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Background: Rapid sequence induction and intubation (RSII) with application of \"Cricoid pressure\" and avoidance of \"facemask ventilation\" (FMV) is believed to minimize the risk of pulmonary aspiration of gastric contents during general anesthesia. However, some patients may be at risk of developing hypoxemia and may benefit from FMV during RSII. The purpose of this study was to assess the effectiveness of \"cricoid pressure\" in preventing gastric insufflation during FMV using gastric ultrasonography. Materials and Methods: Eighty-four adult patients were randomized to receive cricoid pressure (CP) or no cricoid pressure (NCP), during FMV after induction of general anesthesia. Gastric antral cross-sectional area (CSA) was measured with ultrasonography before and after FMV in supine and right lateral decubitus positions (LDP). Appearance of \"comet tail\" artifacts created by acoustic shadows of gas in the gastric antrum was noted. Results: The incidence of insufflation indicated by \"comet tail\" artifacts during FMV was lower in group CP (17 vs 71%; P < 0.001). The lowest Paw at which gastric insufflation occurred was higher in group CP (20 vs 14 cmH2O). The change in mean gastric antral CSA was significantly lower in group CP than in group NCP in supine (0.02 vs 0.36 cm2, P = 0.012) and right LDP (0.03 vs 0.67 cm2, P < 0.001). Conclusion: Cricoid pressure is effective in preventing gastric insufflation during FMV at Paw less than 20 cmH2O. Observation of comet tail artifacts in gastric antrum along with measurement of change in antral CSA on ultrasound examination is a feasible and reliable method to detect gastric insufflation.

Second-generation laryngeal mask airways are equipped with an additional lumen for a gastric tube, with the intention to reduce the risk of aspiration by draining gastric content. However, the effect of an inserted gastric tube through the gastric channel on gastric insufflation, a substantial part of the pathomechanism of aspiration, during positive-pressure ventilation is not clear. We hypothesized, that an inserted gastric tube increases the risk of gastric insufflation. Single center, prospective, randomized-controlled cross-over trial. Tertiary academic hospital in Germany. 152 patients, ASA I-III, scheduled for general anesthesia with a laryngeal mask airway. Gastric insufflation was investigated during an incremental pressure trial up to a maximum airway pressure of 30 cmH2O and during oropharyngeal leak pressure measurement with and without an inserted gastric tube while one of two laryngeal mask airways with different cuff designs (inflatable or thermoelastic) was used. Gastric insufflation was detected with real-time ultrasound. Frequency of gastric insufflation was higher with than without inserted gastric tube during the incremental pressure trial (10.9 % (16/147) vs. 2.7 % (4/147), p = 0.009) and during oropharyngeal leak pressure measurement (16.3 % (24/147) vs. 5.4 % (8/147), p = 0.004). Risk of gastric insufflation didn't differ between the two cuff-types (p = 0.100). Flow over the open gastric channel was associated with gastric insufflation during positive-pressure ventilation (p = 0.003) and during oropharyngeal leak pressure measurement (p = 0.049). Incidence of postoperative nausea and vomiting was higher in patients in which gastric insufflation was detected, compared to others (17.1 % (6/35) vs. 5.4 % (6/112), p = 0.037). Placement of a gastric tube through the gastric channel of a second-generation laryngeal mask airway, independent of the cuff-type, increases the risk of gastric insufflation. Flow over the gastric channel indicate a higher risk of gastric insufflation and gastric insufflation may increase the risk of postoperative nausea and vomiting. [Display omitted] •Risk of gastric insufflation in 2nd generation LMAs increases with a gastric tube.•Cuff-type of 2nd generation LMA does not influence the risk of gastric insufflation.•Flow over the gastric channel is a sign of an increased risk of gastric insufflation.•Patients with gastric insufflation experienced PONV more often at the PACU.

Background Proper mask ventilation is important to prevent air inflow into the stomach during induction of general anesthesia, and it is difficult to send airflow only through the trachea without gastric inflation. Changes in gastric insufflation according to mask ventilation during anesthesia induction were compared. Methods In this prospective, randomized, single-blind study, 230 patients were analyzed to a facemask-ventilated group (Ventilation group) or no-ventilation group (Apnea group) during anesthesia induction. After loss of consciousness, pressure-controlled ventilation at an inspiratory pressure of 15 cmH2O was performed for two minutes with a two-handed mask-hold technique for Ventilation group. For Apnea group, only the facemask was fitted to the face for one minute with no ventilation. Next, endotracheal intubation was performed. The gastric cross-sectional area (CSA, cm 2 ) was measured using ultrasound before and after induction. After pneumoperitoneum with carbon dioxide, gastric insufflation of the surgical view was graded by the surgeon for each group. Results Increase of postinduction antral CSA on ultrasound were not significantly different between Ventilation group and Apnea group (0.04 ± 0.3 and 0.02 ± 0.28, p-value = 0.225). Additionally, there were no significant differences between the two groups in surgical grade according to surgeon’s judgement. Conclusions Pressure-controlled ventilation at an inspiratory pressure of 15 cmH 2 O for two minutes did not increase gastric antral CSA and insufflation of stomach by laparoscopic view. Trial Registration http://cris.nih.go.kr (KCT0003620) on 13/3/2019.

