Cricoid pressure: Where do we stand?

Risks in the Management of Polytrauma Patients: Clinical Insights

Polytrauma, a patient's condition with multiple injuries that involve multiple organs or systems, is the leading cause of mortality in young adults. Trauma-related injuries are a major public health concern due to their associated morbidity, high disability, associated death, and socioeconomic consequences. Management of polytrauma patients has evolved over the last few decades due to the development of trauma systems, improved pre-hospital assessment, transport and in-hospital care supported by complementary investigations. Recognising the mortality patterns in trauma has led to significant changes in the approach to managing these patients. A structured approach with application of advanced trauma life support (ATLS) algorithms and optimisation of care based on clinical and physiological parameters has led to the development of early appropriate care (EAC) guidelines to treat these patients, with subsequent improved outcomes in such patients. The journey of a polytrauma patient through the stages of pre-hospital care, emergency resuscitation, in-hospital stabilization and rehabilitation pathway can be associated with risks at any of these phases. We describe the various risks that can be anticipated during the management of polytrauma patients at different stages and provide clinical insights into early recognition and effective treatment of these to improve clinical outcomes.

Cricoid Pressure: Contradictory Evidence Regarding a Standard Practice

The purpose of applying cricoid pressure is to prevent pulmonary aspiration of regurgitated gastric contents during airway management in mask-ventilated patients who are at risk of aspiration. Providers may apply cricoid pressure during induction and intubation if they expect a difficult intubation or if the patient has a high risk for regurgitation. Although the application of cricoid pressure has been accepted as a standard practice worldwide, controversy persists because pulmonary aspiration can occur even when cricoid pressure is applied. The perioperative nurse should have thorough knowledge of the anatomy of the upper respiratory and gastrointestinal tracts, be able to demarcate the surface landmarks of the neck, and be skilled in applying cricoid pressure properly and safely. This article discusses cricoid pressure in the context of safe airway management as well as the perioperative nurse's role as an assistant to the anesthesia professional when applying cricoid pressure.

Left paratracheal pressure versus cricoid pressure for successful laryngeal mask airway insertion in adult patients: a randomized, non-inferiority trial

BACKGROUND

Cricoid pressure (CP) is used to prevent pulmonary aspiration of regurgitated gastric contents and gastric insufflation during positive-pressure ventilation. However, CP impedes the successful insertion of laryngeal mask airway (LMA). Left paratracheal pressure (LPP), a manoeuvre of applying backward digital force at the lower left paratracheal level, was recently introduced as an alternative to CP. We assessed whether LPP is non-inferior to CP in successful LMA insertion on the first attempt in adult patients undergoing general anaesthesia.

METHODS

In this non-inferiority randomized controlled trial, 108 patients undergoing general anaesthesia were randomly allocated to receive either LPP or CP during LMA insertion. The primary outcome was the success rate of LMA insertion on the first attempt. The margin of non-inferiority was defined as 15%.

RESULTS

The success rate of LMA insertion on the first attempt was 68.5% (37/54) in the LPP group and 51.9% (28/54) in the CP group (P=0.077) with between-group difference of 16.7% (two-sided 95% CI, -1.9% to 35.2%). Time for successful device insertion was comparable in the two groups (P=0.355), whereas LMA insertion was easier in the LPP group than in the CP group (P=0.001). There was no significant difference between the two groups for change in antral cross-sectional area measured before and after mask ventilation (P=0.081). No serious complication was evident in any group.

CONCLUSIONS

This randomized clinical trial demonstrated the non-inferiority of LPP over CP in the success rate of LMA insertion on the first attempt in adult patients undergoing general anaesthesia.

