January FY20

[kristenhorsman]

The January journal club is presented by Jen Hannon. The article discusses the prevention of pulmonary aspiration- an interesting topic as the evidence and practice of cricoid pressure is constantly changing.

Please refer to the attachment sent in the email. The article is Lesson 1 Volume 42 of Current reviews: Prevention of Pulmonary aspiration: Current Opinions

Please answer the following 2 questions:

1) If PPIs are deemed more effective than H2, how will this change your preop orders and how will you plan to administer?

2) Will you use cricoid pressure? Why or why not or why will it depend?

[Dahlia Rouchon, CRNA]

1. Regarding preop orders for medications, as applied to inpatients only, I can see the benefit of adding a PPI prior to the anesthetic and also to be given the morning of. It would be beneficial to contact the floor attending and nurse to inform them of this change to ensure compliance and acceptance of this addition. On the whole for outpatient cases, I would add famotidine and reglan if the patient has active reflux of surgery and possibly even bicitra if there's added risk, i.e. morbid obesity and diabetes.
2. I do use cricoid pressure and feel it is useful, especially if a patient has anxiety preop, leading to delayed gastric emptying. There have been times when during laryngoscopy I see gastric contents and cricoid pressure is a lifesaver here.

[Jessica Hadley]

1. Although PPIs have been deemed more effective, the article states that for maximum benefit they need to be administered the night before surgery. This isn't realistic for patients who are coming in from home, therefore I would continue to give H2 blockers and try to make sure they are administered 45-60 minutes preinduction. This presents challenges, I know many times patients are being given these meds immediately before being taken to the OR so the true effect is questionable.

2. I was trained using cricoid pressure for RSI, however based on the article it seems like there are few people who would be able to properly administer cricoid pressure making its benefit unknown. I do agree with the article in that there have been times where the cricoid pressure being administered has made DL more challenging which isn't desirable in a situation where speed of securing the airway is the goal.

[Vania Milnes]

1. As Jessica mentioned, the problem with PPI's is the necessity to administer so long before surgery. This may be a more viable option for inpatients however, but this may require some adaptation by anesthesia providers and floor staff to the practice. I will continue with H2's for now.

2. This isn't the first time I've read an article regarding the innacuracy of our cricoid pressure... Do I feel like it's 100% effective? No. Does it make most people feel better? Yes.

[kels]

1.) Like many folks on here have said. Maybe using PPIs in the inpt population will be of benefit for next day surgeries
2.) I was also trained using cricoid pressure. At least back in the day it was standard of care for RSI and so if sued and cricoid was not used I am not sure what the verdict would be

[jkim54]

1. Administering PPIs the night before surgery would most practically by done for the inpatient population. If there is also a way to order them for the outpatients who have high risk factors (obesity, DM, high opioid consumption), this would also be ideal. But this would require a coordinated effort with surgery and the preoperative education process to ensure they are instructed to take it the night before. Otherwise administering H2 blockers is a reasonable alternative.

2. I would still apply cricoid pressure for pts at risk of aspiration. I have found that in my own practice it has been useful and can help prevent aspiration.

[Wai-Ling Lo]

1) I too agree that it is technically difficult to prescribe PPI for outpatients that we haven't met or assessed. Moreover, we should reserve PPI therapy for patients who are at high risks and on chronic acid suppression who may have developed some degree of tolerance to H2 blocker.


2) I remembered reading an article saying that a judge in UK did rule against an anesthesiologist for failing to apply the CP in a patient with irreducible hernia who had regurgitated and aspirated. The judge argued that “We cannot assert that CP is not effective until trials have been performed, especially as it is an integral part of anesthetic technique that has been associated with a reduced maternal death rate from aspiration since the 1960's.” Until further evidence is available, I will still use cricoid pressure for RSI but it is important that CP is released if there is any difficulty in either intubating or ventilating the patient.

[Anne McNulty]

It would be fabulous if the Pec center could prescribe a PPi for Pts at risk for aspiration. Physicians clearing patients for surgery do not appreciate the anesthetic risks that we face every day, especially as the population is becoming more obese. Many patients at risk for aspiration are not on PPIs as they have more side effects the H2 blockers. Timely administration of reglan /Pepcid in any preop area at JHU is doubtful. The Aspiration risk will always be with us . As for the correct application of cricoid pressure, even if less than perfect it may be helpful. The debate regarding effectiveness of cricoid pressure has been around for a long, long time.

