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PRESENTED BY- Dr RICHIE SANAM
1ST YEAR POST GRADUATE
MODERATOR- Dr SUBRAHMANIAM MD PROF
DEPT OF ANAESTHESIA AND CRITICAL CARE
MEDICINE
 History
 Introduction
 Primary goal
 Pre-operative fasting guidelines in adults
and children
 Fasting in special cases
-children
-diabetes
-trauma
-obstetrics
JOSEPH LISTER In the
year 1882
“While it is desirable that
there be no solid matter in
the stomach when
chloroform is administered,
it will be found very salutary
to give a cup of tea or beef-
tea about two hours
previously.”
DEFINITION- Prescribed period of time before
a PROCEDURE where patients
are not allowed the oral
intake of liquids or solids
 Preoperative fasting times
allow for gastric emptying
and reduction of aspiration risk
NULLA PER OS IN LATIN
NIL PER ORAL
 Reduce the occurrence of
pulmonary aspiration
WHAT IS PULMONARY ASPIRATION
 Aspiration of gastric contents occurring
after induction of anaesthesia,
during a procedure or in the immediate
period after surgery.
patient’s age
Patients size,
general medical condition,
scheduled time of surgery if it is known
 In 2011 ASA published updated Practice
Guidelines for Preop-Fasting and Pharmacologic
Intervention for the Prevention of Perioperative
Aspiration
 Guidelines deal with healthy patients of all ages
 PROLONGED FASTING
DEHYDRATION PATIENT DISSATISFACTION
HYPOGLYCEMIA
 pre-op fast does not guarantee an empty stomach
 timing of last fluid ingestion has little relation to
volume of gastric contents at induction
Clear fluids Breast milk Cow milk Solids
3 months 2 4 4 6
3-12 2 4 6 6
Child 2 - 6 6
Clear fluid includes
water,PEDIALYTE, fruit juice
Without pulp, carbonated
beverages,
Clear tea and black coffee
A clear liquid is a solution
(as opposed to a suspension)
that contains no particulate
matter.
Type of liquid ingested
important than volume
infants < 5 months 10 ml/kg
children and adults 15 ml/kg
 The fasting recommendations
for breast milk is 4hrs
 does contain milk solids
 cleared from the stomach
more quickly than nonhuman milk
 Allowing infants and children to have oral intake
closer to the time of surgery can help reduce patient
irritability, parental stress, and risk of dehydration
 Children are encouraged to have clear fluids up
to 2 hours before surgery.
 Rapid fluid turnover and high metabolic rate makes
dehydration and hypoglycaemia more likely in the
fasting child than potential aspiration.
 Children who have had unrestricted clear fluids until 2
hrs prior to surgery have residual gastric volumes equal
to or less than those fasted overnight
 younger the child, the smaller the glycogen stores;
therefore,the occurrence of hypoglycemia
 Good hydration may reduce post-operative nausea and
vomiting
 Who have not fasted the requisite length of time and
have sustained a severe injury during this period
 esophageal dysmotility
 Incompetent gastroesophageal sphincters
(gastroesophageal reflux diseases)
 delayed gastric emptying times
 abdominal conditions associated with ileus, vomiting, and
electrolyte disorders
 Diabetic autonomic nueropathy is the most common form
of nueropathy
 Diabetic gastroparesis is associated with increased risk
during GA
 GASTROPARESIS is caused by vagal degeneration
 AWAKE OR RSI IS NEEDED in patients with GASTROPARESIS
 Treated as having full stomach
At risk of aspiration of gastric contents DURING INDUCTION OF
GA
REASON
TAKEN FOOD JUST SWALLOWED BLOOD From
B4 INJURY DELAYED GASTRIC ORAL OR NASAL
EMPTYING injury
DUE TO STRESS
NON PARTICULATE ANTACIDS BEFORE INDUCTION OF
ANESTHESIA
 ALL PREGNANT WOMAN SHOULD UNDERGO A PRE-
OP EVALUATION REGARDLESS OF PLANNED
DELIVERY MODE OR TYPE OF ANESTHETIC
TECHNIQUE
 PREGNANT WOMEN WHO UNDERGO GA ARE AT
INCREASED RISK FOR MORTALITY FROM
PULMONARY ASPIRATION OF GASTRIC CONTENTS
 MORTALITY-5-15%
 TIMELY ADMINISTRATION OF NON-PARTICULATE
ANTACIDS
H2 RECEPTOR ANTAGONISTS AND OR
METOCLOPRAMIDE FOR ASPIRATION PROPHYLAXIS
CONTENTS
 HISTORY
 INTRODUCTION
 PRESENTATION
 DIAGNOSIS
 MANAGEMENT
 PREVENTION
 In 1946 Mendelson first
described aspiration pneumonitis
In pregnant woman undergoing
anesthesia
 Nitrous oxide and ether anaesthesia
administered by face mask for
operative delivery was complicated
by aspiration in 66 women from 44 016 maternities (0.15%)
between 1932 and 1945.
