Your SlideShare is downloading. ×

Cricoid pressure, David Levy

1,241

Published on

Published in: Business, Technology
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
1,241
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
38
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • 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]

    ×