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Anesth Analg 2002;94:762-763
© 2002 International Anesthesia Research Society

LETTERS TO THE EDITOR

Gastroesophageal Reflux and Aspiration of Gastric Contents

John G. Brock-Utne, MD PhD

Department of Anesthesia, Stanford University School of Medicine, Stanford, California

I have read with interest the review article by Ng and Smith (1). I would like to make the following points.

1. In Table 2, ranitidine is shown to have no effect on lower esophageal sphincter (LES) pressure. No reference is given to this statement. One study has shown no effect (2). Other studies have shown ranitidine to increase the LES tone (3,4). Furthermore, if ranitidine is given before atropine, there is no significant decrease in LES. This is also true for metoclopramide in both nonpregnant and pregnant subjects (5). This is important information for those clinical anesthesiologists who like to use atropine before general anesthesia, especially in the pregnant subject (5).
2. Protective airway reflexes have been shown to be decreased by many drugs including ketamine, neurolept analgesia with diazepam, and nitrous oxide in oxygen (6–8).
3. The author’s recommendation that a nasogastric tube should be left in situ during a rapid sequence technique induction is not supported by the evidence given by the authors. In a study by Manning et al. (9), episodes of reflux were significantly higher in patients with a nasogastric tube. Added to this was the fact that the LES pressure was lower in patients with a nasogastric tube compared with those without. Clinicians who have seen aspiration of gastric contents with a nasogastric tube in situ will, no doubt, remove the nasogastric tube before anesthesia induction to hopefully prevent aspiration.
4. It is well known that the LES tone showed adductive changes with increased abdominal compression. This is akin to the pregnant patient (10).

References

  1. Ng A, Smith G. Gastroesophageal reflux and aspiration of gastric contents in anesthesia practice. Anesth Analg 2001; 93: 494–513.[Abstract/Free Full Text]
  2. Denis P, Galiniche JP, Ducrotte P, et al. Effect of ranitidine on resting gastric pressure and pentagastrin response of human lower esophageal sphincter. Dig Dis Sci 1981; 26: 999–1002.[ISI][Medline]
  3. Bertaccini C, Molina E, Bobbio P, Fogg E. Ranitidine increases lower oesophageal sphincter pressure in man. It J Gastroenterology 1981; 13: 149–50.
  4. Brock-Utne JG, Downing JW, Humphrey D. Effect of ranitidine given before atropine sulphate on lower oesophageal sphincter tone. Anaesth Intensive Care 1984; 12: 140–2.[ISI][Medline]
  5. Brock-Utne JG, Dow TGB, Welman GE, et al. The effect of metoclopramide on the lower oesophageal sphincter in late pregnancy. Anaesth Intensive Care 1978; 6: 26.[ISI][Medline]
  6. Taylor PA, Towey RM. Depression of laryngeal reflexes during ketamine anaesthesia. BMJ 1971; 2: 688.
  7. Brock-Utne JG, Winning TJ, Kingston HG Jr. Laryngeal incompetence during neuroleptanalgesia in combination with diazepam. Br J Anaesth 1976; 48: 699–701.[Abstract/Free Full Text]
  8. Rubin J, Brock-Utne JG, Greenberg M, et al. Laryngeal incompetence during experimental "relative analgesia" using 50% nitrous oxide in oxygen. Br J Anaesth 1977; 49: 1005.[Abstract/Free Full Text]
  9. Manning B, McGreal G, Winter DC, et al. Nasogastric intubation causes gastrooesophageal reflux in patients undergoing elective laparatomy. Br J Surg 2000; 87: 637.
  10. Dow TGB, Mrcog JG, Brock-Utne JG, et al. The effect of atropine on the lower esophageal sphincter in late pregnancy. Obstet Gynecol 1978; 51: 426–30.[ISI][Medline]
 

Response

Alexander Ng, FRCA, and Graham Smith, MD FRCA

University Department of Anaesthesia, Critical Care and Pain Management, Leicester Royal Infirmary, Leicester LE1 5WW, UK

In Response:

We would like to reply to Dr. Brock-Utne’s letter concerning our Review Article (1). The statement concerning the effect of ranitidine and other drugs on the lower esophageal sphincter (LES) was taken from Reference 27 (2). The weight of evidence does not support the view of Dr. Brock-Utne that ranitidine increases LES pressure for the following reasons.

First, one of the studies showing that ranitidine increases LES pressure involved only 6 subjects (3); hence caution is required in accepting this work.

Second, the possibility of false positive results with ranitidine on the LES may be related to normal variations in LES pressure in the interdigestive states (4). LES pressure rises from phase one to phase three of the interdigestive states. This fact was not taken into account in the methodology of the study cited by the author (3).

