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Making The Case for Cricoid Pressure. D. John Doyle MD PhD FRCPC SAM Annual Meeting September 2003. Outline. Rules of the Debate The Problem – Aspiration The Solution – The Sellick Maneuver Case Report Curtis Lester Mendelson Brian A Sellick Cricoid Pressure "BURP" Maneuver

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making the case for cricoid pressure

Making The Case for Cricoid Pressure

D. John DoyleMD PhD FRCPC

SAM Annual Meeting

September 2003

outline
Outline
  • Rules of the Debate
  • The Problem – Aspiration
  • The Solution – The Sellick Maneuver
  • Case Report
  • Curtis Lester Mendelson
  • Brian A Sellick
  • Cricoid Pressure
  • "BURP" Maneuver
  • Conclusions
starting the debate
Starting the Debate
  • Thanks to Dr. Cooper for agreeing to take the weaker position
  • Dr Cooper asked that the handouts not be distributed until after the debate – perhaps he was afraid of something
  • Agree to discuss cricoid pressure only, not RSI
  • Purpose of the debate – educate and amuse
inoculating the audience
Inoculating the Audience
  • BEWARE: Dr Cooper may try to befuddle you with statistics
  • BUT: I will present an argument based on simple physics and backed up by plenty of scientific literature
the problem6
The Problem

General anesthesia may predispose patients to aspiration of gastroesophageal contents because of depression of protective reflexes during loss of consciousness and the use of neuromuscular blockade.

Ng A. Smith G. Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesthesia & Analgesia. 93(2):494-513, 2001

the problem7
The Problem

Some patients may be at increased risk of pulmonary aspiration because of retention of gastric contents caused by pain, inadequate fasting, gastrointestinal pathology resulting in reduced gastric emptying, and gastroesophageal reflux.

Ng A. Smith G. Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesthesia & Analgesia. 93(2):494-513, 2001

the problem8
The Problem

Despite increasing knowledge of the problems associated with aspiration, the relatively small incidence and associated mortality rates in the perioperative period do not appear to have changed markedly over the last few decades.

Ng A. Smith G. Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesthesia & Analgesia. 93(2):494-513, 2001

case report
Case Report

“A 21-yr-old, 75-kg man presented for repositioning of an intraocular lens under general anesthesia. He had a history of esophageal reconstruction by gastric pull-through to treat childhood achalasia. General anesthesia about 2 yr earlier for eye surgery had resulted in pulmonary aspiration of gastric contents during induction of anesthesia. No further details were available.”

(Gundappa Neelakanta. Cricoid Pressure Is Effective in Preventing Esophageal Regurgitation. Anesthesiology 2003; 99:242)

case report10
Case Report

“Preoperatively, he was apprehensive about recurrent aspiration. On the day of surgery, he was given metoclopramide 10 mg and ranitidine 20 mg intravenously; he had taken nothing by mouth for 15 h previously. In the operating room, he was positioned supine with extension of the neck.”

(Gundappa Neelakanta. Cricoid Pressure Is Effective in Preventing Esophageal Regurgitation. Anesthesiology 2003; 99:242)

case report11
Case Report

“The cricoid cartilage was identified while the patient was awake. Following adequate preoxygenation, continuous cricoid pressure was applied immediately before the induction of anesthesia with propofol 200 mg and succinylcholine 120 mg in a rapid sequence manner.”

(Gundappa Neelakanta. Cricoid Pressure Is Effective in Preventing Esophageal Regurgitation. Anesthesiology 2003; 99:242)

case report12
Case Report

“Laryngoscopy and tracheal intubation with a 7.5 endotracheal tube were easily accomplished, the endotracheal tube cuff was inflated with 10 ml of air, and cricoid pressure was released. This was followed immediately by the appearance of copious, greenish fluid in the mouth, which was suctioned. There were no further sequelae.”

