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Cricoid pressure, David Levy

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  • due to some being >20 yrs old, differences in type of patients included, low numbers and differences in outcome definitions 3.3% (1:30) (95% CI 2.3-4.5) (most recent study 1999) All studies except 1 are old and don’t really reflect the case mix that we deal with today

Transcript

  • 1. Dr David M Levy Consultant Obstetric Anaesthetist Myth or evidence-based practice ? Cricoid force is essential to prevent aspiration
  • 2. Cricoid Pressure (CP)
    • Sellick’s 1961 case series
    • Modern imaging
      • MR
      • Endoscopy
    • Tracheal intubation
      • Supraglottic airways
    • Application of CP
    • End-point: aspiration
        • Regurgitation
  • 3. ‘The Lancet’, 1961
    • BA Sellick, 1918-1996
    • ME Tunstall, 1928-
  • 4. ‘The Lancet’, 1961
    • Two notable preliminary communications
      • Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia
        • BA Sellick, August 19
      • The use of a fixed nitrous oxide and oxygen mixture from one cylinder
        • ME Tunstall, 28 October
  • 5. ‘The Lancet’, 1961
    • Two notable preliminary communications
      • Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia
        • BA Sellick, August 19
      • The use of a fixed nitrous oxide and oxygen mixture from one cylinder
        • ME Tunstall, 28 October
  • 6. Sellick’s case series (1961)
    • No randomisation
    • Position: head-down
      • Head & neck fully extended
    • ? Induction drug regimen
  • 7. Sellick’s case series (1961) Sellick BA Lancet 1961; 2: 404-6 26 ‘high-risk’ cases 23: no regurgitation after intubation and release of CP 3: regurgitation after intubation and release of CP 17 laparotomies 3 pyloric stenoses 2 oesophagoscopies 1 forceps delivery 1 laparotomy 1 oesophagectomy 1 forceps delivery
  • 8. Sellick’s case series (1961) Sellick BA Lancet 1961; 2: 404-6 26 ‘high-risk’ cases 23: no regurgitation after intubation and release of CP 3: regurgitation after intubation and release of CP 17 laparotomies 3 pyloric stenoses 2 oesophagoscopies 1 forceps delivery 1 laparotomy 1 oesophagectomy 1 forceps delivery
  • 9. Sellick’s case series
    • ? Force applied
    • ? Effect on laryngoscopy/intubation
    • ?  Gastric distension with IPPV
      • ‘ pure speculation’
    Priebe H-J Seminars in Anesthesia, Perioperative Medicine and Pain 2005; 24: 120-6
  • 10. CP: the downside (primum non nocere)
    • Distortion of airway anatomy
      • Impediment to
        • Laryngoscopy
        • Tracheal intubation
        • Supraglottic airways
    • Laryngeal trauma
    • Oesophageal rupture
        •  Lower oesophageal sphincter tone
          • Regurgitation
    • Failure of technique
    •  Failure to
      • Intubate
      • Ventilate
    Priebe H-J Seminars in Anesthesia, Perioperative Medicine and Pain 2005; 24: 120-6
  • 11. 40 years on from Sellick - MR imaging Smith KJ et al Anesthesiology 2003; 99: 60-4
  • 12. CP: view at laryngoscopy
    • ‘… a force close to 30N may cause complete loss of the glottic view’
    Haslam, Parker, Duggan Anaesthesia 2005; 60: 41-47
  • 13. Cricoid yoke; view through LMA
    • Force-dependent cricoid deformation
      • Complete occlusion & airway obstruction at 44N in  50%
        • ♀ at greater risk
    Palmer & Ball Anaesthesia 2000; 55: 260-8
  • 14. CP: failed intubation Turgeon AF et al Anesthesiology 2005; 102: 315-9
  • 15. CP: failed intubation
    • Failure rate at 30s, Macintosh 3 blade
    • Mean BMI 25, all <35
    • Mostly Mallampati 1 & 2
    • Trained assistants
      • 30 N, daily simulation
    • Lateral shift of larynx
      • 43 CP, 9 sham p<0.0001
    • Failure to intubate
      • 15 CP, 13 sham NS
    Turgeon AF et al Anesthesiology 2005; 102: 315-9
  • 16. CP: application
    • British Association of Operating Department Assistants
        • n=135
    • Performance improves with practical training
    Meek, Gittins, Duggan Anaesthesia 1999; 54: 59-62
  • 17. CP: regurgitation in high-risk patients
    • Methylene blue capsule pre-induction
      • Oehlkern L, Anesthesiology 2003; A1235
    0.7 6 7 Extubation 0.05 0 3 Induction P CP n=65 No CP n=65
  • 18. Aspiration : Australian Incident Monitoring Study
    • Anonymous self-reporting
      • First 5000 incidents
    • 133 cases of aspiration
      • Majority in elective cases
        • Mostly at induction
      • Commonest with facemask or LMA
    • CP applied in 11 (8%)
    Kluger MT, Short TG Anaesthesia 1999; 54: 19-26
  • 19. CP:  incidence of aspiration?
    • Neilipovitz DT, Crosby ET (2007)
      • No evidence for decreased incidence of aspiration after rapid sequence induction
    • Cricoid pressure
      • Level 5 evidence (Expert opinion)
        • Grade D recommendation
          • ‘ troublingly inconsistent’ or inconclusive studies
  • 20. CP in the ED: risk-benefit analysis
    • ‘ We recommend that the removal of CP be an immediate consideration if there is any difficulty intubating or ventilating the ED patient’
    Ellis DY et al Ann Emerg Med 2007; 50: 653-65
  • 21. CP: supraglottic airways [1]
    • Proseal ™ LMA
        • n = 50
    • Cricoid pressure impedes
      • Placement
      • Ventilation
    Li et al Anesth Analg 2007; 104: 1195-8
  • 22. LMA Supreme  Verghese C, Ramaswamy B BJA 2008; 101: 404-10
  • 23. CP: supraglottic airways [2]
    • Laryngeal tube (-suction II)
        • n = 40
    • Cricoid pressure impedes
      • Placement
      • Ventilation
    Asai et al BJA 2007; 99: 282-5
  • 24. Emergency abdominal surgery
    • Fabregat-López et al:
    • Proseal ™ LMA
      • No cricoid pressure
      • No complications
    • Controversial –
      • Editorial: Pandit
    2008; 63: 967
  • 25. CP – current opinion
    • Koerber et al: Variation in RSI techniques
      • current practice in Wales
        • 5 scenarios; % who would intubate trachea without CP
          • Appendicectomy 5%
          • Symptomatic hiatus hernia 11%
          • Asymptomatic hiatus hernia 12%
          • Elective C Section 2%
          • Bowel obstruction 1%
    2009; 64: 54
  • 26. Conclusion
    • Cricoid pressure in RSI - what’s the evidence base?
  • 27. Conclusion
    • Cricoid pressure in RSI - what’s the evidence base?
    • ‘ Must weigh efficacy in preventing aspiration against risk of impeding tracheal intubation/ventilation’ Turgeon et al 2005
    • ‘ By today’s standards, cricoid pressure can hardly be considered an evidence-based practice’. Priebe 2005
  • 28. A personal view…
    • ~30° h ead-up position
    • Precalculated doses
      • Induction agent
      • Rocuronium
    • Forget CP
      • Little faith in correct application
      • Don’t provoke emesis
    • Priority = Optimal conditions for successful airway management
    May the (cricoid) force be with you?
  • 29. Questions... [email_address]