CURTIS LESTER MENDELSON
 Also known as ACID ASPIRATION SYNDROME
 This syndrome is due to the irritation of bronchioles
by gastric HCL, producing bronchiolar spasm,
a peribronchiolar exudates, and congestion.
 Aspiration of acidic and usually sterile gastric contents
into the lungs.
 Mendelson went on to show that acid was responsible for
this asthma-like syndrome
 EARLIEST AND MOST RELIABLE
SIGN OF ASPIRATION IS HYPOXEMIA
 presence of wheezing and ronchi,
which may be localised to one lung
 Aspiration of solid material causes
plugging of the large airways and is
often fatal.
 In those who aspirated liquid, a syndrome of dyspnoea,
cyanosis and tachycardia was observed.
 Bronchospasm, pulmonary oedema and ventilation
perfusion mismatch all contribute to worsening arterial
hypoxaemia
 patients were at risk of aspiration from the presence of
25 ml residual gastric volume (RGV) or volume > 0.3–0.4
ml/kg and pH>2.5
 Maximal pulmonary damage is achieved at an aspirate
pHvalue of 1.5
 Recovery after 24–36 h was universal
 PHASE-1-PROFOUND DYSPNEA AND
TACHYPNEA.BRONCHOSPASM IS OFTEN
PRESENT.CHEST X RAY NORMAL
 PHASE-2-LATENT PERIOD
INCREASED CYANOSIS AND HYPOXEMIA
MINOR CHEST X RAY ABNORMALITIES
 PHASE-3-RESPIRATORY FAILURE,PROFOUND
HYPOXEMIA
REDUCED COMPLIANCE
DIFFUSE BILATERAL INFILTRATES
 PHASE-4-HYPOXEMIA UNRESPONSIVE TO OXYGEN
METABOLIC AND RESPIRATORY ACIDOSIS
 Moderate amounts of aspiration will only present after
6-8 hrs
 Severe liquid aspiration may cause immediate collapse
 Suction through E T TUBE showing bile stained fluid is
often diagnostic
 Cxr and ABG are helpful in long term cases
mediastinal shift
densities are seen
CHEST X RAY OF A PATIENT WITH MENDELSONS SYN
 Tilt the operating table to a 30-degree head-down
position
 Larynx at a higher level than
the pharynx
 To allow gastric content to drain to the outside
 maintain cricoid pressure, suction the mouth and pharynx
 endotracheal intubation should be performed(if extubated)
immediate inflation of the endotracheal cuff to prevent
further aspiration
 Quickly suction through the endotracheal tube before
administering 100% oxygen by PPV
 orogastric tube should be inserted to empty the stomach
 pH value of the gastric content should be determined.
 Tracheobronchial aspirate is collected for culture and
sensitivity tests
 Only way to maintain adequate oxygenation is to institute
mechanical ventilation with 100% oxygen and the addition
of positive end-expiratory pressure
 Analysis of arterial blood gases should be performed to
determine the severity of hypoxemia
 Application of PEEP is recommended to improve pulmonary
function
 Membrane oxygenator may be indicated if paO2
CONTINUES TO FALL below 50mmHg
 Bronchial lavage is contraindicated and is likely to
aggravate the injury by removing or dispersing
surfactant
 Ultimate degree of pulmonary destructioncant be guaged
at the time of destruction
 Early diagnosis and appropraite management will
decrease mortality
 Role of steroids is controversial
 Pre-operative fasting guidelines
 Premedication with drugs which decrease risk
of aspiration
 Specialised induction techniques
 Gastric decompression by a wide bore
orogastric tube
ELECTIVE PROCEDURES
SEDATION REGIONAL GENERAL ANESTH
NIL BY MOUTH FROM MIDNIGHT
EMPTY STOMACH
DECREASE RISK OF REGURGITATION
 In the absence of c/i nasogastric drainage
should be used to reduce residual gastric
volume
 prior to induction of anaesthesia for patients
with bowel obstruction or paralytic ileus.