(Gundappa Neelakanta. Cricoid Pressure Is Effective in Preventing Esophageal Regurgitation. Anesthesiology 2003; 99:242)

case report13
Case Report

“Although no prospective randomized controlled clinical studies can be done to prove its clinical efficacy, the above case illustrates that proper application of cricoid pressure is effective, at least in some patients, in the prevention of gastric aspiration from passive regurgitation.”

(Gundappa Neelakanta. Cricoid Pressure Is Effective in Preventing Esophageal Regurgitation. Anesthesiology 2003; 99:242)

mendelson syndrome
Mendelson Syndrome

Synonyms:Acid aspiration syndrome, acid aspiration pneumonitis syndrome, acid-pulmonary-aspiration syndrome, acute exuditative pneumonitis syndrome, aspiration pneumonitis syndrome, chemical pneumonitis syndrome, gastric acid aspiration syndrome, obstetric bronchopulmonary aspiration syndrome, peptic aspiration pneumonia, pulmonary acid aspiration.

curtis lester mendelson
Curtis Lester Mendelson

Curtis Lester Mendelson studied at Cornell University, where he completed his medical education in 1938. He received his postgraduate education at New York Hospital, in obstetrics and gynecology.

curtis lester mendelson16
Curtis Lester Mendelson

Between 1932 and 1945, 66 cases of aspiration occurred during obstetrical anesthesia at New York Hospital. He described this in print: Mendelson CL The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecol 52:191 1946

curtis lester mendelson17
Curtis Lester Mendelson

In 1959 Mendelson and his wife hired a small single engine plane and took off for the West Indies. They happened to pass the Abaco Islands, a small group if islands in the Bahamas, and landed for supplies.

(http://www.whonamedit.com/doctor.cfm/2069.html)

curtis lester mendelson18
Curtis Lester Mendelson

Mendelson felt he had found his paradise, and the next year the Mendelsons settled on Green Turtle Cay, a very small island in the Abaco group with just 700 inhabitants, no clinic and no doctor.

Mendelson became a doctor for both inhabitants and their domestic animals, and both he and his wife enjoyed life there immensely.

(http://www.whonamedit.com/doctor.cfm/2069.html)

curtis lester mendelson19
Curtis Lester Mendelson

In 1961 New York Hospital regrettingly accepted his resignation as professor of obstetrics and gynaecology, and at the age of only 46 years Mendelson abandoned his brilliant medical career for a totally different life.

Curtis Mendelson served the inhabitants on his paradise island until 1990 when he, aged 77, moved to West Palm Beach in Florida.

(http://www.whonamedit.com/doctor.cfm/2069.html)

brian a sellick 1918 1996 london anaesthetist
Brian A Sellick 1918-1996, London Anaesthetist

"Cricoid pressure must be exerted by an assistant. Before induction, the cricoid is palpated and lightly held between the thumb and second finger; as anaesthesia begins, pressure is exerted on the cricoid cartilage mainly by the index finger. Even a conscious patient can tolerate moderate pressure without discomfort but as soon as consciousness is lost, firm pressure can be applied without obstruction of the patient's airway. Pressure is maintained until intubation and inflation of the cuff of the endotracheal tube is complete.”

Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia: preliminary communication. Lancet. 1961; 2:404-406.

slide24

“The esophagus is compressed between the posterior aspect of the cricoid and the vertebrae behind. The cricoid is used because it forms the only complete ring of the larynx and trachea.”

How pressure on the cricoid

cartlilage can occlude the esophagus

Source http://www.nda.ox.ac.uk/wfsa/html/u02/u02_b03.htm

slide25

“The cricoid is located at the level of C6. Moderate pressure may be applied before loss of consciousness, and firmer pressure maintained until the cuff of the tracheal tube is inflated.”

