University of Gondar

College of Medicine and Health Sciences

Department of Anesthesia

Anesthesia for abdominal surgery

Girmay T.Fitiwi
tsagir.fitiwi@gmail.com
Anaesthesia for the patient with a full
stomach
 Course objective

• After completion of this session the student will be able to

manage patients with full stomach in order to deliver “safe”
and smooth anaesthesia.
Full stomach

 A patient who recently ingested food or drunk fluid.

 An emergency patient with potential risk of aspiration.

 A patient with pain, stress, pregnancy, trauma, DM, shock,

premedication with opioids ,bowel obstruction.

with a potential risk of aspiration of gastric

contents.
 In Emergency surgery

 Having a patient who consumed nothing for more than 6hrs

doesn’t guarantee an empty stomach.

 The most important time is the time from the last food
intake up to the incidence (i.e. trauma, pain…)

 All emergency patients should be treated as having a full

stomach and so at risk of vomiting , regurgitation and aspiration.
 A patient with full stomach, when consciousness is lost as during
induction of general anaesthesia , stomach contents may regurgitate
gastric material via the oesophagus which may be aspirated into the
lungs causing a severe pneumonitis (Aspiration pneumonitis) .

 Severe, and often fatal may occur, if the gastric contents are

 Markedly acidic (pH < 2.5) and as little as 30mls will cause a severe
reaction.

 When solid foodstuffs are aspirated complete obstruction of the

airway may occur.
Why do people regurgitate?

 The junction between esophagus and stomach is called

esophagogastric junction.

 Gastro–esophageal sphincter/Lower esophageal sphincter acts

as a sphincter to prevent material returning to the oesophagus
after entering the stomach.

.
 Two major factors affect the Lower esophageal
junction/sphincter

1.When the conscious level is depressed this junction works less

efficiently.

2.If the pressure within the stomach (the intragastric pressure)

is greater than the closing pressure of the sphincter/barrier
pressure then regurgitation will occur
 Conditions associated with changes in LEST
 Decrease LEST

 Obesity, Pregnancy, intra abdominal  Increase LEST

swelling o Metoclopramide
 Hiatal hernia
o Suxamethonium
 Decreased concioussness
o Anticholinesterase :
 Drugs
Neostigmine, Edrophonium
 Anticholinergics, Opioids

 Inhalational anesthetics, Thiopental

 Tricyclic antidepressants(TCA)
No change on LEST

 Propranolol, Cimetidine , Ranitidine

 Atracurium and N2O

• What is the difference between regurgitation

and vomiting ?
 Vomiting

 it is an active process and involves contraction of the abdominal

muscles.

 occurs in lighter stages of anaesthesia or in awakening state.

 Regurgitation

 It is passive process/silent that may occur at any time and

involving smooth muscles only.

 Regurgitation is particularly likely at induction of anesthesia when

several drugs used.

– The most common cause of regurgitation is a decreasing closing

pressure of sphincter (IGP>CPS).
 Factors determining the extent of gastric regurgitation

– Function of the LES

– Rate of gastric emptying

– Volume of gastric content

 Factors affecting gastric emptying
Cause Increase Decrease
Physiologic Gastric distension Food
Neurosis Acid
Pregnancy

Pathologic Thyrotoxicosis Anxiety

GERD
Pyloric stenosis
Pain ( angina ,heart burn )
Shock
DM
Pharmacologic Metocloropramide Opioids
Neostigmine Alcohol
Anticholinergics
TCA
 Effect of pulmonary aspiration

– Airway obstructionHypoxia

– Chemical pneumonitis

– Bacterial contamination

 Having a patient consumes NPO 4-6/8hrs preoperatively doesn’t

guarantee an empty stomach.