 Nasogastric tubes (NGT) REDUCE LOS tone
and may be associated with GER around the
tube.
 The presence of an NGT does not appear to
reduce the effectiveness of cricoid pressure
in cadaver studies.
 Basal skull fracture
 Severe midface trauma
 Recent nasal surgery
 Coagulopathy
 Oesophageal varices or stricture
 Recent banding or cautery of oesophageal varices
 Gastric bypass surgery
 Goal of aspiration prophylaxis
1)-to decrease gastric volume
2)-increase gastric pH
 Decrease risk of aspiration
 Routine use of drugs as prophylaxis is not recommended by
ASA guidelines
 Beneficial in
 full stomach patients
 Symptomatic GERD
 HIATAL HERNIA
 presence of NG TUBE
 MORBID OBESITY
 DIABETIS GASTROPARESIS
 PREGNANCY
 Empty the stomach by medication
 Apomorphine slow I .V of1-3mg is given until vomiting
occurs
 Then naloxane o.4 mg which will suppress vomiting
 Atropine and glycopyrrolate will control salivation,they
decrease gastric acid secretion but decrease los tone
 Dopamine D2 receptor antagonist
 Prokinetic agent that stimulates gastric motility
 Antiemetic
 Used to treat nausea GER AND DIABETIC GASTROPARESIS
 AGENTS USED
 IN OLDEN DAYS 0.3MOLAR SODIUM CITRATE 30ml
solution was used to nuetralise gastric contents
 Sodium citrate is a clear, soluble, non-particulate alkali.
 Effective at raising gastric pH, but may cause an increase
in gastric volume.
 Failure to neutralise gastric acidity in some patients may
be related to inadequate mixing with stomach contents
 Unfortunately, the DURATION OF ACTION of sodium citrate
is dependent on the rate of gastric emptying and may be
as short as 20 minutes, thereby not providing adequate
prophylaxis at the time of recovery.
 In some patients it is emetogenic.
H2 antagonists or proton pump inhibitors can
alter the volume and pH of gastric contents.
Timing of administration is important, a single
dose of ranitidine, lanzoprazole or rabeprazole
given a few hours before surgery reduces the
volume and acidity of gastric secretions.
Omeprazole needs to be given the night prior to
and on the morning of operation. There is no
evidence to support the routine use of these
drugs.
 MOST POTENT SUPPRESSORS OF GASTRIC ACID
SECRETION
 INHIBITORS OF H-K-ATPASE
 What equipment must be prepared and
checked prior to undertaking RSI?
 Anaesthetic machine and breathing circuit
 Routine patient monitoring applied
 Airway equipment
 Tipping trolley
 Suction switched on and immediately to hand
 Drugs – including emergency drugs
 A trained assistant
The application of cricoid pressure to prevent passive
regurgitation at induction of anaesthesia was proposed
by Sellick (1961).
ANATOMY
The cricoid cartilage is a ring-
shaped cartilage which when
pressed backwards onto the
vertebral column will occlude
the upper end of the
oesophagus
Applied with thumb and index
finger
Pressure of 25-30 newtons
 Elevating the patients chin
(without displacing cervical spine)
 Pushing the CRICOID CARTILAGE posteriorly to close
esophagus
 Lower oesophageal sphincter pressure decreases as
anaesthesia is induced
 cricoid pressure should, therefore be applied whilst the
patient is still awake and increased immediately
consciousness is lost
 Cricoid pressure should be maintained until the trachea
has been intubated, the cuff inflated and the correct
position of the tube confirmed
 Cricoid pressure should still be maintained if active
vomiting occurs
 BECAUSE risk of aspiration outweighs the potential risk of
oesophageal rupture from high intraoesophageal pressures
 Applying cricoid pressure is difficult in patients with short
and thick necks
 If pressure has been applied incorrectly the larynx may be
pushed away from the midline, making the process of
intubation difficult
 Worsen laryngoscopic View without providing
Effective prevention Of aspiration
 In case where the applied pressure is not central, there is a
risk of tracheal deviation
 A very high contact pressure can lead to a flattening of the
tracheal lumen
 If the operator applies the maneuver before the patient loses
consciousness, then the patient may cough which increased
intragastric pressure
 This method is strictly against in patients with acute
vomiting.
