OG after RSI

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dilaudid

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When you guys RSI, do you ALWAYS drop an OG afterwards?
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Not always; depends on the procedure/pathology, i don't think everybody drops a OG for an appy, in patients with significant ileus yes.
 
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fakin' the funk said:
Yes.

If you were concerned enough about a "full stomach" to do an RSI, then you should do an easy and low-risk procedure to treat said fullness.
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Agreed.

In the past, on more than one occasion, I had done an RSI on a patient who I woke up afterwards, extubated, and had them proceed to vomit out copious amounts of bilious crap. Sure they were able to protect their airway because they were awake, but it would have been easier to drop an OG and suction out that 1 L of gastric contents rather than trying to suction it off their face later.

dhb said:
Not always; depends on the procedure/pathology, i don't think everybody drops a OG for an appy, in patients with significant ileus yes.
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In an appy patient who I just RSIed, I will drop an OG. I won't force the issue; if it's challenging and I feel like I am traumatizing the patient's oropharynx in doing so, I won't go above and beyond to try to get it in. But if it goes smoothly, I figure it is worth the 10 seconds it takes for the reason that fakin' the funk gave above.
 
I don't do things to make myself feel better, or worse, that give a false sense of security. "Full stomach" is a generic categorization that means different things. If the post op management requires an OG or NG, I put one in. A Big Mac and fries doesn't fit thru an 18 fr conduit and you can just as easily get 50 or 100 cc of fluid out of someone's stomach that you didn't RSI. Add to that that leaving as much as you took out is as frequent as fluid refluxing thru the pylorus intraoperatively.

Doing it right before emergence would make more sense.
 
Its not a must but imagine how this would go down in court if a patient ended up aspirating on extubation weather or not they were asleep or fully awake (still possible). If you were concerned enough to do RSI to prevent aspiration on induction, then you should also do all you can in a reasonable manner to prevent aspiration on emergence/extubation. Even if you do OGT and suction fully, its possible to aspirate but at least you tried to minimize it and that counts. Just my 2 cents..
 
Unless obviously needed, I try to avoid rapid sequence intubations as much as possible. Don't like sux and don't like 1.2mg/kg of rocuronium. Don't get me started on cricoid pressure.
 
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I actually think the literature supports cricoid pressure, if performed correctly. But agree with your points about sux and high dose roc.
 
Hawaiian Bruin said:
I actually think the literature supports cricoid pressure, if performed correctly. But agree with your points about sux and high dose roc.
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I think the literature is at best conflicting. Some say it does. Some say it doesn't. Clinically, I just don't buy it.
 
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BLADEMDA said:
RSI with Cricoid pressure is still the standard of care in the USA for full stomachs, SBO, etc.
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I disagree. And the literature is at best conflicting as well, with theoretical (and direct personal) evidence dictating that it can make BMV and DL more difficult.

As an aside, a SBO deserves a RSI but there better be an OG tube in before induction. Thinking cricoid will save you is a violation in the standard of care, IMO.
 
It's true that the evidence for cricoid pressure is conflicting. Howver, if you look at closed claims, cases involving aspiration without cricoid pressure were viewed as substandard care compared to cases where cricoid pressure was used. This translated to lost cases and or higher payouts than if cricoid pressure was used.
 
Without getting all Blade on you guys with the cut and paste, I challenge you that think that the evidence for cricoid - when performed properly- is conflicting, to share the negative studies they know of.

And if you want to post an MRI study that says it doesn't work, I'll preempt that with a more recent one that does-http://www.ncbi.nlm.nih.gov/pubmed/19843793
 
kazuma said:
It's true that the evidence for cricoid pressure is conflicting. Howver, if you look at closed claims, cases involving aspiration without cricoid pressure were viewed as substandard care compared to cases where cricoid pressure was used. This translated to lost cases and or higher payouts than if cricoid pressure was used.
Click to expand...

You bring up a good point, but let's remember aspiration is a sliver of the closed claims database, and that aspiration was documented to occur in numerous patients who received cricoid pressure. I understand it's an ongoing controversy. To each his own.

I am open to evidenced-based research, and I see some studies that support it, but I don't believe in "What would the judge say?" medicine. It's sad that a "courtroom anesthesiologist" probably screwed his colleagues over something not scientifically proven to be efficacious. But hey, no one has ever accused our field of eating their own, right?