 A recent study suggests that oral intake of small volumes of clear

fluid or water (150-250ml) may actually facilitate gastric

emptying.
• Factors that increase the severity of aspiration are:

1. Volume of aspirate >25ml - sever

2. PH of aspirated matter: PH<2.5- sever/ fatal

3. Extent of lung involved: One or both.

4. Type of aspiration: Solid/food/,liquid/blood/

5. Health status of the patient

 Risky patients for aspiration
1. Altered mental status

• Head injury, Drug over dose, Coma, CVA, anesthesia drugs

and Sepsis.

• These patients have impaired pharyngeal & airway

protective reflexes.
2. Impaired coughing or gag reflex

- Recent extubation

- Neck & pharyngeal trauma & surgery

- Esophageal abnormalities

3. Hiatus hernia- may render the OGJ ineffective

4. Obesity- increased gastric volume & delayed gastric emptying.

5. Pregnancy: Decreased gastric emptying & increased gastric volume &
acid or hormonal changes that decrease the efficiency of OGJ.

6. Some pre- medicants: Opioids

7. DM : delayed gastric emptying secondary to autonomic dysfunction.

8. Shock / emergency / traumatic patient

9. Parkinson’s disease

10. Addison’s disease

 Prevention methods of aspiration

 Prevention of aspiration of gastric contents and the acidic aspiration

syndrome can be facilitated by:

1. NGT suction or insertion before operation

2. Inducing vomiting pharmacologically. e.g. Apomorphine

3. Facilitating of gastric emptying

4. Increasing gastric fluid PH

5. Rapid sequence induction(RSI)

 Neither NGT suctioning nor inducing vomiting doesn’t guarantee

an empty stomach.
 The Anaesthetic Approach to the Patient with a Full
Stomach.
1. Identify the patient at risk

• Identify the patient at risk. Any patient who falls into any of the
categories above should be treated as having a ‘full stomach’.

2. Consider the operation planned and its urgency

• If the operation can be delayed to allow the stomach to empty then

this approach should be adopted. However the patient's life should
not be put at risk by delaying urgent procedures.

• It should be remembered that some ill patients may be unable to

empty their stomachs.
3. If possible reduce the volume, pressure and acidity of the
stomach contents

 Volume

 Patients with a stomach full of liquid, bowel obstruction or who are

drunk should have a large nasogastric tube passed prior to GA.
Often the patients will vomit during attempts at passing of a
nasogatric tube.

 Remember that even after passing the tube the stomach is unlikely to
be completely empty as NGTs are inefficient for removing liquids
and useless for solids.
 Metoclopramide

– Facilitate gastric emptyingdecrease gastric volume

– Increase LEST and bowel motility.

– 10mg PO / IV before surgery.

– Intra venous is best to be given 15 min before operation

• It is given through slow IV push over 3-5 minutes, in order to avoid

an abdominal cramp which may occur due to fast injection.

• Relaxes pylorus and duodenum.

 Neutralizing and decease acidity:

 Gastric PH can be reduced with

 Non particulate Antacids(sodium citrate)

 H2 receptor antagonists( cimetidine ,ranitidine)

 Proton pump inhibitors (omeprazole )

 A. Non-particulate antacid

 Particulate antacids are the most potent ones.

e.g. Aluminum hydroxide , Magnesium trisilicate

 But the particulate antacids produce sever pulmonary damage if

they are aspirated.

 So we give the non particulate ones.

 Sodium citrate 30ml of 0.3M solution 1hr before

operation

 Bicitrate 30ml PO before operation.

 It increases PH & doesn’t form particulate.

B. H2 blockers

 Decrease acidity

 Not affect the gastric volume

 Cimetidine : 200 mg IV TID

 Ranitidine : 50 mg IV TID

• Such techniques will raise the pH of the gastric fluid and make the
consequences of aspiration less serious.
4. Consider the Best Form of Anaesthesia

 In circumstances if the surgery allows to use RA ( central neuraxial

and peripheral nerve blocks ) use it.

 If general anaesthesia is required in a patient at risk of having a full

stomach the airway should be protected by a cuffed endotracheal tube.

