Editorials
neighbouring teaching hospitals. Key to success will be the
formation of large informatic databases, or clinical quality
registries, linking preoperative and intraoperative clinical
data, imaging, genomics, and cancer and drug prescription
databases.
From a clinical perspective, we forsee patients undergoing
the same operation receiving a different anaesthetic depend-
ing on their outcome risk. Taking knee arthroplasty as an
example, patients deemed at low risk of experiencing out-
comes such as postoperative pain or chronic pain may
receive intra-articular local anaesthesia infiltration; patients
at medium risk may obtain additional analgesia via a saphe-
nous nerve catheter; and patients at high risk may also
receive nerve blocks and anti-hyperalgesics. Best possible
treatment in low- and high-risk groups, based on the clinical
balance of efficacy and side-effects, would be determined by
stratified RCTs.
We believe that, by adopting this philosophy, a stratified,
holistic approach to research will bring a more personalized
approach to anaesthesia.
Authors’ contributions
S.M. and G.M.: conceived the idea and wrote the editorial.
Declaration of interest
None declared.
References
1 Fischer HB, Simanski CJ, Sharp C, et al. A procedure-specific systematic
review and consensus recommendations for postoperative analgesia
following total knee arthroplasty. Anaesthesia 2008; 63: 1105–23
2 Joshi GP, Group PW, Schug SA, et al. Postoperative pain manage-
ment: number-needed-to-treat approach versus procedure-
specific pain management approach. Pain 2013; 154: 178– 9
British Journal of Anaesthesia 114 (4): 545–8 (2015)
Advance Access publication 29 October 2014 . doi:10.1093/bja/aeu369
Ultrasound assessment of gastric contents in the perioperative
period: why is this not part of our daily practice?
D. Benhamou
Département d’Anesthésie-Réanimation, Hôpitaux Universitaires et Faculté de Médecine Paris-Sud, France
E-mail: dan.benhamou@bct.aphp.fr
In 1946, Mendelson1 showed that pulmonary complications
and death could arise in pregnant women because of aspir-
ation of gastric contents. Since then, prevention of aspiration
of gastric contents has contributed significantly to a decrease
in maternal deaths. Aspiration of gastric contents also impacts
other areas of anaesthetic practice, particularly emergency
surgery. Warner and colleagues2 demonstrated in a large
BJA
3 Scott NB. Wound infiltration for surgery. Anaesthesia 2010;
65(Suppl. 1): 67– 75
4 The National Hip Fracture Database: Anaesthetic Sprint Audit of
Practice. London, 2014
5 Andersen LO, Gaarn-Larsen L, Kristensen BB, Husted H, Otte KS,
Kehlet H. Subacute pain and function after fast-track hip and
knee arthroplasty. Anaesthesia 2009; 64: 508–13
6 Lavand’homme PM, Grosu I, France MN, Thienpont E. Pain trajectories
identify patients at risk of persistent pain after knee arthroplasty: an
observational study. Clin Orthop Relat Res 2014; 472: 1409–15
7 Macrae WA. Chronic post-surgical pain: 10 years on. Br J Anaesth
2008; 101: 77– 86
8 Hingorani AD, Windt DA, Riley RD, et al. Prognosis research strategy
(PROGRESS) 4: stratified medicine research. Br Med J 2013; 346:
e5793
9 Moore A, Derry S, Eccleston C, Kalso E. Expect analgesic failure;
pursue analgesic success. Br Med J 2013; 346: f2690
10 Stratified Medicine in the UK. Vision and Roadmap. Technology Strat-
Downloaded from http://bja.oxfordjournals.org/ at University of Manitoba on April 15, 2015
egy Board, 2013
11 MRC Stratified Medicine Strategy Workshop. London: Medical Re-
search Council, 2013
12 Realising the Potential of Stratified Medicine. London: Academy of
Medical Sciences, 2013
13 Landau R, Kraft JC, Flint LY, et al. An experimental paradigm for
the prediction of Post-Operative Pain (PPOP). J Vis Exp 2010; 35:
http://www.jove.com/index/Details.stp?ID=1671 (accessed 18
September 2014)
14 Strulov L, Zimmer EZ, Granot M, Tamir A, Jakobi P, Lowenstein L. Pain