A survey of self-reported use of cricoid pressure amongst Australian and New Zealand anaesthetists: Attitudes and practice

We conducted a survey of Australian and New Zealand anaesthetists designed to quantify self-reported use of cricoid pressure (CP) in patients presumed to be at risk of gastric regurgitation, and to ascertain the underlying justifications used to support individual practice. We aimed to identify the perceived benefits and harms associated with the use of CP and to explore the potential impact of medicolegal concerns on clinical decision-making. We also sought to ascertain the views of Australian and New Zealand anaesthetists on whether recommendations relating to CP should be included in airway management guidelines. We designed an electronic survey comprised of 15 questions that was emailed to 981 randomly selected Fellows of the Australian and New Zealand College of Anaesthetists (ANZCA) by the ANZCA Clinical Trials Network on behalf of the investigators. We received responses from 348 invitees (response rate 35.5%). Of the 348 respondents, 267 (76.9%) indicated that they would routinely use CP for patients determined to be at increased risk of gastric regurgitation. When asked whether participants believed the use of CP reduces the risk of gastric regurgitation, 39.8% indicated yes, 23.8% believed no and 36.3% were unsure. Of the respondents who indicated that they routinely performed CP, 159/267 (60%) indicated that concerns over the potential medicolegal consequences of omitting CP in a patient who subsequently aspirates was one of the main reasons for using CP. The majority (224/337; 66%) of respondents believed that recommendations about the use of CP in airway management guidelines should include individual practitioner judgement, while only 55/337 (16%) respondents believed that routine CP should be advocated in contemporary emergency airway management guidelines.

Ultrasound guided paralaryngeal pressure versus cricoid pressure on the occlusion of esophagus: a crossover study

The primary objective of this study is to compare the effectiveness of cricoid pressure (CP) and paralaryngeal pressure (PLP) on occlusion of eccentric esophagus in patients under general anesthesia (GA). Secondary objectives include the prevalence of patients with central or eccentric esophagus both before and after GA, and the success rate of CP in occluding centrally located esophagus in patients post GA. Fifty-one ASA physical status I and II patients, undergoing GA for elective surgery were enrolled in this study. Ultrasonography imaging were performed to determine the position of the esophagus relative to the trachea: (i) before induction of GA, (ii) after GA before external CP maneuver, (iii) after GA with CP, and (iv) after GA with PLP. CP was applied to all patients whilst PLP via fingertip technique was only applied to patients with an eccentric esophagus. Among a total of 51 patients, 28 of them (55%) had eccentric esophagus pre GA, while this number increase to 33 (65%) after induction of GA. CP success rate was 100% in 18 patients with central esophagus post GA versus 27% in 33 patients with eccentric esophagus post GA (P<0.00001). Overall success rate for CP was 53%. In 33 patients with eccentric esophagus anatomy post GA, PLP success rate was 30% compared with 27% with CP (P=1.000). Ultrasound guided PLP fingertips technique was not effective in patients with an eccentrically located esophagus post GA. Ultrasound guided CP achieved 100% success rate in patients with a centrally located esophagus post GA.

Use of point-of-care ultrasound to assess esophageal insufflation during bag mask ventilation: A case report

Bag-valve-mask ventilation is a basic airway management technique often used in patients with acute respiratory failure. Although highly effective in providing oxygenation and ventilation, this technique has been associated with gastric regurgitation and tracheal aspiration. In this case, the esophagus was visualized with bedside ultrasonography during bag-mask ventilation of an unresponsive and critically ill patient. Images were obtained both with and without cricoid pressure. Additionally, images were obtained during ultrasound-guided probe pressure on the lateral neck. Esophageal insufflation was identified consistently during bag mask ventilation. Cricoid pressure did not prevent esophageal insufflation. Ultrasound-guided probe pressure attenuated esophageal insufflation. This case depicts a unique instance of using a novel method to assess breath delivery during bag mask ventilation of a critically ill patient.

A modified Montpellier protocol for intubating intensive care unit patients is associated with an increase in first-pass intubation success and fewer complications

BACKGROUND

The Montpellier protocol for intubating patients in the intensive care unit (ICU) is associated with a decrease in intubation-related complications. We sought to determine if implementation of a simplified version of the Montpellier protocol that removed selected components and allowed for a variety of pre-oxygenation modalities increased first-pass intubation success and reduced intubation-related complications.

METHODS

A prospective pre/post-comparison of a modified Montpellier protocol in two medical and one medical/surgical/cardiac ICU within a hospital system. The modified eight-point protocol included: fluid administration, ordering sedation, two intubation trained providers, pre-oxygenation with non-invasive positive pressure ventilation, nasal high flow cannula or non-rebreather mask, rapid sequence intubation, capnography, sedation administration, and vasopressors for shock.