 RSI/crush induction is the best possible techniques preventing

aspiration during GA with ETT.
 5. Rapid sequence induction
 Rapid sequence induction (RSI) /Crash induction

 It is a method of achieving rapid control of the airway whilst

minimising the risk of regurgitation and aspiration of gastric
contents.

 Intravenous induction of anaesthesia, with the application of

cricoid pressure, is swiftly followed by the placement of an
endotracheal tube (ETT).
1. Preoxygenation

2. Induce a patient with full stomach using ultra short acting

intravenous anesthetic agents and muscle relaxants with
applying of cricoid pressure to secure the trachea with
cuffed endotracheal tube.

 Goal is to prevent pulmonary aspiration .

 History of RSI/Classic RSI
• RSI was originally described in 1961 by Sellick as:

1. Emptying of the stomach via a gastric tube which is then removed

2. Pre-oxygenation

3. Positioning the patient supine with a head-down tilt

4. Induction of anaesthesia with a barbiturate (e.g. thiopentone) or

volatile, and a rapid-acting muscle relaxant (e.g. suxamethonium)

5. Application of cricoid pressure

6. Laryngoscopy and intubation of the trachea with a cuffed tube

immediately following fasciculations.
 Preoxygenation/ Denitrogenation
 Preoxygenation is the administration of 100% of O2 for 3-5 minutes
to a patient prior to intubation to extend ‘the safe apnoea time’.
• It is a critical step at maximizing blood oxygen saturation level and
creating oxygen reservoir in the lungs and eliminate the need for bag-
valve-mask(BVM) ventilation  avoid gastric insufflation and
aspiration.

• Safe apnoea time : It is the duration of time following cessation of

breathing/ventilation until critical arterial desaturation occurs
(typically considered SaO2 88% to 90% in clinical settings)

– Oxygen consumption during apnea is approximately 200-250

mL/min (~3 mL/kg/min) in healthy adults.
 Denitrogination of the lungs
– Removes N2 & replaces by O2 Denitrogination
– When breathing room air (79% nitrogen) ~450 mL of oxygen
is present in the lungs of an average healthy adult.
– When a patient breathes 100% oxygen, this washes out the
nitrogen, increasing the oxygen in the lungs to ~3L achieve
as close to SaO2 100% as possible.
– This maximizes oxygen content of the blood by ensuring
Haemoglobin is fully saturated.
• In a healthy preoxygenated patient the safe apnea time is up to 8
minutes, compared to ~1 min if they were breathing room air.

• In some critically ill patients critical desaturation may occur

immediately despite attempts at preoxygenation.

Q. Techniques, Duration and Types of preoxygenation ?

 Optimal Time:3 minutes of tidal volume breathing (normal

respiratory pattern) with a high FiO2 source.

 8 vital capacity breaths (maximal inhalation and maximal

exhalation) with a high FiO2 source in cooperative patients
Cricoid pressure /sellick’s maneuver
• 10 Newtons of force is applied by the thumb and index finger of an
assistant increasing to 30N once consciousness is lost.

• When firm backward pressure is applied to itthe oesophagus is

occluded preventing any regurgitated gastric fluid from entering the
pharynx.

• The backward pressure should be firm; if the equivalent pressure

is applied to the bridge of the nose it feels uncomfortable.

• This pressure is maintained until endotracheal tube placement is

confirmed.
• Cricoid pressure should be reduced or released

 If laryngoscopy is difficult, or

 If vomiting occurs (to reduce the chance of

esophageal rupture from active vomiting).
 Sellick maneuver

• Initiate upon loss of

consciousness.

• Continue until ETT

balloon inflation

• Release if active vomiting

 Techniques /Components of RSI
1. Preparation : Equipment ,team member and patient

 Preparation is vital, both of equipment and team members.

 Anticipation of difficult airway and establishing oxygenation plans

prior to conducting RSI are essential.

 Check all equipment before starting and ensure that everything is at

hand.

 Preparation of patient : Explanation should be offered to the patient.

 Induction drugs

 Careful dosing of any drug used is more important than the

choice of drug.