Per Dr. Kron of Anesthesiology News (ISSUE: OCTOBER 2010 | VOLUME: 36:10), "Legal, Clinical Data Paint Conflicting Picture of Cricoid Pressure".....

“I’m not saying it’s the standard of care,” he added, “but if it is used, people should know how to use it correctly.”
 
Hawaiian Bruin said:
Without getting all Blade on you guys with the cut and paste, I challenge you that think that the evidence for cricoid - when performed properly- is conflicting, to share the negative studies they know of.

And if you want to post an MRI study that says it doesn't work, I'll preempt that with a more recent one that does-http://www.ncbi.nlm.nih.gov/pubmed/19843793
Click to expand...

By your own admittance, it is conflicting. We can play the cherry pickin' game all day. Dr. Google makes it easy. Let's talk endpoint, and that is aspiration, not what an MRI shows.

Per the International Journal of Obstretic Anesthesia, "

"Life-saving or ineffective? An observational study of the use of cricoid pressure and maternal outcome in an African setting"

"This study does not provide any evidence for a protective effect of cricoid pressure as used in this context, in preventing regurgitation or death. Preoperative gastric emptying may be a more effective measure to prevent aspiration of gastric contents."

It IS conflicting. And I get that some data exists, maybe more reputable than above, to show that it is effective. And that's fine. But I think being unbiased and ascertaining from my own clinical experience, that it is hogwash. Kind of an aside, I think a lot of that studies have "outcome bias" (Is that what it is called?").
 
I agree that's a great review, but I disagree with your conclusion that the evidence within is conflicting. It seems to agree that the MRI study I posted above renders those "conflicting" studies that looked only at esophageal position irrelevant, and that CP must be performed correctly to have efficacy. Correctly means a force of 30 Newtons, which must be practiced to be done properly.

Here's what I think. What I've seen most people do- tell an untrained assistant to "just hold some cricoid"- could absolutely be incorrect, since cricoid pressure relaxes the lower esophageal sphincter, eliminating a built-in physiologic barrier to regurgitation. Without proper cricoid force replacing upper esophageal sphincter tone, that absolutely could lead to regurgitation if intragastric pressure is high enough. So you have to train somebody who is going to do it on the proper force, which I've done with all the anesthesia techs I work with. The quick and dirty method is to tell them to push on the bridge of their nose until it hurts- that's about the right amount of force.

Regardless, I'm not so naive as to think that some may read this literature and come to a different conclusion than me. But I think if you look at the work of Vanner and Wraight and people who have actually really studied this, my interpretation is that it does work if done properly, and the recent MRI study confirms that anatomically.

Any study that says "we held cricoid and they regurgitated, therefore cricoid doesn't work" doesn't hold water to me unless they detail that they truly did it correctly. Most of the "negative" studies, such as your African study, are of this type.

So in summary: yes, there's conflicting evidence. But I believe the quality of the evidence in favor of CP is relatively good, and the quality of the evidence against is relatively poor.
 
Hawaiian Bruin said:
I agree that's a great review, but I disagree with your conclusion that the evidence within is conflicting. It seems to agree that the MRI study I posted above renders those "conflicting" studies that looked only at esophageal position irrelevant, and that CP must be performed correctly to have efficacy. Correctly means a force of 30 Newtons, which must be practiced to be done properly.

Here's what I think. What I've seen most people do- tell an untrained assistant to "just hold some cricoid"- could absolutely be incorrect, since cricoid pressure relaxes the lower esophageal sphincter, eliminating a built-in physiologic barrier to regurgitation. Without proper cricoid force replacing upper esophageal sphincter tone, that absolutely could lead to regurgitation if intragastric pressure is high enough. So you have to train somebody who is going to do it on the proper force, which I've done with all the anesthesia techs I work with. The quick and dirty method is to tell them to push on the bridge of their nose until it hurts- that's about the right amount of force.

Regardless, I'm not so naive as to think that some may read this literature and come to a different conclusion than me. But I think if you look at the work of Vanner and Wraight and people who have actually really studied this, my interpretation is that it does work if done properly, and the recent MRI study confirms that anatomically.

