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Journal of Obstrectic Anaesthesia and Critical Care
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 Table of Contents  
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 170-171

Real-time assessment of esophageal occlusion by ultrasound-guided paralaryngeal pressure application in emergency LSCS—Time to change practices?

1 Department of Anaesthesia, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India
2 Department of Anaesthesia, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission28-Dec-2021
Date of Acceptance31-Dec-2021
Date of Web Publication02-Sep-2022

Correspondence Address:
Dr. Bhavna Gupta
Department of Anaesthesia, AIIMS, Rishikesh, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JOACC.JOACC_114_21

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How to cite this article:
Ahluwalia P, Gupta B. Real-time assessment of esophageal occlusion by ultrasound-guided paralaryngeal pressure application in emergency LSCS—Time to change practices?. J Obstet Anaesth Crit Care 2022;12:170-1

How to cite this URL:
Ahluwalia P, Gupta B. Real-time assessment of esophageal occlusion by ultrasound-guided paralaryngeal pressure application in emergency LSCS—Time to change practices?. J Obstet Anaesth Crit Care [serial online] 2022 [cited 2023 Feb 5];12:170-1. Available from: https://www.joacc.com/text.asp?2022/12/2/170/355342


Anesthesiologists all over the world are terrified of risk of stomach regurgitation and pulmonary aspiration, especially in full-term pregnant females, and that is the reason, despite controversies in cricoid pressure application, it is still applicable for conduct of anesthesia for an emergency lower-segment cesarean section (LSCS) under general anesthesia.[1] Dr. B.A. Sellick pioneered cricoid pressure (CP), an esophageal occlusion technique used in emergencies and full stomach individuals to reduce gastric regurgitation following tracheal intubation. The efficacy of Sellick or cricoid pressure maneuver was questioned anew around the century, and the fundamental reason is that even with the cricoid pressure in place, some occurrences of regurgitation and aspiration have been documented.[2] The debate about the efficacy of cricoid pressure in decreasing pulmonary aspiration, together with the safety risk of difficult airway associated with improperly administered cricoid pressure (such as difficult mask ventilation, difficult direct laryngoscopy, or difficult supraglottic airway device insertion resulting in failure of tracheal intubation, and incorrect positioning of the laryngeal mask airway), has resulted in ongoing debate about the usefulness of cricoid pressure.[3–6]

In many recent published literature studies, it has been seen that esophageal lateral displacement occurs in 50% to 90% of adults.[2] Vanner and Pryle[5] identified lateral esophageal displacement when investigating computed tomography (CT) images during CP administration. In alliance with this finding, a retrospective analysis of 51 cervical CT scans and a prospective analysis of 22 cervical MRI scans demonstrated lateral displacement of the esophagus comparable to the midline of the vertebral body in 49 percent and 53 percent of cases, respectively, even in the absence of any CP. The use of CP increased the prevalence of esophageal lateral displacement from 53% to 91%.

Because of the esophagus's lateral placement, paralaryngeal pressure (PLP) is recommended as an alternative to CP.[6] PLP lowered the anteroposterior (AP) width of the upper esophagus considerably in conscious volunteers, according to ultrasonography which can be easily accessible in the operating theater. Ultrasound-guided occlusion of the esophagus is a more reliable method to prevent the chances of aspiration during rapid sequence induction and emergency intubation. With ultrasound-guided approach, we can easily locate the position of the esophagus in relation to the trachea and can further prevent the misalignment of the airway. The following steps are suggested to perform this technique: Surface landmarks, cervical cartilages, and muscles are identified. Then, the position of the esophagus relative to the surrounding anatomy is identified via standard US probing. In a cross-sectional view, the esophagus can be located to the left or right of the trachea (most commonly on the left), usually at four or seven o'clock. Now, the esophagus is gently pressed with the US probe to maintain CP and to compress the esophagus lateral medially until the internal lumen is occluded. PLP reduces esophageal diameter and has the potential to occlude it. By using an ultrasonic probe to visualize the pressure, it may be administered more uniformly.

The consequences of improper cricoid pressure administration are detrimental. Inadequate force produces inefficient cricoid pressure, whereas excessive force might result in esophageal and airway injuries. Real-time visualization turns a blind procedure to a guided one, allowing achievement of the target cricoid pressure with a lower variance. Nowadays, handheld portable or pocket ultrasound scanners are available, which are user-friendly, easy, and convenient and would require only a few seconds to minutes in an emergency. Therefore, we suggest performing real-time ultrasound-guided paralaryngeal pressure application to occlude esophagus during procedural induction in pregnant females presenting for emergency procedures under general anesthesia.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL, et al. Obstetric Anaesthetists' association and difficult airway society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia 2015;70:1286–306.  Back to cited text no. 1
Sorbello M. Aristotle, Galileo and Sellick: The unsolved dilemma of cricoid pressure. Trends Anaesth Crit Care 2016;6:1–2.  Back to cited text no. 2
Zeidan AM, Salem MR, Mazoit JX, Abdullah MA, Ghattas T, Crystal GJ. The effectiveness of cricoid pressure for occluding the esophageal entrance in anesthetized and paralyzed patients: An experimental and observational glidescope study. Anesth Analg 2014;118:580–6.  Back to cited text no. 3
Hocking G, Roberts FL, Thew ME. Airway obstruction with cricoid pressure and lateral tilt. Anaesthesia 2001;56:825–8.  Back to cited text no. 4
Vanner RG, Pryle BJ. Regurgitation and oesophageal rupture with cricoid pressure: A cadaver study. Anaesthesia 1992;47:732–5.  Back to cited text no. 5
Bermede O, Meço BC, Baytaş V, Diken O, Güçlü CY, Erkoç SK, et al. What about compressing the oesophagus with an ultrasound probe for a modified sellick manoeuvre? Turk J Anaesthesiol Reanim 2021. doi: 10.5152/TJAR.2021.1427.  Back to cited text no. 6


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