catastrophizing, response to experimental heat stimuli, and post-
cesarean section pain. J Pain 2007; 8: 273–9
15 Puolakka PA, Rorarius MG, Roviola M, Puolakka TJ, Nordhausen K,
Lindgren L. Persistent pain following knee arthroplasty. Eur J Anaes-
thesiol 2010; 27: 455– 60
16 Fernandez Robles CR, Degnan M, Candiotti KA. Curr Opin Anesthesiol
2012; 25: 444–9
17 Modeling Strategies: With Applications to Linear Models, Logistic Re-
gression, and Survival Analysis. New York: Springer, 2006
series from the Mayo Clinic that no aspiration occurred in preg-
nant or post-partum women (probably because of the routine
use of prophylactic measures), while both its occurrence and
severity were significant in emergency procedures. An import-
ant risk factor for aspiration is gastric volume, determined in
large part by gastric emptying. Unfortunately, measuring
gastric volume over time is not easy, and scintigraphy has
545
BJA
remained the gold standard technique for many years.3
However, because of cost, radiation exposure, and the need
for specific equipment, this technique has remained largely
restricted to research purposes. Ultrasound has progressively
emerged as a useful replacement because it is cheap and
can be performed at the bedside. After years of uncertainty
recent studies provide sufficient evidence of accuracy and re-
producibility. Clearly, ultrasound assessment cannot provide
complete information about gastric function and status (i.e.
pH), but it can deliver important and useful information, such
as gastric volume. It also allows identification of particles
that could increase risk if aspiration occurs. In the article by
Okabe and colleagues4 in this issue of the BJA, important
new information about the mechanisms driving gastric empty-
ing is presented.
Hillyard and colleagues5 have recently challenged the
traditional view that milk is slow to evacuate from the
stomach. The study by Okabe and colleagues is important in
showing that the greater the caloric content, the slower is
gastric emptying. The authors do not speculate on what physio-
logical sensor detects calorie content, but several mechanisms
have been suggested. Gastric emptying is modulated by local
mechanical factors6 and gastric wall stress,7 but neurohumoral
mechanisms are also implicated. For example, when a lipid
emulsion is infused directly into the duodenum, gastric motility
decreases and appetite is suppressed.8 Filling the intestine
with food or drink triggers a neurohumoral response mediated
by the vagus nerve, the myenteric plexus, and the release of
small bowel peptide hormones (e.g. CCK, glucagon-like
peptide-1), which affect gastrointestinal function and slow
gastric emptying.9 A similar mechanism is involved when nutri-
ents enter the distal part of the small intestine (called the ‘ileal
brake’).10 This latter effect partially explains the different (and
slower) gastric emptying during the late post-prandial period.
According to Kwiatek and colleagues,7 gastric emptying half-life
increases by 18 min for each additional 100 kcal load. This esti-
mate is largely consistent with the study of Okabe and collea-
gues4 (their Fig. 4) in which gastric emptying half-life was close
to 30 and 50 min for the 220 and 330 kcal fluids, respectively.
The nutrient content is less important than the calorie load,
but there is a complex interaction between calorie load, gastric
volume, and time. For example, during the early period of
gastric emptying, volume is more important, and a ‘bolus’ of
gastric content is rapidly evacuated into the duodenum, what-
ever its calorie load. Sensory mechanisms that sense gastric
volume and its chemical content (calories) then modulate
gastric emptying. This would explain the relationship of gastric
volume to time: an initial rapid steep decrease subsequently flat-
tening out when neurohumoral mechanisms take effect.
