full stomach anesthesia prophylaxis

1. PREPARATION AND CONDUCT OF
ANAESTHESIA IN FULL STOMACH
PATIENT
Dr.
ZIKRULLAH
1

2. HEADINGS
 What is full stomach(Predisposing factors of
aspiration)
 Neutralisation of ph
 RSI technique
 Sellicks maneuver
 Aspiration syndrome and management
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3. ANAESTHETIC APPROACH TO A FULL STOMACH
PATIENT
 CONSIDER THE MODE OF
ANAESTHESIA
 Regional OR general
Risk is still present during RA with sedation,
toxic reactions to LA.
3

4. IF POSSIBLE REDUCE THE VOLUME,
PRESSURE AND ACIDITY OF THE
STOMACH CONTENTS
 Have a large nasogastric tube passed prior
to general anaesthesia
 Even after passing the tube the stomach is
unlikely to be completely empty .
 nasogastric tubes are inefficient for removing
liquids and useless for solids.
4

5.  Neutralization of ph
30 ml of 0.3M Sodium Citrate should be given within 60 min of
anesthetic induction & may be repeated intraoperatively
 H2-recepter blocking agents can be given 60-90
min before surgery. Ranitdine-50 mg iv
 Gastro-prokinetic agent 30 min before surgery
Metoclopramide- 10-20 mg iv
o Proton pump inhibitor. Pantoprazole 40 mg iv
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6.  Prepare for RSI: SOAP-ME
 ♦ S : Suction
 ♦O : Oxygen
 ♦A : Airway Equipment
 ♦ P : Pharmacology
 ♦ME : Monitoring Equipment
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7. 7

8. Rapid Sequence Induction (RSI)
Method
 Preparation to deal with any difficult intubation must be
kept in advance.
 P/O with 100% O2 for 3-5 min.
 Precalculated dose of induction agent(eg thiopentone
5mg/kg) given intravenously, immediately followed by
short acting muscle relaxant (suxamethonium 1.5mg/kg).
 As soon as consciousness is lost apply cricoid pressure.
 Without interposed assissted ventilation.
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9.  As soon as the suxamethonium is effective intubate
the patient, inflate the endotracheal tube cuff and
confirm the correct placement of the tube.
 When satisfied that the tube is placed correctly, fix
it and then instruct assistant to release the cricoid
pressure.
 At the end of the surgery turn the patient on to their
side and do not remove the endotracheal tube until
the patient is fully awake and capable of protecting
their own airway.
9

10. DIFFICULTIES WITH THE TECHNIQUE
 Intubation is unexpectedly difficult: Ensure that
the cricoid pressure is not pushing the larynx to
one side.
 If it is, move the larynx and cricoid cartilage by
moving your assistant's hand to the correct
position
 No oxygen :In this situation the patient will need
to be gently ventilated with air to prevent hypoxia
after apnoea develops
10

11.  The BURP (Backwards, Upwards and Right sided
pressure on the thyroid cartilage) manoeuver was
introduced by Knill in 1993
 Improve glottic view during endotracheal intubation .
 Nausea and vomiting are also associated with application
of CP. This occurs more often when the CP is relatively
more than normal and particularly in awake subjects.
 Hence an initial pressure of 10N in the awake patient and
gradually increasing it to a maximum of 30N after the
patient loses consciousness is recommended.
11

12.  The patient regurgitates despite the application of
cricoid pressure. If there is only a small quantity of
fluid suck it out of the pharynx and intubate the
patient.
 Use a suction catheter to aspirate the trachea after
intubation.
 If there is copious fluid then the patient should be
turned on to the side and placed head down to
protect the airway.
 Suction the pharynx and then intubate the patient
12

13. Sellick Maneuver

15. SELLICKS MANEUVER
 The application of pressure over the cricoid
cartilage of the trachea in patients at risk of
gastric aspiration
 It is applied by placing the thumb and forefinger
together in a downward fashion over the cricoid
cartilage.
 This pressure pushes the cricoid cartilage on the
anterior body of c6 causing an effective closure of
oesophagus which reduces the possibility of 15

16.  Pressure required to effectively seal the
oesophagus is 44N.
 Performing the maneuver on oneself applying
suficient force to prevent swallowing of liquid.
 Cricoid yoke is a mechanical device that can be
used to provide optimal cricoid pressure
consistently.
 Cricoid pressure is applied just before
commencing induction of anaesthesia.The
patient should be explained before applying the
pressure. 16

17.  The only absolute contraindication for applying
cricoid pressure is suspected airway
injury,specially injuries involving cricotracheal
junction.
 Relative c/I is any foreign body located in
oesophagus or airway.
 DISADVANTAGES:
 -May cause oesophageal rupture
during vomiting.
 -It decreases the cormacks and
lehannes laryngoscopic view of glottic
structure by grade 1.
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18. MAINTENANCE OF ANESTHESIA
 Nitrous oxide – 50-60%
 Inhalational anesthesia
halothane-0.5%
isoflurane – 0.5-1%
enflurane-0.5-1%
Muscle relaxant
vecuronium-80-100mics/kg
pancuronium-50-100mics/kg
alcuronium-250-300 mics/kg
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19. EXTUBATION
 Discontinue any inhalational agent 5-10 min
before extubation.
 On insertion of last suture do direct
laryngoscopy to see if any secretions/ debris
is present.
 Reverse with atropine and neostigmine and
ventilate manually.
19