 Resuscitation drugs should be readily available.

 In shocked patients a very modest dose of hypnotic may be

sufficient as these drugs can easily lead to circulatory collapse
and cardiac arrest.
 Propofol (1-3 mg/kg):

 For patients who are haemodynamically stable.

 In elderly or hypovolemic patients, the dose is drastically reduced:

often 0.5-1mg/kg is sufficient, although time to effect is increased due
to lower cardiac output.

 Ketamine (1-2mg/kg):

 used in pre-hospital settings and in unstable patients. The usual effect

is an elevation in heart rate and variable but modest blood pressure
changes.

 Secretions increase
 Thiopentone (3-5mg/kg):

 Has the most rapid and predictable effect, with less haemodynamic
instability than propofol.

 However, there may be issues with poor availability and the harmful
sequelae following extravasation or intra-arterial injection should be
considered.

 Midazolam (0.1-0.2mg/kg): may be used, although the time to effect

may be very prolonged. It is most suitable in patients who are already
obtunded and primarily require amnesia rather than true anaesthesia.
• Fast acting muscle relaxants

1. Suxamethonium ( 2mg/kg ) …immediately after

fasciculation insert the ETT as soon as possible

2. Rocuronium is an alternative agent (0.9-1.6mg/kg )

,profound relaxation is obtained with 45-60 second.
 Pharmacological adjuncts

• Opioids are commonly used: fentanyl (1-2mcg/kg), alfentanil

(10-15mcg/kg), or remifentanil (0.5-1 mcg/kg) are all
sufficiently rapid-acting for use in RSI.

• Lidocaine (lignocaine) (1-1.5 mg/kg) is also effective at

reducing cough and bronchospasm, solely or in combination
with an opioid.
 Preparation of team members

• Tasks that need to be allocated and performed include:

– Pre-oxygenation and Intubation

– Assisting the intubator (passing equipment, etc.)

– Drug administration

– Cricoid pressure application (if used)

– Manual in-line stabilisation (if indicated)

NB: A minimum of two people are required to fill these roles.

2. Position and preoxygenation
 The patient should be positioned appropriately for pre-
oxygenation and intubation; this may involve
 Ramping, manual inline stabilisation, or a semi-recumbent
position for pre-oxygenation if respiratory function is impaired
by lying supine.
 Preoxygenation for 3-5 minutes or 8 vital capacity breaths for
minute .
 When satisfactory pre-oxygenation has been obtained, and all
team members are ready to proceed.
3. Induction ,paralysis and intubation with Cricoid pressure

 the chosen medications should be administered and the patient should

be observed for evidence of effect.

 If cricoid pressure is to be used, it should be in situ and increased

from 10N to 30N at the moment consciousness is lost.

• When intubating conditions are obtained intubation should be

performed. Given the need to rapidly secure the airway, first pass
success is highly desirable.

• Once the endotracheal tube is placed, the cuff is immediately inflated

and correct position should be confirmed by multiple means
 Regurgitation during intubation

– If regurgitation is observed, suction should be rapidly

applied, and the bed should be placed in a head-down
(Trendelenburg) position to minimise the chance of
aspiration into the trachea.
• Once the ETT is placed, the cuff is immediately inflated and correct
position should be confirmed by multiple means.

 Observing chest rise and fall, tube misting, and a normal feeling of
airflow in and out of the endotracheal tube are useful, but neither
sufficiently sensitive nor specific.

 The gold standard is the appearance of a 4 phase capnography

waveform for 5 breaths, although this is reliant on cardiac output.

 Auscultation, in conjunction with the clinical assessment methods

described above, must be used if capnography is unavailable.

 Cricoid pressure, if used, should be released only when ETI is

confirmed.
 CONTROVERSY AROUND CRICOID PRESSURE

• Although routinely performed in many parts of the world –

particularly the United Kingdom, North America, and Australia
cricoid pressure is not established practice elsewhere and is
contentious.

