propofol (34%) were commonly used prior to intubation. Rocuronium was the muscle relaxant of choice for RSI among the majority (44%), compared to succinylcholine (39%). Statistical analyses were performed after the initial entry onto a spreadsheet. Data were summarised descriptively using frequency distribution.Conclusion:In a rapid sequence intubation situation, the practice differed significantly among anaesthesiologists. Owing to disagreements and paucity of evidence-based data regarding the standards of RSI, it is apparent that RSI practice still has considerable variability in clinical practice.

Cricoid pressure during rapid sequence induction: using the force or not.

Cricoid pressure during rapid sequence induction: using the force or not.

Aristotle, Galileo and Sellick: The unsolved dilemma of cricoid pressure

For almost one thousand years, the principles and structure of the Universe were studied, reported, understood and believed to be in accordance with Aristotle's theory of the five elements (earth, fire, air, water and ether), with the invisible immobile engine and geocentric depiction of planets, stars and deep space (what he called cosmos, Greek word for order and beauty). There was no idea of gravity andmass, as it was time for limited scientific instruments and a generous imagination hypothesis, philosophy being a substitute for science whenever something could not be explained with the sole (limited) available knowledge. At that time religion and science were in some kind of continuum, with any physical principle or event, including health and sickness, being explained with the first or latter, or sometimes with both. As time passed by, and it took almost nine centuries, a curious and obstinate scientist named Galileo started to raise some doubts. It was 1619, and, thanks to being a forerunner of the scientific approach, the italian scientist was the first to see truth through the mist. His doubts were so big that, at a certain point, despite being sure of his intuition and experiments, not to be considered heretic in the face of such big changes, he had to withdraw and deny everything in front of the Inquisition. In a certain sense, Science had to bow to Religion, the interest of the many in comparisonwith the reason of one. As a curiosity, we had towait until October 31st, 1992 when Galileo's opera omnia was removed by the Vatican from the Index of prohibited books. And we had to wait for Isaac Newton, and his general gravity