Effect of facemask ventilation with different ventilating volumes on gastric insufflation during anesthesia induction in patients undergoing laparoscopic cholecystectomy

Gastric Injury at Laparoscopy for Gynecologic Indications: A Systematic Review

OBJECTIVE

This systematic review aims to identify causes of increased risk for and location and mechanism of gastric injury at laparoscopy for gynecologic indications and determine optimal management.

DATA SOURCES

A prospectively registered systematic review (PROSPERO: CRD42021237999) was undertaken and performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases searched included Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Medline, Embase, Web of Science, SCOPUS, and Google Scholar from 1960 to 2021.

METHODS OF STUDY SELECTION

All study types were included involving female patients of any age with gastric injury at laparoscopy for gynecologic indication.

TABULATION, INTEGRATION, AND RESULTS

A total of 6294 articles were screened, from which 67 studies were selected for a full-text review. Twenty-eight articles were included, which contained 42 cases drawn from 7 observational studies, 4 case series, and 17 case reports. Of these, 93% (39/42) were at the time of laparoscopic entry, with Veress entry technique used in 79% of these cases (31/39). Eighteen cases reported an entry point, with 77% (14/18) occurring at the periumbilical entry point and 11% (2/18) occurring at Palmer's point. Of the cases with reported etiology for gastric distention or displacement, 64% (9/14) were owing to anesthetic cause. The most common sites of gastric injury were on the anterior stomach wall (n = 8) and the greater curvature (n = 5). Among patients with reported management (32/42), a similar proportion were managed conservatively (11) when compared with repair through laparotomy (13) or laparoscopy (8). All injuries were detected intraoperatively with no reported short-term sequelae.

CONCLUSION

This systematic review of the literature reveals that gastric injury at laparoscopy for gynecologic indications is a rare complication predominantly occurring during laparoscopic entry, most commonly at the periumbilical entry point. When detected intraoperatively, conservative management, laparoscopic, or open repair in the appropriate patient has been performed with no short-term sequelae. The limitations of this review include paucity of cases, detail, and timeline of publications.

[Is pre-oxygenation with high-flow nasal oxygen safe? randomized control trial of 56 cases of elderly patients during induction of general anesthesia with endotracheal intubation]

OBJECTIVE

To evaluate the safety of preoxygenation with high-flow nasal oxygenation in elderly patients during induction of general anesthesia with endotracheal intubation.

METHODS

Fifty-six elderly patients without difficult airway were randomized equally into high-flow nasal oxygen group (HF group) and conventional mask oxygen group (M group). Preoxygenation was performed for 5 min before induction of general anesthesia and endotracheal intubation. Oxygenation was maintained during laryngoscopy in HF group, and ventilation lasted until laryngoscopy in M group. For all the patients, the general data, cross-sectional area (CSA) of the gastric antrum measured by ultrasonography, arterial partial pressure of oxygen (PaO₂), arterial partial pressure of carbon dioxide (PaCO₂) and arterial oxygen saturation (cSO₂) were recorded before preoxygenation (T1), at 5 min of preoxygenation (T2) and immediately after intubation (T3). The safety time of asphyxia, intubation time, times of mask ventilation and postoperative complications were compared between the two groups.

RESULTS

The general data were comparable between the two groups. After 5 min of preoxygenation, PaO₂ and cSO₂ were significantly increased in both groups, and PaO₂ was significantly higher in HF group than in M group (F=118.108 vs 9.511, P < 0.05). Both PaO₂ and cSO₂ decreased after intubation, but PaO₂ decreased more slowly in HF group and still remained higher than that at T1; cSO₂ decreased significantly in M group to a lower level than that at T1. Compared with those in M group, the patients in HF group showed a significantly longer safety time of asphyxia (t=5.305, P < 0.05) with fewer times of mask ventilation (χ²= 6.720, P < 0.05). PaCO₂ increased after intubation in both groups but was comparable between the two groups (F=3.138, P > 0.05).

CONCLUSION

High-flow nasal oxygen is safe, simple and effective for pre-oxygenation, which, as compared with the conventional oxygen mask, improves arterial oxygen partial pressure and prolongs the safety time of asphyxia to ensure the safety of airway management during induction of general anesthesia in elderly patients with endotracheal intubation.