The study by Okabe and colleagues4 also confirms that vis-
cosity and osmolality play lesser roles compared with caloric
content,11 – 13 although this has been challenged.14 Milk per
se is not slow to evacuate, but it is rather its fat-related
caloric content that determines the slower rate of gastric
emptying. A small volume of whole milk or a larger volume of
skimmed milk poses a similar risk. For example, whole cow’s
milk (fat content 4%) contains around 650 kcal litre21,
546
Editorials
whereas the same volumes of skimmed and semi-skimmed
milk contain 340 and 460 kcal, respectively.15 The effect
might be linked at least partially to the size of lipid droplets,8
smaller lipid droplets leading to more intense inhibition, pos-
sibly due to a greater contact surface area between the intes-
tine and the nutrient. Milk cannot be used as a generic term, but
requires precise definition as to what can (or cannot) be drunk.
Simple explanations should be given to the patient, possibly
with practical examples to facilitate understanding. This new
information could have impact on professional recommenda-
tions if our willingness to be more patient-centred is predomin-
ant. Some patients like to have a milk-based drink in the
morning before surgery. However, explaining subtle differ-
ences and providing precise limits for each type of milky drink
would not be easy.16 As milk can curdle in the acid stomach en-
vironment, it can then act more like a solid, thus delaying
Downloaded from http://bja.oxfordjournals.org/ at University of Manitoba on April 15, 2015
gastric emptying. Gastric ultrasound can be of use as visualiza-
tion of very small particles is possible with current ultrasound
machines.
Studies such as those by Okabe and colleagues show that
our research agenda is far from complete. Owing to the simpli-
city and non-invasive nature of ultrasound gastric volume as-
sessment, this easy-to-learn technique can help in at least
two ways. First, as discussed above, additional studies on
gastric physiology could be done to refine and extend our
knowledge, including both general mechanisms of gastric
emptying and the various physiological situations (solid food,
pregnancy, post-partum, children, sleep, etc.) that might be
useful in anaesthetic practice. Ultrasound assessment of the
stomach could also be useful in routine clinical practice.
Fasting guidelines exist, but unfortunately, we often face situa-
tions in which they are unhelpful. For instance, the ability of dia-
betic patients to eliminate gastric contents is said to be delayed
because of autonomic gastroparesis. Up to 50% of diabetic
patients have altered gastric emptying and the predictive
value of clinical symptoms is low.17 Interestingly, in most
cases, the delay is modest and in some patients, gastric empty-
ing is accelerated. Therefore, how do we determine which dia-
betic patients have significant gastroparesis and which are at
risk on an individual basis? Studies performed in anaesthesia
(i.e. after several hours of fasting) do not demonstrate with
certainty the best course of action. Some show that solid par-
ticles remain in the stomach after a normal fasting period,18
but clinical practice does not suggest an increased risk.19
Similarly, morbidly obese patients are a cause of concern for
the anaesthetist. Delayed gastric emptying has traditionally
been an important preoperative factor to consider even in
elective surgery, but more recent studies have shown that
obese patients usually have a normal preoperative gastric
volume.20 Of particular concern are patients who have previ-
ously undergone anti-obesity surgery and now require
another procedure months or years later. One feels that
these patients are at risk, but this may not always be the
case. The anaesthetic literature would suggest these patients
are at increased risk,21 but is unhelpful in individual situations.
