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
  • Cricoid pressure, David Levy

    1. 1. Dr David M Levy Consultant Obstetric Anaesthetist Myth or evidence-based practice ? Cricoid force is essential to prevent aspiration
    2. 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. 3. ‘The Lancet’, 1961 <ul><li>BA Sellick, 1918-1996 </li></ul><ul><li>ME Tunstall, 1928- </li></ul>
    4. 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. 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. 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. 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. 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. 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. 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. 11. 40 years on from Sellick - MR imaging Smith KJ et al Anesthesiology 2003; 99: 60-4
    12. 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. 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. 14. CP: failed intubation Turgeon AF et al Anesthesiology 2005; 102: 315-9
    15. 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. 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. 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. 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. 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. 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. 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. 22. LMA Supreme  Verghese C, Ramaswamy B BJA 2008; 101: 404-10
    23. 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. 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. 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. 26. Conclusion <ul><li>Cricoid pressure in RSI - what’s the evidence base? </li></ul>
    27. 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. 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. 29. Questions... [email_address]

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