• It is not common practice in Europe, and some pre-hospital

organisations do not endorse its use.

• It may also not be used in areas of the world where there is a

lack of dedicated personnel to assist the anaesthetist.
 Concerns include:

1. Reduced quality of laryngoscopy

2. Lack of evidence of effectiveness in preventing reflux and

aspiration.

3. Reduced LEST and therefore increasing reflux risk.

4. Worsening of undetected laryngeal or cervical spine injury.

5. unmeasurable and likely highly variable location, direction, and

degree of force being applied by the operator .

6. patient discomfort, gagging or coughing, and

• A systematic review has found no data from randomized trials
providing any clinically relevant outcome measures. Despite
the ongoing controversy, use is considered standard of care in
many settings.

• It is advisable to seek guidance from individual institutions

about their expectations and guidelines.
 Recent developments
• Classically ventilation is not usually provided during the apnoeic
periodto avoid inflation of the stomach and associated increased
risk of regurgitation.

• Some anaesthetists may give a single breath, or several gentle

breaths, to both confirm that mask ventilation is possible and reduce
the development of hypercapnia, acidaemia, and hypoxia.

• Some recent guidelines now advocate use of mask ventilation for this
reason in patients at elevated risk of hypoxia, for example, the
pregnant patient.
• Recently apnoeic oxygenation is increasingly being used, especially in
critically unwell patients, to provide an oxygen rich environment in
the oropharynx to minimise hypoxia during the apnoeic period of RSI.

• This is provided by an alternative oxygen source; commonly via

nasal prongs with oxygen flow at 10 L/min or more, or via
insertion of tubing carrying oxygen into the oropharynx.

• Limitations can include difficulty with the face-mask seal, pressure-

induced damage from misplaced tubing (e.g. gastric rupture), and lack
of efficacy in at least one trial.
 SPECIFIC CLINICAL SITUATIONS
1. Obstetrics

• Patients in the second or third trimester of pregnancy are at higher risk

of aspiration due to anatomical and physiological changes. These
patients are also more likely to be difficult to intubate, and desaturate
faster than non-pregnant women.

• For these reasons, RSI is employed with meticulous attention to

positioning, pre-oxygenation, and availability of difficult airway
equipment and expertise. Routine, gentle face-mask ventilation may
be utilised.
• Use of opioids as an adjunct to induction may be required if
the pregnancy is complicated by hypertension or pre-
eclampsia.

• As with all advanced pregnancies, the woman should be

positioned with a left tilt using a wedge or a tilted table.
2. Paediatrics

• Neonates, infants and children desaturate rapidly and can have

pronounced vagal responses to laryngoscopy.

• A standard approach to RSI is generally performed, with a range of

appropriately-sized equipment, and carefully calculated drug dosages.

• Required doses may be higher than for adults on a per kilogram basis
3. Suspected or known cervical spine injury

• In patients who have an unstable cervical spine injury, laryngoscopy

with attendant manipulation of the head and neck presents a risk of
worsening any injury.

• There is no consensus as to the safest way to intubate these patients,

but two alternative approaches are commonly practiced.

1. Perform laryngoscopy with minimal movement of the cervical spine,

often with a hyper-angulated video laryngoscope if it is available, whilst
the neck is immobilized by an assistant performing manual in-line
stabilisation.

2. An awake fibre-optic technique, using local anaesthesia only.

 Emergence

• In patients for whom an RSI was indicated due to aspiration risk,

emergence remains a high-risk time for further aspiration events.

• Strong consideration should be given to extubating the patient

1. Awake with full reversal of neuromuscular blockade.

2. Left lateral head-down positioning : may reduce the

chance of aspiration, at the expense of reduced access to the airway.
 Summary

• Rapid sequence induction is performed to secure the airway in

patients at elevated risk of aspiration.

• Preparation of equipment, drugs, the team and the patient is

essential; excellent communication should be routine.

• The technique may be tailored to the specifics of the clinical

scenario.

• Classifies in to two : Classic versus modified