[R Boynton]

If I knew preoperatively that any given pt was at high risk, I would order PPI preop. However, Pts coming in from home, would be difficult, especially in endo. The ability to get a PPI administered 45 min prior to surgery would be difficult in a fast moving unit.

I continue to use Cricoid pressure routinely in any pt at risk for aspiration. Always RSI for high risk pts. I had read in the past that you need at 25 lbs of cricoid pressure for accurate pressure. I think doing this in a Sim lab would be beneficial.

[Ben Waldbaum]

1.) PPI's are more effective when administered the night before and the day of surgery. Despite this, I regularly order both H2 and PPI's to be administered concurrently.

2) I do not use cricoid pressure.

[Katya Podin]

1. PPIs are more effective than H2 blockers only if given the night before, so if I wright orders for morning of surgery, H2 blockers are more effective. I order H2 blockers for day of surgery.
2. I still use cricoid pressure since it's still part of RSI protocol if it is true full stomach RSI.

[Jocelyn Datud]

1) Even though PPI's are deemed more effective than H2 blockers, it is necessary that they are started the night before surgery. Just like what others commented, this will be more effective with in patients. Maybe, this can be ordered to those patients who are seen and evaluated to be high risk for aspiration by anesthesia in pre-op clinics.

2) I would still use cricoid pressure. However, I would communicate closely with the person doing it since there are circumstances that it affects the view of the cords.

[Bgar]

To give PPIs effectively prior to surgery there would need to be a coordinated effort on the behalf of PEC and the surgical team to get these medications started prior to the day of surgery so H2s, Reglan and Bictira will have to continue to suffice.

Even though Cricoid pressure has not been shown to be completely effective against aspiration I will continue to use it in my practice in the chance it may help prevent aspiration during RSI/full stomachs/high aspiration risks unless there is data suggesting it is more harmful or becomes not standard of practice.

[Jules Chander]

I agree with and echo the statements that to be able to order and have PPIs administered the night before surgery would be beneficial. In my scrutiny of charts, it appears that most patients with GERD and already on a PPI are directed to continue this prior to and the morning of surgery just like their beta-blocker. Furthermore, most inpatients are on PPI therapy as part of their stay. I tend to see that IP nurses are pretty good at continuing this therapy. However, I see it as a potential teaching point. I think the biggest hurdle in my practice is timely administration of ordered pre-op medications by preop nursing staff.

As far as cricoid pressure goes, consistent and correct execution is dependent on whomever is assisting with induction. I agree with the article that "safe, vigilant, and well-planned anesthesia induction plans" are crucial, often I have little contact with my attending prior to letting them know we are ready for induction.

I have had the opportunity to use subglottic suctioning ET tubes in Endoscopy for the POEM procedures and although they were not mentioned in the article, wonder if these should be used more often for people with known history of aspiration, "full stomach," or hight risk patients and an adjunct to medication management. Yesterday, I performed an anesthetic for a POEM for a patient with esophageal achalasia. Despite following our pre/intraop medication protocol and RSI (including cricoid pressure), we had immediate return of gastric contents into the airway. We actively suctioned the airway during intubation and hooked suction to the subglottic port after induction and suctioned an impressive amount of gastric (most likely esophageal contents) from the airway. During the initial introduction of the endoscope we had continuous return of contents through the subglottic port. Has anyone else have any experience or other applications for the subglottic suctioning ETTs?

[clawry]

1) If PPIs are deemed more effective than H2, how will this change your preop orders and how will you plan to administer?



2) Will you use cricoid pressure? Why or why not or why will it depend?

1) PPIs are stated to be more effective, however it is easier to give IV pepcid typically prior to surgery for a patient who is high risk for aspiration. Typically these patients take their PPI the morning of surgery. Thie will probably not change my pre-op orders at this point unless their are significant studies showing that PPIs are superior to H 2 antagonists. H2 antagonists were found to be more effective in emergency situations where the risk of pulmonary aspiration is increased.

2) I will continue to use cricoid pressure in my practice. I have always practiced using cricoid in RSII situations. I find that it usually helps my view with DL, not hinder it.  Cricoid pressure could be helpful to prevent aspiration if applied correctly.  Unless there is overwhelming evidence stating that cricoid is harmful to our patients, I will continue to apply cricoid in high risk aspiration situations.