Article

The Effects of Cricoid Pressure, Remifentanil, and Propofol on Esophageal Motility and the Lower Esophageal Sphincter

Department of Anesthesiology and Intensive Care, Orebro University Hospital, 701 85 Orebro, Sweden.
Anesthesia & Analgesia (Impact Factor: 3.47). 04/2005; 100(4):1200-3. DOI: 10.1213/01.ANE.0000147508.31879.38
Source: PubMed

ABSTRACT

Cricoid pressure is the gold standard during the induction of anesthesia when there is a risk of aspiration of gastric contents. However, the effect of cricoid pressure during the different steps of complete anesthesia induction has not been studied. The purpose of this study was to investigate the effects of cricoid pressure, remifentanil, and propofol on lower esophageal sphincter (LES) and esophageal motility. We recorded LES pressure (LESP) and calculated barrier pressure ([BrP] = LESP - gastric pressure) in 10 healthy volunteers using a Dent sleeve device. There was a significant decrease in LESP and BrP when a cricoid pressure of 30 N was performed in the awake volunteers (P < 0.05). However, this effect was not seen during the infusion of remifentanil 0.2 microg . kg(-1) . min(-1). Remifentanil per se or together with a bolus dose of propofol 1 mg/kg IV did not induce any statistical change in LESP or BrP. Remifentanil abolished spontaneous esophageal motility and completely eliminated the experience of discomfort induced by cricoid pressure. In conclusion, cricoid pressure of 30 N induced a decrease of LESP and BrP in awake volunteers. These effects were not seen during the remifentanil infusion. This shows the importance of when to apply cricoid pressure during rapid-sequence induction.

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    • "The results demonstrated increased reflux with propofol but no significant change with thiopentone. Thorn et al. compared the effect of propofol with remifentanil and concluded that both anesthetics did not have a significant effect on LES pressure or esophageal motility [3]. Studies by Marsh et al. and Fung et al. evaluated the effect of midazolam on esophageal motility [4] [8]. "
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    • "La prise en charge d'une dysphagie basse repose avant tout sur la réalisation d'une endoscopie digestive haute : celle-ci peut être normale, mais il faut s'attacher à identifier des signes tels qu'une stase salivaire, un ressaut au passage du cardia (plus difficile à évaluer avec les endoscopes fins de dernière génération), un aspect atone du corps de l'oesophage, ou au contraire hypertonique (contractions répétées de grande amplitude, spasmes localisés). La réalisation de l'examen sous anesthésie modifie sans doute la motricité oesophagienne, et peut participer au retard au diagnostic très fréquemment observé dans ce contexte [8]. "
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    ABSTRACT: The vast majority of anaesthetists considers application of cricoid pressure for reasons of patient safety an integral part of rapid sequence induction. Cricoid pressure is applied with the idea that it will prevent regurgitation of gastric content into the pharynx, thereby reducing the incidence of pulmonary aspiration. This review describes the background of the introduction of cricoid pressure into clinical practice, analyzes published data concerning clinical relevance of perioperative pulmonary aspiration and efficacy of cricoid pressure in reducing it, discusses problems associated with its use, assesses knowledge and technical performance of cricoid pressure and presents various recent recommendations regarding application of cricoid pressure. The combination of complete lack of evidence for the efficacy of cricoid pressure in preventing pulmonary aspiration and numerous reports of clinically relevant interference with airway management during its use, seriously question the rationale of recommending the general use of cricoid pressure during rapid sequence induction.
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