 5 point auscultation
 capnography
 Bilateral chest rise
Richie sanam

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Richie sanam

  • 1. PRESENTED BY- Dr RICHIE SANAM 1ST YEAR POST GRADUATE MODERATOR- Dr SUBRAHMANIAM MD PROF DEPT OF ANAESTHESIA AND CRITICAL CARE MEDICINE
  • 2.  History  Introduction  Primary goal  Pre-operative fasting guidelines in adults and children  Fasting in special cases -children -diabetes -trauma -obstetrics
  • 3. JOSEPH LISTER In the year 1882 “While it is desirable that there be no solid matter in the stomach when chloroform is administered, it will be found very salutary to give a cup of tea or beef- tea about two hours previously.”
  • 4. DEFINITION- Prescribed period of time before a PROCEDURE where patients are not allowed the oral intake of liquids or solids  Preoperative fasting times allow for gastric emptying and reduction of aspiration risk
  • 5. NULLA PER OS IN LATIN NIL PER ORAL
  • 6.  Reduce the occurrence of pulmonary aspiration WHAT IS PULMONARY ASPIRATION  Aspiration of gastric contents occurring after induction of anaesthesia, during a procedure or in the immediate period after surgery.
  • 7. patient’s age Patients size, general medical condition, scheduled time of surgery if it is known
  • 8.  In 2011 ASA published updated Practice Guidelines for Preop-Fasting and Pharmacologic Intervention for the Prevention of Perioperative Aspiration  Guidelines deal with healthy patients of all ages
  • 9.  PROLONGED FASTING DEHYDRATION PATIENT DISSATISFACTION HYPOGLYCEMIA  pre-op fast does not guarantee an empty stomach  timing of last fluid ingestion has little relation to volume of gastric contents at induction
  • 10.
  • 11. Clear fluids Breast milk Cow milk Solids 3 months 2 4 4 6 3-12 2 4 6 6 Child 2 - 6 6
  • 12. Clear fluid includes water,PEDIALYTE, fruit juice Without pulp, carbonated beverages, Clear tea and black coffee A clear liquid is a solution (as opposed to a suspension) that contains no particulate matter. Type of liquid ingested important than volume infants < 5 months 10 ml/kg children and adults 15 ml/kg
  • 13.  The fasting recommendations for breast milk is 4hrs  does contain milk solids  cleared from the stomach more quickly than nonhuman milk
  • 14.
  • 15.  Allowing infants and children to have oral intake closer to the time of surgery can help reduce patient irritability, parental stress, and risk of dehydration  Children are encouraged to have clear fluids up to 2 hours before surgery.  Rapid fluid turnover and high metabolic rate makes dehydration and hypoglycaemia more likely in the fasting child than potential aspiration.
  • 16.  Children who have had unrestricted clear fluids until 2 hrs prior to surgery have residual gastric volumes equal to or less than those fasted overnight  younger the child, the smaller the glycogen stores; therefore,the occurrence of hypoglycemia  Good hydration may reduce post-operative nausea and vomiting
  • 17.  Who have not fasted the requisite length of time and have sustained a severe injury during this period  esophageal dysmotility  Incompetent gastroesophageal sphincters (gastroesophageal reflux diseases)  delayed gastric emptying times  abdominal conditions associated with ileus, vomiting, and electrolyte disorders
  • 18.  Diabetic autonomic nueropathy is the most common form of nueropathy  Diabetic gastroparesis is associated with increased risk during GA  GASTROPARESIS is caused by vagal degeneration  AWAKE OR RSI IS NEEDED in patients with GASTROPARESIS
  • 19.  Treated as having full stomach At risk of aspiration of gastric contents DURING INDUCTION OF GA REASON TAKEN FOOD JUST SWALLOWED BLOOD From B4 INJURY DELAYED GASTRIC ORAL OR NASAL EMPTYING injury DUE TO STRESS NON PARTICULATE ANTACIDS BEFORE INDUCTION OF ANESTHESIA
  • 20.  ALL PREGNANT WOMAN SHOULD UNDERGO A PRE- OP EVALUATION REGARDLESS OF PLANNED DELIVERY MODE OR TYPE OF ANESTHETIC TECHNIQUE  PREGNANT WOMEN WHO UNDERGO GA ARE AT INCREASED RISK FOR MORTALITY FROM PULMONARY ASPIRATION OF GASTRIC CONTENTS  MORTALITY-5-15%  TIMELY ADMINISTRATION OF NON-PARTICULATE ANTACIDS H2 RECEPTOR ANTAGONISTS AND OR METOCLOPRAMIDE FOR ASPIRATION PROPHYLAXIS
  • 21. CONTENTS  HISTORY  INTRODUCTION  PRESENTATION  DIAGNOSIS  MANAGEMENT  PREVENTION
  • 22.  In 1946 Mendelson first described aspiration pneumonitis In pregnant woman undergoing anesthesia  Nitrous oxide and ether anaesthesia administered by face mask for operative delivery was complicated by aspiration in 66 women from 44 016 maternities (0.15%) between 1932 and 1945. CURTIS LESTER MENDELSON
  • 23.  Also known as ACID ASPIRATION SYNDROME  This syndrome is due to the irritation of bronchioles by gastric HCL, producing bronchiolar spasm, a peribronchiolar exudates, and congestion.  Aspiration of acidic and usually sterile gastric contents into the lungs.  Mendelson went on to show that acid was responsible for this asthma-like syndrome
  • 24.  EARLIEST AND MOST RELIABLE SIGN OF ASPIRATION IS HYPOXEMIA  presence of wheezing and ronchi, which may be localised to one lung  Aspiration of solid material causes plugging of the large airways and is often fatal.  In those who aspirated liquid, a syndrome of dyspnoea, cyanosis and tachycardia was observed.