20.  Extubation is accomplished only when
pharyngeal reflexes are once again active,
with patient able to follow commands and
sustain a head lift for 5 sec
 The patient turned to the lateral decubitus
position immediately and transported in
same position.
• Stomach should be decompressed with a
large bore nasogastric tube before
extubation. 20

21. COMPLICATION…..
The important syndromes associated are
ASPIRATION PNEUMONITIS.
( MENDELSON’S SYNDROME).
ASPIRATION PNEUMONIA
21

22. PREDISPOSING FACTORS OF ASPIRATION
A. Perioperative
 Parturition
 Emergency
 Obesity
 Out patient status
 Gastrointestinal dysfunction
 Hiatal hernia
 Scleroderma
 Intestinal obstruction
 Esophageal diverticulae
 Gastroesophageal reflux
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23. B. Decreased Consciousness
 Head injury
 Drug overdose
 Metabolic coma
 CNS infection
 Seizure
 Hypothermia
 Sepsis
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24. C. Laryngeal Incompetence
 CNS disease causing bulbar dysfunction
 Guillain-Barre Syndrome/ Multiple Sclerosis
 CVA in brain-stem/Posterior fossa tumour
 Muscular dystrophy/ Amyotrophic Lateral Sclerosis
 Traumatic vocal paralysis
 Extensive surgery of pharynx & hypo-pharynx.
 D. NASOGASTRIC FEEDING.
 E. GASTROINTESTINAL HEMORRAGE.
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25. Drug Effect
Many drugs commonly in anesthesia also effect the LES.
INCREASE DECREASE NO CHANGE
Metaclopromide Atropine Ranitidine
Domperidone Glycopyrrolate Cimetidine
Neostigmine Dopamine Propranolol
Metaprolol Sod.Nitroprusside Oxprenolol
Suxamethonium Thiopentone Nitrous Oxide
Pancuronium Ganglionic blocker Atracurium
Antacids Opiates
α-Agonists β-Agonists
Cyclizine Halothane
Edrophonium Enflurane
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26. SIGNS & SYMPTOMS
Gastric contents in the oropharynx.
• Wheezing.
• Coughing.
• Shortness of breath.
• Cyanosis.
• Tachypnea.
• Tachycardia.
• Bronchospasm. 26

27. TREATMENT
• Despite all precautions & preventions
aspiration may still occur.
• Success of treatment depends on prompt
recognition of aspiration & immediate
vigorous measures taken.
1. POSITIONING:
- Put the patient in Trendelenburg’s position
with head to the side to prevent further
aspiration. 27

28. 28
Position of trachea with changes
in position in unconscious patient

29. 2. AIRWAY MANAGEMENT :
- Clear the airway as soon as possible.
- If patient is not awake, trachea should be
intubated and suctioned.
- Immediate bronchoscopy ( only when
particulate matter obstructs the airway).
- Frequent suctioning of airway.
- Periodic repositioning of the patient.
- Chest physiotherapy.
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30. 3. OXYGENATION:
- Improve oxygenation by supplementing
100% oxygen.
- Institute Mechanical Ventilation (if
necessary).
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31. 4. Determine the pH of aspirated material.
5. Perform Arterial Blood Gas analysis.
6. Obtain Chest X-ray at first possible post-
operative opportunity.
7. Support Acid Base balance &
Cardiovascular system as necessary.
8. Aminophylline 250 mg injected I.V. slowly
may help to ease bronchospasm & lessen
work of breathing. 31

32. 9. PULMONARY LAVAGE :
• No demonstrated improvement occurs with
lavage (as damage to the lungs by acidic
liquid occurs within 12 – 18 sec.)
• Lavage via bronchoscopy can be performed
to loosen impacted particulate matter /
secretions obstructing the airway.
• DISADVANTAGE:
- Increased risk of greater pulmonary damage
from spread of aspirate.
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33. 10. ROLE OF CORTICOSTEROIDS
• No proved benefit, so not recommended.
• May interfere with normal healing.
• Facilitate secondary bacterial infection.
• Do not show any improvement in
morphologic changes or morbidity &
mortality rates.
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34. 11. ROLE OF ANTIBIOTICS
No role of prophylactic antibiotics.
• It may alter the normal flora of the
respiratory tract, leading to infection with
resistant organisms.
• Antibiotics should be administered
according to the results of Gram stained
smears & Culture of sputum specimens.
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35. 12. HYDRATION
• Aggressive intravenous fluid replacement
should be done to treat hypovolemia.
• Central venous or pulmonary artery cathete
should be inserted:
- to guide fluid management.
- to determine cardiac output.
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36. - for continuous mixed venous oxygen saturation
measurements.
- for calculation of intrapulmonary venous
admixture.
• Administer Crystalloids to maintain organ
perfusion.
• Continuous BP monitoring should be done.
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37. 13.ROLE OF MECHANICAL VENTILATORY
SUPPORT
PEEP or CPAP - reduces the shunt.
- increases arterial oxygen
tension.
- increase FRC.
- re-inflate the alveoli.
- increases the survival rate.
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38. SUMMARY
 If possible reduce the volume, pressure and
acidity of the stomach contents.
 RSI technique and sellicks maneurs should
be applied in full stomach patients.
 Predisposing factors of aspiration must be
kept in mind.
 Treatment includes positioning, airway
management, pulmonary lavage and
adequate hydration.
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39.  Clinical anaesthesiology 5th edition, morgan
&mikhails- 3 section, chapter 36,pg no.769
 Millers anaesthesiology 7 th edition , chapter
50
 Airway management 4 th edition ,Rashid M
Khan, pg. no. 206
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REFERENCES

40. THANK YOU.
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