RESULTS

Patient characteristics and indications for intubation were similar for the 275 intubations in the control (137) and intervention (138) periods. In the intervention vs. control periods, the modified Montpellier protocol was associated with a significant 16.2% [95% CI: 5.1-30.0%] increase in first-pass intubation success and a 12.6% [95% CI: 1.2-23.6%] reduction in all intubation-related complications.

CONCLUSION

A simplified version of the Montpellier intubation protocol for intubating ICU patients was associated with an improvement in first-pass intubation success rates and a reduction in the rate of intubation-related complications.

Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy

OBJECTIVE

This study was a prospective, randomized controlled trial of rapid sequence intubation (RSI) with cricoid pressure (CP) within the emergency department (ED). The primary aim of the study was to examine the link between ideal CP and the incidence of aspiration.

METHOD

Patients > 18 years of age undergoing RSI in the ED of two hospitals in New South Wales, Australia, were randomly assigned to receive measured CP using weighing scales to target the ideal CP range (3.060-4.075 kg) or control CP where the weighing scales were used, but the CP operator was blinded to the amount of CP applied during the RSI. A data logger recorded all CP delivered during each RSI. Immediately after intubation, tracheal and esophageal samples were taken and underwent pepsin analysis.

RESULTS

Fifty-four RSIs were analyzed (25 measured/29 control). Macroscopic contamination of the larynx at RSI was observed in 14 patients (26%). During induction (0-50 seconds), both groups delivered in-range CP. During intubation (51-223 seconds), laryngoscopy was associated with a reduction in mean CP below 3.060 kg in both groups. When compared, there was no statistically significant difference between the groups. For 11 patients, pepsin was detected in the oropharyngeal sample, while three were positive for tracheal pepsin. Seven patients (four control/three measured) were treated for clinical aspiration during hospitalization. As a result of the finding that neither group could maintain ideal range CP during laryngoscopy, the trial was abandoned.

CONCLUSION

Laryngoscopy provides a counter force to CP, which is negated to facilitate tracheal intubation. The concept that a static 3.060 to 4.075 kg CP could be maintained during laryngoscopy and intubation was rejected by our study. Whether a lower CP range could prevent aspiration during RSI was not explored by this study.

Implementation of NAP4 emergency airway management recommendations in a quaternary-level pediatric hospital

Emergency airway management, particularly outside of the operating room, is associated with a high incidence of life-threatening adverse events. Based on the recommendations of the 4th National Audit Project, we aimed to develop hospital-wide systems changes to improve the safety of emergency airway management. We describe a framework for governance in the form of a hospital airway special interest group. We describe the development and implementation of the following systems changes: 1. A local intubation algorithm modified from the Difficult Airway Society's plan A-B-C-D approach, including clear pathways for airway escalation, and emphasizing the concepts of resuscitation prior to intubation, planning for failure, and avoidance of fixation error. 2. Simplified and standardized airway equipment located in identical airway carts in all critical care areas. 3. A preintubation checklist and equipment template to standardize preparation for airway management. 4. Availability of continuous waveform endtidal capnography in all critical care areas for confirmation of correct endotracheal tube placement. 5. Multidisciplinary team training to address the technical and nontechnical aspects of nonoperating room intubation. In addition, we describe methodology for ongoing monitoring of performance through a quality assurance framework. In conclusion, changes in the process of emergency airway management at a hospital level are feasible through collaboration. Their impact on patient-based outcomes requires further study.

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.

Laparoscopic Nissen fundoplication with Baska Mask® laryngeal mask

Tracheal intubation has historically been considered the ideal technique to handle the airway in laparoscopic surgical procedures. The introduction of such procedures in ambulatory surgery requires the use of anesthetic techniques that offer optimal and early postoperative recovery under strict security conditions. Laryngeal mask is proposed as a suitable alternative to tracheal intubation, even in high risk patients due to new devices which have been modified to improve their characteristics, becoming great alternatives in the overall management of the airway. We report the first case of laparoscopic Nissen fundoplication performed with a laryngeal Baska Mask in patient with high risk of regurgitation due to its gastroesophageal reflux.

