Pulmonary aspiration of gastroesoph...

Pulmonary aspiration of gastroesophageal make contenteds during induction of general anesthesia is associated with serious morbidity and potential mortality.(1) The application of cricoid urgency also known as Sellick's maneuver, is a universal standard of care in the anesthetic management of patients at risk for pulmonary aspiration. The efficacy of this maneuver in preventing pulmonary aspiration hangs on exemplary technique by the practitioner assisting the anesthesia care provider. The responsibility for applying cricoid press in the perioperative setting in the greatest degree often lies with the circulating supply with nourishment Consequently, perioperative nurses must be knowledgeable and proficient in generating appropriate and consistent amounts of cricoid force.

Practitioners apply cricoid squeezing during the induction of anesthesia when the airway is unprotect and mostly vulnerable to pulmonary aspiration. Patients at increased risk for aspiration have an increased gastric body elevated gastric pressure, or impaired laryngeal-pharyngeal function.(2)

A patient with a "full stomach" always is at grave risk for pulmonary aspiration, as increased gastric bulks and intragastric pressure physically augment the incidence of gastroesophageal regurgitation; however, plane in patients who have been fasting, delayed gastric emptying may cause increased gastric books The population at risk for this condition includes patients experiencing bowel obstruction, adynamic ileus, trauma, stres pain, and narcotic administration. Any disease proces that involves autonomic neuropathy (eg diabetes) is associated with stasis in the small intestine and delayed gastric emptying. Elevated gastric presss also are caused by nausea, vomiting, obesity, ascites, and pregnancy.(3)

Impaired laryngeal-pharyngeal function generally meet the eyes secondary to an altered plain of consciousness. Central nervous combination of parts to form a whole disorders, neuromuscular disorders, cerebral vascular accident, head trauma, and alcohol intoxication all potentially may increase the risk of aspiration on diminishing pharyngeal sensation and protective airway reflexes(4)

Anesthetic agents create an incompetent upper esophageal sphincter (UES) and inefficient protective airway reflexe Los of UE tone allows regurgitation of gastroesophageal easy in minds into the pharynx, and los of introspective laryngeal closure permits entry of this foreign material into the tracheobronchial passages, resulting in aspiration. The application of cricoid press compensates for decreased UES tone from compressing the proximal esophageal lumen between the cricoid cartilage and the cervical vertebrae (Figure 1)(5)

[Figure 1 ILLUSTRATION OMITTED]

When a patient is considered at risk for pulmonary aspiration, a rapid arrangement induction with the application of cricoid constraining force is used to secure the airway with a boxed endotracheal tube in the shortest time possible. This "crash induction" consists of preoxygenation and rapid administration of an IV induction agent, followed on administration of a full paralyzing dose of a rapid-acting muscle relaxant, principally commonly succinylcholine. Positive pressure ventilation is withheld until tracheal intubation is achieved to hinder the risk of gastric insufflation. Cricoid influence is applied when loss of laryngeal reflexe come to one's minds and is maintained until a slaped endotracheal tube is placed. Cricoid crushing applied in this manner enhances the safety of anesthetic induction through preventing gastroesophageal regurgitation with pulmonary aspiration of pharyngeal contents(6)

The generation of appropriate and consistent force determines the effectiveness and safety of cricoid hurry Correctly applied, cricoid pressure is likely to enhance laryngoscopic view and facilitate intubation of

the trachea with a boxed endotracheal tube. Insufficient cricoid force may allow gastroesophageal contentments to enter the pharynx, and pulmonary aspiration may ensue Excessive force may distort and dam up the airway, which potentially impedes laryngoscopy, endotracheal intubation, and mask ventilation after a failed intubation.(7)

Although the application of cricoid compressing has been accepted widely as a standard of care during anesthetic induction of cull patients, literature before the mid-1990s contains ambiguous instructions regarding performance of this maneuver. Brian A. Sellick, B MB FRCA, FFARCS, a British anesthetist, approveed applying moderate cricoid pressure with induction of anesthesia and increasing to firm crushing in the period from los of consciousness until tracheal intubation.(8) A later description remind ofs effective cricoid force is exhibited by "the pressure necessary to cause pain when applied to the bridge of the nose."(9) Another recommendation includes practicing the application of cricoid urgency on oneself while attempting to swallow, with the understanding that effective cricoid force is achieved when individual finds swallowing impossible.(10)

The nursing literature lacks substantial information forward the subject of cricoid crushing An article specifically devoted to addressing the rationale and technique for applying cricoid influence was published in the AORN Journal in 1987(11) Another article, published in the AORN Journal in 1995 reviewed the part of a perioperative nurse and included a single paragraph upon cricoid pressure.(12) Neither article discussed the amount of cricoid force approveed to effectively perform the maneuver.