The Use of Muscle Relaxants at the Induction of Anaesthesia of Patients With a Full Stomach

Abstract

The use of a muscle relaxant after a rapid induction of anaesthesia will facilitate intubation and prevent vomiting when the patient is paralyzed. After paralysis, fluid may flow passively from the stomach and oesophagus if the patient be horizontal or tilted head-down, and will make rapid endotracheal intubation difficult, thus putting the patient in hazard from hypoxia. Tracheal aspiration is, however, unlikely. The passive movement of fluid is prevented by a foot-down tilt during induction, but, if any other factor cause fluid to reach the oropharynx in this position, tracheal aspiration is very likely, and has occurred in several instances. Possible factors are attempted vomiting before the onset of paralysis, abnormalities of the gastro-oesophageal junction, perhaps associated with respiratory trouble during induction, and changes in intragastric pressure during induction. The dangers of methods dependent on a muscle relaxant in the hands of inexperienced doctors are stressed, and the need to consider gastric decompression and to practice pre-oxygenation of the patient prior to anaesthesia are emphasized. It is concluded that insufficient evidence is available to favour one position more than another during induction. Cricoid pressure to occlude the oesophagus against the cervical veretebrae should be used, if the supine horizontal position be chosen.

Perioperative pulmonary aspiration is infrequent and low risk in pediatric anesthetic practice

“…He was an advocate of ventilating the patient at induction. It is in the years after that paper that apnoeic induction techniques were recommended and the rapid sequence induction as we know it today probably stems from Safar .…”

Pathophysiology of Apnea, Hypoxia, and Preoxygenation

“…Tracheal Intubation an integral component during rapid sequence induction/intubation [22][23][24][25]. It is also important when difficulties associated with preoxygenation, ventilation, or tracheal intubation are predicted and the patient's O 2 reserves are limited [26,27].…”

Reflux Reflections

“…Those who favour intubation argue that, as it is impossible to tell which patient will regurgitate, every patient should be intubated. Yet such statistical arguments as exist (Hodges & Tunstall 1961) for the safety of intubation are far from convincing; all such techniques have sometimes failed in their object of preventing aspiration and examples are quoted in the reports of the confidential inquiry into maternal mortality (Walker et al 1963, Walker et al 1966, by Wylie (1963) and in my own review of 600 deaths (Dinnick 1964). Occasionally anatomical considerations or lack of facilities make intubation impossible.…”