Pulmonary aspiration under GA: a 13-year audit in a tertiary pediatric unit

INTRODUCTION

Pulmonary aspiration is a known risk of general anesthesia. We aim to find out the incidence, risk factors, and outcome of pulmonary aspiration in our pediatric population.

METHODS

Since 2000, all critical incidents are reported on a standardized audit form. All cases with pulmonary aspiration being reported as a critical incident were identified and their case notes traced to look at the perioperative details.

RESULTS

From 2000 to 2013, a total of 102 425 pediatric cases were done in our hospital. Twenty-two cases were reported to have aspirated during anesthesia giving an incidence of 0.02% (1 in 4655). Majority (59.0%) of the children were between the ages of 3-12 and of ASA 1 (54.5%). None of them had any history of pulmonary aspiration. Of the 22 cases, 12 occurred during induction, three during maintenance, three during emergence, three during recovery, and one occurred preinduction. Twelve cases had intravenous induction while the rest received inhalational induction. The type of induction does not appear to affect the incidence of aspiration (OR 1.139 95% CI: 0.457-2.818 P = 0.76). Two cases were found to have a difficult airway during induction and 45.5% were emergency operations. Emergency surgeries put the patient at a higher risk of aspiration (OR 4.321 95% CI: 1.735-10.687 P = 0.001). No mortality was reported. Surgery was canceled for one patient, two had unplanned admissions, seven were admitted to high dependency unit or intensive care unit with two requiring postoperative ventilation.

CONCLUSION

The incidence of aspiration under general anesthesia in our hospital is comparable to published reports. Our audit highlights the fact that pulmonary aspiration although rare mostly occur in healthy ASA 1 and 2 children with no prior history. Emergency surgeries put the patient at a higher risk of aspiration. They occurred usually during induction, a process which tends to be variable (in technique and duration) for pediatric patients.

Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach

According to the Advanced Trauma Life Support recommendations for managing patients with life-threatening injuries, securing the airway is the first task of a primary caregiver. Airway management of patients with maxillofacial trauma is complex and crucial because it can dictate a patient's survival. Securing the airway of patients with maxillofacial trauma is often extremely difficult because the trauma involves the patient's airway and their breathing is compromised. In these patients, mask ventilation and endotracheal intubation are anticipated to be difficult. Additionally, some of these patients may not yet have been cleared of a cervical spine injury, and all are regarded as having a full stomach and having an increased risk of regurgitation and pulmonary aspiration. The requirements of the intended maxillofacial operation may often preclude the use of an oral intubation tube, and alternative methods for securing the airway should be considered before the start of the surgery. In order to improve the clinical outcome of patients with maxillofacial trauma, cooperation between maxillofacial surgeons, anesthesiologists, and trauma specialists is needed. In this review, we discuss the complexity and difficulties of securing the airway of patients with maxillofacial trauma and present our approach for airway management of such patients.

Implementing new advanced airway management standards in the Hungarian physician staffed Helicopter Emergency Medical Service

In 2011 the Hungarian Air Ambulance Nonprofit Limited Company introduced a new Rapid Sequence Intubation standard operating procedure using a template from London’s Air Ambulance. This replaced a previous ad-hoc and unsafe prehospital advanced airway management practice. It was hoped that this would increase clinical standards including internationally comparable results. All Rapid Sequence Intubations performed by the units of the Hungarian Air Ambulance under the new procedure between June 2011 and November 2013 were reviewed in a retrospective database analysis. During this period the air ambulance units completed 4880 missions with 433 intubations performed according to the new procedure. The rate of intubations that were successful on first attempt was 95.4% (413), while intubation was successful overall in 99.1% (429) of the cases; there was no failed airway. 90 complications were noted with 73 (16.9%) patients. Average on scene time was 49 minutes (ranging between: 15–110 minutes). This data shows that it is possible to effectively change a system that was in place for decades by implementing a new robust system that is based on a good template.