Pros and Cons Cricoid Pressure

Click to edit Master subtitle style Pros Dr Pius Kurian M Armed Forces Hospital Muscat

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Introduction
Sellick (Sellick BA. Lancet 1961;2:404; Sellick BA Cricoid pressure to prevent aspiration Proceedings of the First European Congress of Anaesthesiology, Vienna 1962;1:89) Gastric inflation during mask ventillation Cricoid pressure became essential part of Rapid Sequence of Induction and Intubation RSII
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Introduction
Recommendation by Sellick in the abovementioned papers received worldwide acceptance inspite of its technical, clinical and statistical pitfalls(Grade D Level of Evidence ) Probably a)M & M from aspiration was at peak at the time of its introduction b)Statistical methods were not as meticulous ,as of now c)Medicolegal pressures 5/3/12

Introduction
Its wide acceptance in anaesthetic and emergency medicine is reflected in a Review article by Brinacombe Canadian Journal of Anaesthesia 1997;44:414-25 Merits and demerits discussed in indepth detail

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Controversy
a)Jackson S H Anaesthesiology 1996;84:751-2 questioned its scientific validity

b)Tournadre et al Anaesthesiology:1997:86:7-9 Effect of Cricoid Pressure on Lower Oesophageal Sphincter tone -Efficacy

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History
Mention of Cricoid pressure is found in medical literature 230 years back-Its use in prevention of regurgitation in drowning and prevention of gastric inflation during mask ventillation Anaesthesia Analgesia 1974;53:230-2 It is inconceivable that a maneuver effective in preventing gastric inflation during manual ventilation would not be effective in preventing esophageal contents from reaching the pharynx
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Still a Controversy
a)Randomised Clinical Trials-almost impossible due to ethical reasons b)With low incidence of aspiration studies to yield significant results will need huge numbers in the both the studygroups c)Legal pressures-Emergency intubations without cricoid pressure are considered to be substandard care by legal and medical insurance practices
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Controversial Points of debate Specific areas

a)Effectiveness b)Physiology- Loss of LES tone c)Anatomy-Is it possible to occlude alimentary tract by CP d)Reports of failure e)Complication like nausea,vomiting,and even oesophageal rupture f)Interfere with airway Management
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Controversial Point a)Efficacy

Practice of CP was accepted without proper clinical statistical and technical evidence Pros- Most evidence come from effect of Cricoid pressure on oesphageal pressure in cadavers and gastric insufflation during mask ventillation in anaesthetised patients Some studies from cadaveric studies(clinical workshop) a)Fanning Anaesthesiology Fanning ; 5/3/12 1970:32:553-5

Controversial point a)Efficacy

Pros Some studies come from effect of CP in preventing gastric inflation in anaesthetised patients with and without Cricoid Pressure/NMBD Moynihan RJ Anesthesiology 1993;78:6526 (paediatrics) Lawes EG, et al Br J Anaesth 1987;
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Controversial point b)Physiology-Loss of LES tone that LES tone is reduced by It is a fact
GA/drugs/Cricoid Pressure hence fall in barrier pressure Pros Idea of CP is not to prevent regurgitation but to prevent entry into the pharynx.

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Controversial point c)Anatomy

Pros

Oesophageal position is variable in relation to cricoid hence cannot compress Alimentary tract Rice MJ et al Cricoid pressure results in compression of thepostcricoid hypopharynx: the esophageal position is irrelevant.MRI imaging on awake volunteers with and without cricoid pressure Anaesthesiology 2009;109:1546-1552

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g with and without CP Sniffing position

a)Without CP b)With CP c)Compression in a

laterally moved postcricoid hypopharynx with compression

d)Patent Oesophagus

lumen at point 2 cm inferior to Cricoid

Post cricoid

hypopharynx/hypopha ryngeus/upper oesophageal sphincter moves along with Cricoid 5/3/12 , as a unit irrespective of

Controversial point c)Anatomy

Pros Concept of Hypopharynx and Upper Oesophageal Sphincter was earlier suggested and pressures measured by Vanner R G Anaesthesia 1992;47:95100 He demonstrated that UES tone is affected by induction of GA and CP augments the UES tone
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Controversial Point d)Failures

Cons-Regurg aspiration occurs despite CP Schwartz et al Anaesthesiology;1995:82;37676.Postintubation infiltrates seen in 4% J Clin Anesth 1995;7:297305 Vanner RG, Asai T. Safe use of cricoid pressure.