  • 25.  Bronchospasm, pulmonary oedema and ventilation perfusion mismatch all contribute to worsening arterial hypoxaemia  patients were at risk of aspiration from the presence of 25 ml residual gastric volume (RGV) or volume > 0.3–0.4 ml/kg and pH>2.5  Maximal pulmonary damage is achieved at an aspirate pHvalue of 1.5  Recovery after 24–36 h was universal
  • 26.  PHASE-1-PROFOUND DYSPNEA AND TACHYPNEA.BRONCHOSPASM IS OFTEN PRESENT.CHEST X RAY NORMAL  PHASE-2-LATENT PERIOD INCREASED CYANOSIS AND HYPOXEMIA MINOR CHEST X RAY ABNORMALITIES  PHASE-3-RESPIRATORY FAILURE,PROFOUND HYPOXEMIA REDUCED COMPLIANCE DIFFUSE BILATERAL INFILTRATES  PHASE-4-HYPOXEMIA UNRESPONSIVE TO OXYGEN METABOLIC AND RESPIRATORY ACIDOSIS
  • 27.  Moderate amounts of aspiration will only present after 6-8 hrs  Severe liquid aspiration may cause immediate collapse  Suction through E T TUBE showing bile stained fluid is often diagnostic  Cxr and ABG are helpful in long term cases
  • 29. CHEST X RAY OF A PATIENT WITH MENDELSONS SYN
  • 30.  Tilt the operating table to a 30-degree head-down position  Larynx at a higher level than the pharynx  To allow gastric content to drain to the outside  maintain cricoid pressure, suction the mouth and pharynx
  • 31.  endotracheal intubation should be performed(if extubated) immediate inflation of the endotracheal cuff to prevent further aspiration  Quickly suction through the endotracheal tube before administering 100% oxygen by PPV  orogastric tube should be inserted to empty the stomach  pH value of the gastric content should be determined.  Tracheobronchial aspirate is collected for culture and sensitivity tests
  • 32.  Only way to maintain adequate oxygenation is to institute mechanical ventilation with 100% oxygen and the addition of positive end-expiratory pressure  Analysis of arterial blood gases should be performed to determine the severity of hypoxemia  Application of PEEP is recommended to improve pulmonary function  Membrane oxygenator may be indicated if paO2 CONTINUES TO FALL below 50mmHg
  • 33.  Bronchial lavage is contraindicated and is likely to aggravate the injury by removing or dispersing surfactant  Ultimate degree of pulmonary destructioncant be guaged at the time of destruction  Early diagnosis and appropraite management will decrease mortality  Role of steroids is controversial
  • 34.  Pre-operative fasting guidelines  Premedication with drugs which decrease risk of aspiration  Specialised induction techniques  Gastric decompression by a wide bore orogastric tube
  • 35.
  • 36. ELECTIVE PROCEDURES SEDATION REGIONAL GENERAL ANESTH NIL BY MOUTH FROM MIDNIGHT EMPTY STOMACH DECREASE RISK OF REGURGITATION
  • 37.  In the absence of c/i nasogastric drainage should be used to reduce residual gastric volume  prior to induction of anaesthesia for patients with bowel obstruction or paralytic ileus.  Nasogastric tubes (NGT) REDUCE LOS tone and may be associated with GER around the tube.  The presence of an NGT does not appear to reduce the effectiveness of cricoid pressure in cadaver studies.
