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

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