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Controversial Point d)Failures

Pros Anaesthesia1999;54:13 Herman NL, Carter B, Van Decar TK. Cricoid pressure: teaching the recommended level. Anesth Analg 1996;83:85963 Above two surveys indicates that Cricoid Pressure practical theorotical knowledge is far from satisfactory hence reason for failures.Also stress on periodic asessment trainning which is proven to improve the performance
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Controversial point- e) Complications like Nausea Vomiting Pros Oesophagealdevoid of rupture No medical intervention is

complications especially if protocol is violated Too little pressure do not protect and too high pressure brings in unwanted effects like retching active vomiting.Again highlights inadequacy in correct application of Cricoid pressure
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Controversial pointInterferes with airway managment Cons

Compromise airway patency-Excess pressures can lead to Cricoid /laryaneal patency Compromise glottic view Interfere with easy use of supraglottic devices and ETT advancement Pros Turgeon et al Anaesthesiology 2005;102:315-19 CP doesnot increase rate of failed intubations
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N/G Tube in situ

There has been studies in cadavers that

presence of NG tubes do not interfere with sphincter integrity and can be kept open to the atmosphere contrary to Sellicks teachings especially in certain case where preO2 was inadequte,high O2 consumption,Nondepolariser is used

There is no need to avoid mask ventillation

It is justified in releasing CP in cant intubate

cant ventillate situations

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Evidence base for CP?

Before summarising few points on RSI evidence base by David Nellipovitz Can J of Anaesthesia 2007;54:9-748 ,in which he usedOvid Therapy ie software for detection of quality of literature-163 RCT s of which 18 were nonpharmacological interventions in RSII

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Evidence base for CP

Role of CP in reducing aspiration is unavailable Due to potential of difficult airway, use is advised only in high risk patients.Grade D recommendation Partial or complete release is justified if CP interferes with bag mask/ETT 15-20 cm H20 presure mask ventillation recommended as Grade C
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Summary
a)CP has still a place emergency intubationshould identify when to avoid b)CP is not substitute for loss of LES tone but to reinforce lost UES tone c)Decision to Sellick-balance potential benefits and potential complications d)CP is complex and trainning,periodic asessment,practice is essential for proper application-Is it possible to train all concerned to ideal levels? e)Is a valid RCT to prove efficacy of CP in
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References
David Nellipovitz-CAN J ANESTH 2007 / 54: 9 /

pp 748764 Evidence Base for RSI

Andranik Ovassapian, MD*Vol. 109, No. 5,

November 2009 Sellick Do or Donot

Jerrold Lermann November 2009 vol. 109 no.

5 1363-1366 On Cricoid Pressure: May the Force Be with You

Mohammed El-Orbany; Lois A Connolly

Anaesthesia Analgesia May 2010;10:1318 RSII and Current Controversy

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Levels of Evidence
1a Systematic review (with homogeneity) of controlled trials 1b Randomized controlled trials (with narrow

randomized

confidence
intervals) 2a Systematic review (with homogeneity) of

cohort studies
2b Cohort study or low quality randomized
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controlled trial

Levels of Evidence
Grade Supporting evidence A Consistent level 1 studies B Consistent level 2 or 3 studies,

extrapolation from level 1

studies C Level 4 studies or extrapolation from

level 2 or 3 studies 1-4

D Level 5 or inconsistent studies at levels

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