To determine the level of inspiratory pressure minimizing the risk of gastric insufflation while providing adequate pulmonary ventilation. In this prospective, randomized, double-blind study, patients were allocated to one of the two groups (P10, P15) defined by the inspiratory pressure applied during controlled-pressure ventilation: 10 and 15 cm H2O. Anesthesia was induced using propofol and sufentanil; no neuromuscular-blocking agent was administered. Once loss of eyelash reflex occurred, facemask ventilation was started for a 2-min period. The cross-sectional antral area was measured using ultrasonography before and after facemask ventilation. Respiratory parameters were recorded. Forty patients were analyzed. Mean tidal volume was about 7 ml/kg in group P10, and was >11 ml/kg in group P15 in the same period. As indicated by ultrasonography test, the antral area in P15 group was markedly incresed compared with P10 group. Inspiratory pressure of 10 cm H2O allowed for reduced occurrence of gastric insufflation with proper lung ventilation during induction of anesthesia with sufentanil and propofol in nonparalyzed and nonobese patients.

Background The application of bedside ultrasound to evaluate gastric content and volume can assist in determining aspiration risk. Applying positive pressure ventilation via supraglottic airway devices (SAD) can result in a degree of gastric insufflation. This study assessed and compared the antral cross-sectional area (CSA) in patients undergoing laparoscopic gynecological surgery when managed with different SAD. Methods One hundred American Society of Anesthesiologists I or II female patients were assessed for inclusion in this study and divided into three groups of different ventilation devices. Patients were randomly allocated into three groups to receive LMA-Supreme (Group S), I-gel (Group I) or tracheal tube (Group T). The primary outcome was the antral cross-sectional area and secondary outcomes included haemodynamic parameters and postoperative morbidity such as sore throat, hoarseness, dry throat, nausea and vomiting. Results The antral CSA was not significantly different among three groups before induction ( P  = 0.451), after induction ( P  = 0.456) and at the end of surgery ( P  = 0.195). The haemodynamic variables were significantly higher in the tracheal tube group than in the LMA-Supreme and I-gel groups after insertion ( P  < 0.0001) and after removal ( P  < 0.01). Sore throat was detected in none in the I-gel group compare to two patients (6.7%) in the LMA-Supreme group and fifteen patients (50%) in the tracheal tube group. Hoareness was detected in one (3.3%) in the I-gel group compare to two patients (6.7%) in the LMA-Supreme group and eleven patients (36.7%) in the tracheal tube group. Conclusions The SADs do not cause obvious gastric insufflation. Thus, LMA-Supreme and I-gel can be widely used as alternative to endotracheal intubation for the short laparoscopic gynecological surgery. Trial registration This trial was registered at the Chinese Clinical Trial Registry ( ChiCTR1800018212 , data of registration, September 2018).

Background and objectives: The laryngeal mask is the method of choice for airway management in children during minor surgical procedures. There is a paucity of data regarding optimal management of mechanical ventilation in these patients. The Supreme™ airway laryngeal mask offers the option to insert a gastric tube to empty the stomach contents of air and/or gastric juice. The aim of this investigation was to evaluate the impact of positive end-expiratory positive pressure (PEEP) levels on ventilation parameters and gastric air insufflation during general anesthesia in children using pressure-controlled ventilation with laryngeal mask. Materials and Methods: An observational trial was carried out in 67 children aged between 1 and 11 years. PEEP levels of 0, 3 and 5 mbar were tested for 5 min in each patient during surgery and compared with ventilation parameters (dynamic compliance (mL/cmH2O), etCO2 (mmHg), peak pressure (mbar), tidal volume (mL), respiratory rate (per minute), FiO2 and gastric air (mL)) were measured at each PEEP. Air was aspirated from the stomach at the start of the sequence of measurements and at the end. Results: Significant differences were observed for the ventilation parameters: dynamic compliance (PEEP 5 vs. PEEP 3: p < 0.0001, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001), peak pressure (PEEP 5 vs. PEEP 3: p < 0.0001, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001) and tidal volume (PEEP 5 vs. PEEP 3: p = 0.0048, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001). All parameters increased significantly with higher PEEP, with the exception of etCO2 (significant decrease) and respiratory rate (no significant difference). We also showed different values for air quantity in the comparisons between the different PEEP levels (PEEP 5: 2.8 ± 3.9 mL, PEEP 3: 1.8 ± 3.0 mL; PEEP 0: 1.6 ± 2.3 mL) with significant differences between PEEP 5 and PEEP 3 (p = 0.0269) and PEEP 5 and PEEP 0 (p = 0.0209). Conclusions: Our data suggest that ventilation with a PEEP of 5 mbar might be more lung protective in children using the Supreme™ airway laryngeal mask, although gastric air insufflation increased with higher PEEP. We recommend the use of a laryngeal mask with the option of inserting a gastric tube to evacuate potential gastric air.