Using rapid sequence induction for all the aforementioned
‘grey area’ situations or for all urgent surgical procedures
Editorials
requiring general anaesthesia is one potential strategy. This
procedure does however place the patient at risk of complica-
tions and is therefore difficult to promote universally. So what
then are the options? The use of ultrasound to assess gastric
contents may well be the way ahead. Measurement of antral
cross-sectional area is easy to learn: 30 examinations are
required to ensure competence.22 It is more than likely that
the complex formula currently used to estimate gastric
volumes from antral cross-sectional area measurement23 will
soon be available as a mobile phone application to facilitate in-
terpretation of readings taken from portable ultrasound
devices. As ultrasound becomes more widely used, the compe-
tence and understanding of this modality will naturally in-
crease. All of the above suggests that routine ultrasound
measurement of gastric contents will become part of our prac-
tice each time, there is any doubt as to residual gastric volume
and the optimum strategy to avoid aspiration. Perlas and col-
leagues24 described a simple clinical score to classify patients
with regard to their gastric content and predict their risk of as-
piration. This study was performed in fasted patients before
scheduled surgery, but the use of ultrasound in patients under-
going emergency surgery would certainly help to determine in-
dividual risk and subsequent prophylactic strategy. Recently,
Bouvet and colleagues25 showed that after induction of
general anaesthesia and before tracheal intubation, positive
pressure ventilation applied with 15 cm H2O achieved adequate
ventilation, while ultrasound more often detected gastric insuf-
flation than did auscultation. In the intensive care unit, ultra-
sound has been used to confirm nasogastric tube
placement26 and has also been shown to provide accurate
antral area measurements.27
Ultrasound assessment of gastric content and volume has
some limitations. Although antral area is visible in a very
large proportion of subjects after fluid ingestion, it can be dif-
ficult to distinguish when the stomach is empty (leaving
doubt between possible technical failure or a genuinely
empty stomach). Placing the patient in the right lateral de-
cubitus position is often helpful.28 After solid food ingestion,
air can limit the ability to see the posterior wall and thereby
to calculate antral area surface area. Wong and colleagues29
did not suggest any difficulty in measuring antral area in
pregnant obese patients (mean pre-pregnancy BMI 42) nor
did a recent study in which gastric ultrasound assessment
was used satisfactorily in 60 fasted severely obese
patients.30 Schmitz and colleagues31 found a significant
correlation (r 2 ¼0.6) between cross-sectional antral area
and a calibrated volume of drink in children, but these
authors suggested that their results could be misleading.
Others have found the technique useful and accurate.32
Finally, Kruisselbrink and colleagues33 recently demon-
strated that ultrasound assessment of gastric volume by
anaesthetists is highly reproducible.
These are examples of recent applications of stomach
ultrasound imaging applied to anaesthesia and intensive
care medicine. After a long period of validation,34 there can
be no doubt that its clinical application will continue to grow.
Use it often: it is simple and it works.
BJA
Author’s contribution
The author has prepared and written the manuscript.
Acknowledgement
The author would like to thank Dr Amanda Bull, who reviewed
the editorial.
Declaration of interest
None declared.
References
1 Mendelson CL. The aspiration of stomach contents into the lungs
during obstetric anesthesia. Am J Obstet Gynecol 1946; 52: 191–205
2 Warner MA, Warner ME, Weber JG. Clinical significance of pulmon-
ary aspiration during the perioperative period. Anesthesiology
Downloaded from http://bja.oxfordjournals.org/ at University of Manitoba on April 15, 2015
1993; 78: 56– 62
3 Maughan RJ, Leiper JB. Methods for the assessment of gastric empty-
ing in humans: an overview. Diabet Med 1996; 13(9 Suppl. 5): S6–10
4 Okabe T, Terashima H, Sakamoto A. What is a determinant of liquid
gastric emptying? Comparisons between milk and isocalorically
adjusted clear fluids. Br J Anaesth 2015; 114: 77– 82
5 Hillyard S, Cowman S, Ramasundaram R, Seed PT, O’Sullivan G. Does
adding milk to tea delay gastric emptying? Br J Anaesth 2014; 112:
66– 71
6 Indireshkumar K, Brasseur JG, Faas H, et al. Relative contributions of
‘pressure pump’ and ‘peristaltic pump’ to gastric emptying. Am J
Physiol Gastrointest Liver Physiol 2000; 278: G604–16
7 Kwiatek MA, Menne D, Steingoetter A, et al. Effect of meal volume
and calorie load on postprandial gastric function and emptying:
studies under physiological conditions by combined fiber-optic
pressure measurement and MRI. Am J Physiol Gastrointest Liver
Physiol 2009; 297: G894–901
8 Maljaars JPW, van der Wal RJP, Wiersma T, et al. The effect of lipid
droplet size on satiety and peptide secretion is intestinal site-
specific. Clin Nutr 2012; 31: 535– 42
9 Camilleri M. Integrated upper gastrointestinal response to food
intake. Gastroenterology 2006; 131: 640–58
10 Shin HS, Ingram JR, McGill AT, Poppitt SD. Lipids, CHOs, proteins: can
all macronutrients put a ‘brake’ on eating? Physiol Behav 2013; 120:
114– 23
11 Zhu Y, Hsu WH, Hollis JH. The impact of food viscosity on eating rate,
subjective appetite, glycemic response and gastric emptying rate.