7: Comparison of real-time cervical oesophageal ultrasonography and gastric antral ultrasonography to detect gastric insufflation during face-mask ventilation under general anaesthesia-Aprospective observational study

Background and Aims:

Face mask ventilation (FMV) is live saving. It is paramount to maintain oxygenation and ventilation. But FMV is avoided in rapid sequence induction( RSI), for fear of gastric insufflation. Gastric insufflation predisposes the patient to pulmonary aspiration. But the current methods available to detect gastric insufflation are not reliable markers. These include epigastric auscultation for insufflated gases, insertion of nasogastric tube to aspirate and measure the gases, and gastric antral cross-sectional area (CSA) measurement. Each of the above have their own limitations. So, reliable markers denoting gastric insufflation can prevent pulmonary aspiration and can enable “safe” FMV. Real-time transcutaneous ultrasonography(USG) of cervical oesophagus during FMV was done to look for comet-tail artefacts (acoustic shadows created by entrainment of gases into digestive tract)The aim of this study was to compare real-time upper cervical USG with gastric antral USG to detect gastric insufflation during FMV under general anaesthesia.

Methods:

Results:

Ninety patients were recruited. One case of accidental intubation was withdrawn. Remaining 89 patients were analysed. There was an increased incidence of comet-tail artefacts in the oesophagus when compared to gastric antrum. This difference was statistically significant as analysed by Mcnemar test. The lowest peak airway pressure at which comet-tail artefacts appeared in oesophagus was 21.47 (SD-2.86) cm H20.

Conclusion:

Cervical oesophageal USG is better than gastric antral USG in identifying insufflation of gas into digestive tract. Limiting the airway pressures to < 20 cm H₂O would be safer in providing safe FMV without cricoid pressure. Real-time USG monitoring of oesophagus in the neck for comet-tail artefacts is useful in early identification of early gastrooesophageal insufflation.

[Ultrasound assessment of gastric insufflation in obese patients receiving transnasal humidified rapid-insufflation ventilatory exchange during general anesthesia induction]

OBJECTIVE

To assess the effect of transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) on gastric insufflation during general anesthesia induction in obese patients.

METHODS

Ninety obese patients (BMI 30-39.9 kg/m²) undergoing laparoscopic cholecystectomy under general anesthesia were randomized into 3 groups (n=30) to receive facemask pre- oxygenation followed by face mask ventilation (FMV) after administration of anesthetics (Group M), oxygenation with THRIVE (Group T), or pre-oxygenation with facemask combined with THRIVE followed continuous oxygenation with both FMV and THRIVE after administration of anesthetics (Group M+T). The patients in the latter two groups received continuous oxygen via THRIVE during tracheal intubation. All the patients received real-time ultrasound monitoring of the gastric antrum, and positive gastric insufflation (GI⁺) was defined by the presence of comet-tail artifacts. The cross-sectional area of the gastic antrum (CSA-GA) was measured by ultrasound before and after pre-oxygenation and after intubation. The patients' SpO₂, PaO₂, and PaCO₂ at admission (T₁), 5 min after pre-oxygenation (T₂), 5 min after medication (T₃), and immediately after intubation (T₄) were recorded, and the incidence of postoperative adverse events was assessed.

RESULTS

The incidence of gastric insufflation was significantly higher in Group M and Group M+T than in Group T (P < 0.05). The CSA-GA was significantly greater at T₄ than at T₁ in Group M and Group M+T and in their GI⁺s ubgroups. The GI⁺ subgroups in Group M and Group M+ T had significantly larger CSA-GA at T₄ than the GI^- subgroups (P < 0.05). CSA-GA did not vary significantly during anesthesia induction in Group T (P>0.05). The incidence of grade Ⅰ gastric distension was lower but grade Ⅱ gastric distention was higher in Group M and Group M+T than in Group T (P < 0.05). Group M showed significantly greater variations of PaO₂ at T₃ and T₄ than Group T and Group M+T (P < 0.05).

CONCLUSIONS

Ultrasound monitoring of the comet tail sign and the changes of CSA-GA in the gastric antrum is feasible and reliable for detecting gastrointestinal airflow, and in obese patients, the application of THRIVE for induction of anesthesia can ensure the oxygenation level without further increasing gastric insufflation.