Any study that says "we held cricoid and they regurgitated, therefore cricoid doesn't work" doesn't hold water to me unless they detail that they truly did it correctly. Most of the "negative" studies, such as your African study, are of this type.

So in summary: yes, there's conflicting evidence. But I believe the quality of the evidence in favor of CP is relatively good, and the quality of the evidence against is relatively poor.
Click to expand...

Although I happen to disagree, I have no problems with your take and commend you for being thorough in your assessment and critical thinking. I am still left with the question, and an honest one at that- Is there any prospective study with aspiration as the primary endpoint that shows a decrease in aspiration with cricoid as opposed to no cricoid?

Also, I have to say. I am not a fan of cricoid but if I assess the airway and assess their stomachs, there are times when I may use it i.e. 100lb demented, edentulous patient with small bowel obstruction, uncooperative with NG placement. Sure, I'll hold some cricoid pressure. It's a risk/benefit thing. In the face of anything that can compromise securing an airway, I am hesitant to use it.
 
kazuma said:
It's true that the evidence for cricoid pressure is conflicting. Howver, if you look at closed claims, cases involving aspiration without cricoid pressure were viewed as substandard care compared to cases where cricoid pressure was used. This translated to lost cases and or higher payouts than if cricoid pressure was used.
Click to expand...
If that's the case, then the evidence for cricoid pressure is not conflicting at all. :)
 
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Liability and Risk Factors Associated with Aspiration: Closed Claims Analysis ** Raymond Bailie, M.D., Linda Stephens, Ph.D., Mary Warner, M.D., Mark Warner, M.D., Karen Domino, M.D., M.P.H. Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington; Anesthesiology, Mayo Clinic, Rochester, Minnesota

Conclusions: Patients who experienced aspiration were older, sicker, and more often had risk factors for aspiration of gastric contents, e.g., emergency and abdominal procedures. Aspiration claims had twice the proportion of death as other claims in the database. Aspiration occurred on induction of anesthesia despite the use of RSI with cricoid pressure in almost half of the claims, raising the question of its effectiveness.1-3 However, in the presence of risk factors for aspiration, anesthesia care was more likely to be judged as substandard when cricoid pressure was not used.
 
This is like ETT vs LMA for elective lap chole and ultrafast surgeons. The correct answer depends on the side of the Atlantic, for the same reason.

First do no harm... to yourself.
 
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kazuma said:
Liability and Risk Factors Associated with Aspiration: Closed Claims Analysis ** Raymond Bailie, M.D., Linda Stephens, Ph.D., Mary Warner, M.D., Mark Warner, M.D., Karen Domino, M.D., M.P.H. Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington; Anesthesiology, Mayo Clinic, Rochester, Minnesota

Conclusions: Patients who experienced aspiration were older, sicker, and more often had risk factors for aspiration of gastric contents, e.g., emergency and abdominal procedures. Aspiration claims had twice the proportion of death as other claims in the database. Aspiration occurred on induction of anesthesia despite the use of RSI with cricoid pressure in almost half of the claims, raising the question of its effectiveness.1-3 However, in the presence of risk factors for aspiration, anesthesia care was more likely to be judged as substandard when cricoid pressure was not used.
Click to expand...

Again, I believe this cannot be used to say whether cricoid is ineffective, as you can't say whether they performed it correctly, and I bet they did not.

I prefer to debate this on medical rather than medicolegal grounds, but recognize there is that aspect of it that does merit consideration.
 
We live in the united states. Lots of lawyers abound.
Cricoid? sure... why not.
For me, the most annoying issue regarding CP is when various staff confuse BURP with CP. Big difference when you are confronted with a full and emergent stomach + a dif. AW.
 
Hawaiian Bruin said:
So in summary: yes, there's conflicting evidence. But I believe the quality of the evidence in favor of CP is relatively good, and the quality of the evidence against is relatively poor.
Click to expand...

I was against it and reverted somewhat due to the study you publish. I still believe it is conflicting, but to say evidence is stronger in favor then against is not true imho.
I don't think it makes a great difference if you see the big picture and that is why the debate is still alive. I use it sometimes based on clinical judgement but not for every RSI (even though i tick the box in the chart).
 
Yes, if I'm concerned about "full stomach."
 
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