PLoS One 2013; 8: e67482
12 Calbet JA, MacLean DA. Role of caloric content on gastric emptying
in humans. J Physiol 1997; 498: 553– 9
13 Vist GE, Maughan RJ. The effect of osmolality and carbohydrate
content on the rate of gastric emptying of liquids in man. J Physiol
1995; 486 (Pt 2): 523–31
14 Maerz LL, Sankaran H, Scharpf SJ, Deveney CW. Effect of caloric
content and composition of a liquid meal on gastric emptying in
the rat. Am J Physiol 1994; 267: R1163–7
15 Nutri-site: le sport et la forme. Available from http://www.nutri-
site.com/index.php (accessed 28 August 2014)
16 Chambers O, Davies M. Does adding milk to tea delay gastric
emptying? Br J Anaesth 2014; 113: 518
17 Darwiche G, Björgell O, Thorsson O, Almér LO. Correlation between
simultaneous scintigraphic and ultrasonographic measurement
of gastric emptying in patients with type 1 diabetes mellitus.
J Ultrasound Med 2003; 22: 459–66
547
BJA
18 Ishihara H, Singh H, Giesecke AH. Relationship between diabetic
autonomic neuropathy and gastric contents. Anesth Analg 1994;
78: 943– 7
19 Jellish WS, Kartha V, Fluder E, Slogoff S. Effect of metoclopramide on
gastric fluid volumes in diabetic patients who have fasted before
elective surgery. Anesthesiology 2005; 102: 904– 9
20 Donohoe CL, Feeney C, Carey MF, Reynolds JV. Perioperative evalu-
ation of the obese patient. J Clin Anesth 2011; 23: 575– 86
21 Jean J, Compère V, Fourdrinier V, et al. The risk of pulmonary aspir-
ation in patients after weight loss due to bariatric surgery. Anesth
Analg 2008; 107: 1257–9
22 Arzola C, Carvalho JC, Cubillos J, Ye XY, Perlas A. Anesthesiologists’
learning curves for bedside qualitative ultrasound assessment of
gastric content: a cohort study. Can J Anaesth 2013; 60: 771–9
23 Perlas A, Mitsakakis N, Liu L, et al. Validation of a mathematical
model for ultrasound assessment of gastric volume by gastroscopic
examination. Anesth Analg 2013; 116: 357– 63
24 Perlas A, Davis L, Khan M, Mitsakakis N, Chan VW. Gastric sonog-
raphy in the fasted surgical patient: a prospective descriptive
study. Anesth Analg 2011; 113: 93 –7
25 Bouvet L, Albert ML, Augris C, et al. Real-time detection of gastric
insufflation related to facemask pressure-controlled ventilation
using ultrasonography of the antrum and epigastric auscultation
in nonparalyzed patients: a prospective, randomized, double-blind
study. Anesthesiology 2014; 120: 326– 34
26 Chenaitia H, Brun PM, Querellou E, et al. WINFOCUS (World Inter-
active Network Focused On Critical Ultrasound) Group France.