Third, ranitidine and cimetidine are H2-receptor antagonists and thus would be expected to have similar effects. Cimetidine does not increase LES pressure (4,7,8), and the majority of studies have found also that ranitidine does not increase LES pressure (4,5,6).

General anesthesia for pregnant patients is becoming increasingly uncommon. Pregnancy is associated with increases in heart rate (9), and in our institution it would be very unusual for anesthesiologists to use atropine before induction of general anesthesia.

We agree that protective airway reflexes are impaired by many sedative agents, a concept that is well known, and we did not think that it was necessary to cite the historical articles of the 1970s enumerated by Dr. Brock-Utne (10,11). The main objective of this section was to characterize the components of these reflexes and describe the effect of drugs from more recent studies (12–14).

Dr. Brock-Utne recommends that a nasogastric tube be removed before a rapid sequence induction. We are unable to support his view for the following reasons.

First, and most importantly, there is good evidence that the nasogastric tube does not impair effective application of cricoid pressure (15,16).

Second, the nasogastric tube provides a passageway for the drainage of gastric contents.

Thus removal of the nasogastric tube is not only unnecessary but it may increase the risk of esophageal perforation in the event of retching during a rapid sequence induction.

References

  1. Ng A, Smith G. Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesth Analg 2001; 93: 494–513.
  2. Cotton BR, Smith G. The lower oesophageal sphincter and anaesthesia. Br J Anaesth 1984; 56: 37–57.[Free Full Text]
  3. Brock-Utne JG, Downing JW, Humphrey D. Effect of ranitidine given before atropine sulphate on lower oesophageal sphincter tone. Anaesth Intens Care 1984; 12: 140–2.
  4. Smout AJPM, Bogaard JW, van Hattum J, Akkermans LMA. Effect of cimetidine and ranitidine on interdigestive and postprandial lower esophageal sphincter pressures and plasma gastrin levels in normal subjects. Gastroenterology 1985; 88: 557–63.[ISI][Medline]
  5. Denis P, Galmiche JP, Ducrotte P, et al. Effect of ranitidine on resting pressure and pentagastrin response of human lower esophageal sphincter. Dig Dis Sci 1981; 26: 999–1002.
  6. Wallin L, Madsen T, Boesby S. Gastro-oesophageal function in normal subjects after oral administration of ranitidine. Gut 1983; 24: 154–7.[Abstract/Free Full Text]
  7. Wesdorp E, Bartelsman , Pape K, et al. Oral cimetidine in reflux esophagitis: a double blind controlled trial. Gastroenterology 1978; 74: 821–4.[ISI][Medline]
  8. Petrokubi RJ, Jeffries GH. Cimetidine Versus Antacid in Scleroderma with Reflux Esophagitis. Gastroenterology 1979; 77: 691–5.[ISI][Medline]
  9. Elton CD, MacDonald R. Maternal and neonatal physiology. In Aitkenhead AR Rowbotham DJ, Smith G, eds. Textbook of Anaesthesia. Edinburgh: Churchill Livingstone, 2001: 325.
  10. Brock-Utne JG, Winning TJ, Rubin J, Kingston HGG. Laryngeal incompetence during neuroleptanalgesia in combination with diazepam. Br J Anaesth 1976; 48: 699–701.
  11. Rubin J, Brock-Utne JG, Greenberg M, Bortz J, Downing JW. Laryngeal incompetence during experimental "relative analgesia" using 50% nitrous oxide in oxygen. Br J Anaesth 1977; 49: 1005–7.
  12. Murphy PJ, Langton JA, Barker P, Smith G. Effect of oral diazepam on the sensitivity of upper airway reflexes. Br J Anaesth 1993; 70: 131.[Abstract/Free Full Text]
  13. Erskine RJ, Murphy PJ, Langton JA, Smith G. Effect of age on the sensitivity of upper airway reflexes. Br J Anaesth 1993; 70: 574–5.[Abstract/Free Full Text]
  14. Caranza R, Nandwani N, Tring JP, et al. Upper airway reflex sensitivity following general anaesthesia for day-case surgery. Anaesthesia 2000; 55: 367–70.[ISI][Medline]
  15. Vanner RG, Pryle BJ. Regurgitation and oesophageal rupture with cricoid pressure: a cadaver study. Anaesthesia 1992; 47: 732–5.[ISI][Medline]
  16. Salem MR, Joseph NJ, Heyman HJ, et al. Cricoid compression is effective in obliterating the oesophageal lumen in the presence of a nasogastric tube. Anesthesiology 1985; 63: 443–6.[ISI][Medline]




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press