Sellick’s Maneuver: To Do or Not Do

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.

Supraglottic jet oxygenation and ventilation via nasopharyngeal airway for a patient with iatrogenic tracheoesophageal fistula: A case report

Background

Iatrogenic tracheoesophageal fistula (TEF) is a rare but life-threatening condition. No consensus has been reached regarding TEF treatment, though, stenting has been gaining popularity for less invasiveness than thoracic surgery. The airway management during stent placement for TEF could be challenging.

Case presentations

We report a patient who suffered from TEF after cardiac surgery with symptoms of persistent coughing and aspiration. He who was admitted for stent placement but ended up in failure and referred to our institution for further treatment. We successfully took advantage of the supraglottic jet oxygenation and ventilation (SJOV) during stent placement.

Conclusion

This is the first case so far describing SJOV in complicated stenting treatment. This demonstrates that SJOV can be applied for stent placement in TEF patients with restricted airways.

Cricoid Pressure Controversies

Since cricoid pressure was introduced into clinical practice, controversial issues have arisen, including necessity, effectiveness in preventing aspiration, quantifying the cricoid force, and its reliability in certain clinical entities and in the presence of gastric tubes. Cricoid pressure–associated complications have also been alleged, such as airway obstruction leading to interference with manual ventilation, laryngeal visualization, tracheal intubation, placement of supraglottic devices, and relaxation of the lower esophageal sphincter. This review synthesizes available information to identify, address, and attempt to resolve the controversies related to cricoid pressure. The effective use of cricoid pressure requires that the applied force is sufficient to occlude the esophageal entrance while avoiding airway-related complications. Most of these complications are caused by excessive or inadequate force or by misapplication of cricoid pressure. Because a simple-to-use and reliable cricoid pressure device is not commercially available, regular training of personnel, using technology-enhanced cricoid pressure simulation, is required. The current status of cricoid pressure and objectives for future cricoid pressure–related research are also discussed.

Cricoid pressure: Where do we stand?

In 1961, Sellick popularized the technique of cricoid pressure (CP) to prevent regurgitation of gastric contents during anesthesia induction. In the last two decades, clinicians have begun to question the efficacy of CP and therefore the necessity of this maneuver. Some have suggested abandoning it on the grounds that this maneuver is unreliable in producing midline esophageal compression. Moreover, it has been found that application of CP makes tracheal intubation and mask ventilation difficult and induces relaxation of the lower esophageal sphincter. There have also been reports of regurgitation of gastric contents and aspiration despite CP. Further, its effectiveness has been demonstrated only in cadavers; therefore, its efficacy lacks scientific validation. These concerns with the use of CP in modern anesthesia practice have been briefly reviewed in this article.

Gastric tubes and airway management in patients at risk of aspiration: history, current concepts, and proposal of an algorithm

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.

The difficult airway with recommendations for management--part 2--the anticipated difficult airway

BACKGROUND

Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway.

METHODS

To review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned.

PRINCIPAL FINDINGS

Previously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician's experience, must also be considered in deciding the appropriate strategy.

CONCLUSIONS

With an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.

The duration of fibre-optic intubation is increased by cricoid pressure. A randomised double-blind study

BACKGROUND

In some categories of patients, a rapid sequence induction using a fibre-optic method may be indicated. The aim of the present study was to examine the effect of cricoid pressure (CP) on the duration of fibre-optic intubation. The hypothesis was that CP would prolong the intubation time.

METHODS

The study was a randomised, double-blind, cross-over study. The patients were intubated twice, in a randomised way, using a flexible fibrescope once with and once without CP. The intubation time and the visualisation of the glottis were registered. If the intubation was not completed within 180 s, it was registered as failed. CP was standardised to a pressure of 30 N. The data are given as the mean (standard deviation) or median [interquartile] (range).

RESULTS

Fifty patients were included, with a mean age of 53 years (14.6) and mean body mass index of 26.4 (4.3). Three intubations without and 13 intubations with CP failed. The durations of intubation without and with CP were 59 s [53-79 s] (34-144 s) and 75 s [67-104 s] (43-179 s), respectively (P < 0.001).

CONCLUSION

The study showed that CP prolongs the duration of fibre-optic intubation in patients with Mallampati grades 1-2.

Management of sleep apnea in adults - functional algorithms for the perioperative period: Continuing Professional Development

PURPOSE

Obstructive sleep apnea (OSA) is defined by repetitive partial or complete upper airway obstruction characterized by episodes of breathing cessation during sleep. It is the most prevalent of sleep disorders, seen in about one in four males and one in ten females. We reviewed current literature, collated expert opinion, and synthesized protocols from several institutions to present practical principles and functional algorithms to assist the anesthesiologist in the perioperative management of known and suspected OSA.

PRINCIPAL FINDINGS

Patients with OSA may have an increase in postoperative adverse respiratory events, sustained arrhythmias, hypertension, and other cardiovascular events. The gold standard for the diagnosis of OSA is polysomnography. The Berlin questionnaire and the American Society of Anesthesiologists OSA checklist are useful screening tools, while the STOP and the STOP-Bang questionnaires are easy to use in adults. Patients scheduled for elective major surgery, who are at high risk of OSA with significant comorbidities, may be referred for preoperative polysomnography. Perioperative precautions, such as anticipation of a possible difficult airway, use of short-acting anesthetic agents, avoidance of opioids, and extubation in a non-supine position, should be undertaken for known or suspected high-risk OSA patients. Postoperative disposition of the OSA patient should be based on the severity of the sleep disorder, recurrent postanesthesia care unit respiratory events, and the need for opioid analgesia.

CONCLUSION

With adequate screening and vigilance in the preoperative period, risk stratification should be undertaken for known and suspected OSA patients, and care should be individualized. Practical algorithms based on current best evidence and expert opinion may be useful in the perioperative management.