British Journal of Anaesthesia 114 (4): 548–50 (2015)
Advance Access publication 3 March 2015 . doi:10.1093/bja/aev033
Fibrinogen concentrates for post-partum haemorrhage? Do
not miss the most relevant population!
B. Ickx1 and C. M. Samama2*
1
Department of Anaesthesiology, Hôpital Erasme, 808 Route de Lennik, Brussels 1070, Belgium
2
Department of Anaesthesia and Intensive Care Medicine, Cochin University Hospital, 27 rue du Faubourg St Jacques, Paris 75014, France
* E-mail: marc.samama@cch.aphp.fr
Post-partum haemorrhage (PPH) is an emotional clinical event
leading to high morbidity and mortality in obstetrics. Among
others, delayed availability of blood products has been identi-
fied as contributing to adverse outcomes. To reduce the
requirements of transfusion, several new approaches have
been suggested during PPH.1 Administration of fibrinogen con-
centrates for prevention or treatment of bleeding is increasing-
ly being supported, even if evidence-based data are still
lacking.2 3 Fibrinogen has been shown to be the first coagula-
tion factor to decrease to critical levels in actively bleeding
patients.4 The decrease is correlated with the volume of
blood loss.5 The trigger level for supplementation has been
increased in recent guidelines on severe bleeding.3 6 Clot
strength increases with fibrinogen level over a wide range of
548
Editorials
Ultrasound to confirm gastric tube placement in prehospital man-
agement. Resuscitation 2012; 83: 447–51
27 Hamada SR, Garcon P, Ronot M, Kerever S, Paugam-Burtz C, Mantz J.
Ultrasound assessment of gastric volume in critically ill patients.
Intensive Care Med 2014; 40: 965–72
28 Perlas A, Chan VW, Lupu CM, Mitsakakis N, Hanbidge A. Ultrasound
assessment of gastric content and volume. Anesthesiology 2009;
111: 82– 9
29 Wong CA, McCarthy RJ, Fitzgerald PC, Raikoff K, Avram MJ. Gastric
emptying of water in obese pregnant women at term. Anesth
Analg 2007; 105: 751– 5
30 Van de Putte P, Perlas A. Gastric sonography in the severely obese
surgical patient: a feasibility study. Anesth Analg Advance Access
published on July 22, 2014
31 Schmitz A, Thomas S, Melanie F, et al. Ultrasonographic gastric
antral area and gastric contents volume in children. Paediatr
Anaesth 2012; 22: 144–9
32 Gomes H, Hornoy P, Liehn JC. Ultrasonography and gastric empty-
Downloaded from http://bja.oxfordjournals.org/ at University of Manitoba on April 15, 2015
ing in children: validation of a sonographic method and determin-
ation of physiological and pathological patterns. Pediatr Radiol
2003; 33: 522–9
33 Kruisselbrink R, Arzola C, Endersby R, Tse C, Chan V, Perlas A. Intra-
and interrater reliability of ultrasound assessment of gastric
volume. Anesthesiology 2014; 121: 46 –51
34 Bolondi L, Bortolotti M, Santi V, Calletti T, Gaiani S, Labò G. Measure-
ment of gastric emptying time by real-time ultrasonography.
Gastroenterology 1985; 89: 752– 9
values, from 0 to 9.5 g litre21.7 An in vitro model has suggested
a plasma level as high as 2.5 g litre21 to optimise coagulation
altered by a dilution coagulopathy.8 At term, parturients
already exhibits a higher level of fibrinogen compared with
non-pregnant women.9 During PPH, a fibrinogen level ,2 g
litre21 has been shown to predict progression to more severe
bleeding or the need for a haemostatic intervention,10 al-
though even higher levels have been suggested.11 Anecdotal
uncontrolled reports in obstetrics have suggested an improved
haemostasis associated with administration of fibrinogen con-
centrates.12 – 14
Wikkelsø and colleagues15 have conducted a multicentre
randomised placebo-controlled clinical trial in an attempt to
evaluate the benefit of fibrinogen concentrates infusion in