  • 38.  Basal skull fracture  Severe midface trauma  Recent nasal surgery  Coagulopathy  Oesophageal varices or stricture  Recent banding or cautery of oesophageal varices  Gastric bypass surgery
  • 39.  Goal of aspiration prophylaxis 1)-to decrease gastric volume 2)-increase gastric pH
  • 40.  Decrease risk of aspiration  Routine use of drugs as prophylaxis is not recommended by ASA guidelines  Beneficial in  full stomach patients  Symptomatic GERD  HIATAL HERNIA  presence of NG TUBE  MORBID OBESITY  DIABETIS GASTROPARESIS  PREGNANCY
  • 41.  Empty the stomach by medication  Apomorphine slow I .V of1-3mg is given until vomiting occurs  Then naloxane o.4 mg which will suppress vomiting  Atropine and glycopyrrolate will control salivation,they decrease gastric acid secretion but decrease los tone
  • 42.  Dopamine D2 receptor antagonist  Prokinetic agent that stimulates gastric motility  Antiemetic  Used to treat nausea GER AND DIABETIC GASTROPARESIS
  • 43.
  • 44.  AGENTS USED  IN OLDEN DAYS 0.3MOLAR SODIUM CITRATE 30ml solution was used to nuetralise gastric contents  Sodium citrate is a clear, soluble, non-particulate alkali.
  • 45.  Effective at raising gastric pH, but may cause an increase in gastric volume.  Failure to neutralise gastric acidity in some patients may be related to inadequate mixing with stomach contents  Unfortunately, the DURATION OF ACTION of sodium citrate is dependent on the rate of gastric emptying and may be as short as 20 minutes, thereby not providing adequate prophylaxis at the time of recovery.  In some patients it is emetogenic.
  • 46. H2 antagonists or proton pump inhibitors can alter the volume and pH of gastric contents. Timing of administration is important, a single dose of ranitidine, lanzoprazole or rabeprazole given a few hours before surgery reduces the volume and acidity of gastric secretions. Omeprazole needs to be given the night prior to and on the morning of operation. There is no evidence to support the routine use of these drugs.
  • 47.
  • 48.
  • 49.  MOST POTENT SUPPRESSORS OF GASTRIC ACID SECRETION  INHIBITORS OF H-K-ATPASE
  • 50.  What equipment must be prepared and checked prior to undertaking RSI?  Anaesthetic machine and breathing circuit  Routine patient monitoring applied  Airway equipment  Tipping trolley  Suction switched on and immediately to hand  Drugs – including emergency drugs  A trained assistant
  • 51.
  • 52.
  • 53.
  • 54. The application of cricoid pressure to prevent passive regurgitation at induction of anaesthesia was proposed by Sellick (1961).
  • 55. ANATOMY The cricoid cartilage is a ring- shaped cartilage which when pressed backwards onto the vertebral column will occlude the upper end of the oesophagus Applied with thumb and index finger Pressure of 25-30 newtons
  • 56.  Elevating the patients chin (without displacing cervical spine)  Pushing the CRICOID CARTILAGE posteriorly to close esophagus
  • 57.  Lower oesophageal sphincter pressure decreases as anaesthesia is induced  cricoid pressure should, therefore be applied whilst the patient is still awake and increased immediately consciousness is lost  Cricoid pressure should be maintained until the trachea has been intubated, the cuff inflated and the correct position of the tube confirmed
  • 58.  Cricoid pressure should still be maintained if active vomiting occurs  BECAUSE risk of aspiration outweighs the potential risk of oesophageal rupture from high intraoesophageal pressures  Applying cricoid pressure is difficult in patients with short and thick necks  If pressure has been applied incorrectly the larynx may be pushed away from the midline, making the process of intubation difficult
  • 59.
  • 60.  Worsen laryngoscopic View without providing Effective prevention Of aspiration  In case where the applied pressure is not central, there is a risk of tracheal deviation  A very high contact pressure can lead to a flattening of the tracheal lumen  If the operator applies the maneuver before the patient loses consciousness, then the patient may cough which increased intragastric pressure  This method is strictly against in patients with acute vomiting.
  • 61.
  • 62.
  • 63.
  • 64.
  • 65.  5 point auscultation  capnography  Bilateral chest rise