Background During facemask ventilation, gastric insufflation is defined as appearance of a comet-tail or an acoustic shadow on ultrasonography. Ultrasonographic measurement of antral cross-section area (CSA) may reflect an insufflated antrum and provide interesting semi-quantitative data in regard to the gastric insufflation. This study aimed to determine the appropriate level of inspiratory pressure sufficient to provide adequate pulmonary ventilation with a lower occurrence of gastric insufflation during facemask pressure-controlled ventilation using real-time ultrasonography in paralyzed children. Methods Ninety children, ASA I-II, aged from 2 to 4 years, scheduled for general anesthesia were enrolled in this randomized and double-blinded study. Children were randomized into one of the five groups (P8, P10, P12, P14, and P16) defined by the applied inspiratory pressure during facemask ventilation: 8, 10, 12, 14, and 16 cm H 2 O. Anesthesia induction was conducted with fentanyl and propofol. Rocuronium was administrated as a muscle relaxant. After rocuronium administration, facemask ventilation was performed for 120 s. Gastric insufflation (GI+) was detected by ultrasonography, and the antral CSA before and after facemask ventilation were also measured using ultrasonography. Respiratory variables were monitored. Results Gastric insufflation was detected in 32 children (3/18 in group P8, 5/18 in group P10, 7/18 in group P12, 8/16 in group P14, and 9/14 in group P16). The antral CSA after facemask ventilation statistically increased in subgroups P14 GI+ and P16 GI+ for whom gastric insufflation was detected by ultrasonography, whereas it did not change statistically in other groups. Lung ventilation was inadequate for group P8 or P10. Conclusion We concluded that an inspiratory pressure of 12 cm H 2 O is sufficient to provide adequate ventilation with a lower occurrence of gastric insufflation during induction of general anesthesia in paralyzed Chinese children aged from 2 to 4 years old. Trial registration ( ChiCTR-IPR-16007960 ). Registered 21 February 2016 Conclusion heading: Ultrasound for determining gastric insufflation

During positive pressure ventilation, gastric inflation and subsequent pulmonary aspiration can occur. Rapid sequence induction (RSI) technique is an age-old formula to prevent this. We adopted a novel approach of RSI for patients with high risk of aspiration and evaluated it further in patients undergoing laparoscopic surgeries. We believe that, in patients with risk of gastric insufflation and pulmonary aspiration, transnasal humidified rapid-insufflation ventilatory exchange can be useful in facilitating pre- and apnoeic oxygenation till tracheal isolation is achieved.

We describe a case of severe gastric insufflation in a patient with amyotrophic lateral sclerosis who was receiving bilevel nasal positive airway pressure (BNPAP) ventilation (BiPAP; Respironics; Murrysville, PA). The injection of inspiratory flow into the esophagus, aerophagia, and air trapping below the gastroesophageal junction after a meal are probably the major causes. We suggest that BNPAP ventilation can be a cause of serious gastric insufflation in a patient who lies supine, especially after a meal, and attention should be paid to avoiding this complication by having the patient sit up for about half an hour after a meal.

Objectives To evaluate the safety and efficacy of transhepatic cardia-gastric fundus puncture (TCFP) for insufflation for CT-guided percutaneous gastrostomy (CPG). Methods The clinical data of 38 patients who underwent TCFP for insufflation and 161 patients who underwent percutaneous gastric body for insufflation at a single center were retrospectively analyzed. The operative time, success rate, complication rate, overall procedure time, and incidence of complications within 3 months were collected. Results The success rate of insufflation was 100%, and no serious complications occurred during percutaneous gastric insufflation. The average time for insufflation via TCFP was 9.60 ± 6.62 min, and that via gastric body puncture was 8.71 ± 71.8 min, with no significant difference between the two ( p  = 0.485). The overall duration of gastrostomy in the TCFP group was 32.16 ± 10.27 min and 33.94 ± 13.82 min in the gastric body group, with no significant difference ( p  = 0.456). The incidence of submucosal air spread was 0% in the TCFP group and 9.9% in the gastric body group, with significant difference ( p  = 0.045). The complication rates following insufflation via TCFP and via gastric body puncture were 18.4% and 21.7%, respectively, with no significant difference between the two groups (p = 0.652). The perioperative pain score was 2 after insufflation via TCFP and via gastric body puncture, with no significant difference ( p  = 0.119). The overall mortality rate was 0 in the first postoperative month, with a 3-month mortality rate of 5% (10/199). The surviving patients showed a significant increase in weight from 51.81 ± 8.52 kg to 52.52 ± 9.39 kg at 3 months postoperatively ( p  = 0.009). Conclusions TCFP for insufflation is safe and effective, with a 100% success rate and no increased risk of complications. The choice of procedure should be based on the patient's specific condition and the physician's experience.