Correct means of

hand positioning

Source: http://www.nda.ox.ac.uk/wfsa/html/u02/u02_b03.htm

slide26

Incorrect (but likely still effective) hand positioning

Source: Bryant A. Tingen MS. The use of cricoid pressure during emergency intubation. Journal of Emergency Nursing. 25(4):283-4, 1999

brian a sellick 1918 1996 london anaesthetist27
Brian A Sellick 1918-1996, London Anaesthetist

Sellick's seminal paper shows lateral X-rays of the neck with the esophagus containing a latex tube full of contrast medium. The effect of cricoid pressure is graphically demonstrated.

Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia: preliminary communication. Lancet. 1961; 2:404-406.

essential elements of cricoid presure
Essential Elements of Cricoid Presure
  • Must apply force to the cricoid cartilage
  • Must apply force in correct direction
  • Must apply correct amount of force
  • Must apply force for correct duration of time
cricoid pressure literature
Cricoid Pressure Literature
  • Cricoid pressure has become a standard of practice during the induction of anesthesia in patients at risk of aspiration [1].
  • The evidence of its efficacy includes prevention of gastric insufflation in children [2] and adults [3, 4], an increase in upper esophageal sphincter pressure [5], and occurrence of reflux in 3 of 26 patients at risk when cricoid pressure was released [6].

[1] Thwaites AJ, Rice CP, Smith I. Rapid sequence induction: a questionnaire survey of its routine conduct and continued management during a failed intubation. Anaesthesia 1999; 54: 372–92[2] Salem MR, Wong AY, Mani M, Sellick BA. Efficacy of cricoid pressure in preventing gastric inflation during bag-mask ventilation in pediatric patients. Anesthesiology 1974; 40: 96–8. [3] Lawes EG, Campbell I, Mercer D. Inflation pressure, gastric insufflation and rapid sequence induction. Br J Anaesth 1987; 59: 315–8. [4] Asai T, Barclay K, McBeth C, Vaughan RS. Cricoid pressure applied after placement of the laryngeal mask prevents gastric insufflation but inhibits ventilation. Br J Anaesth 1996; 76: 772–6 [5] Vanner RG. O’Dwyer JP, Pryle BJ, Reynolds F. Upper oesophageal sphincter pressure and the effect of cricoid pressure. Anaesthesia 1992; 47: 95–100. [6] Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet 1961; 2: 404–6. (Source: Ng A. Smith G. Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesthesia & Analgesia. 93:494-513, 2001)

how much force
How Much Force?

“A force of 30 N (3 kg) is recommended for an unconscious patient”

Clayton TJ, Vanner RG. A novel method of measuring cricoid force. Anaesthesia. 2002;57:326-9.

how much force31
How Much Force?

“Research recommends that 3 to 4 kg of cricoid force be applied to achieve effective esophageal occlusion”

Koziol CA, Cuddeford JD, Moos DD. Assessing the force generated with application of cricoid pressure. AORN J. 2000;72:1018-28, 1030.

how much force32
How Much Force?

“ ... a cricoid force of 44 N was judged to be effective in protecting the majority of adult patients from regurgitation.”

Wraight WJ, Chamney AR, Howells TH. The determination of an effective cricoid pressure. Anaesthesia. 1983;38:461-6.

how much force33
How Much Force?

“Prevent regurgitation when the tracheal intubation is performed in trauma patient ( if you always consider this patients as "full stomach") but it has some problems: the force that you should apply is tremendous ( about 40 Kg !!!) to prevent regurgitation in 95% of cases; it is describile (sic) a high incidence of esophagus perforation due the high pressure produced by regorgitation (sic). But the problem discussed is the same: how intubed (sic) with move the head and neck and without a assistance ?”

http://www.trauma.org/archives/csintu.html

WARNING

Don’t believe everything you read on the Internet!!

james curry observations on apparent death 1796
James Curry Observations on Apparent Death ... (1796)

"Not merely blowing into the nostril or mouth will do ­ Air will pass into and distend the stomach. Therefore the second assistant with his right hand to press backwards and draw gently downwards towards the chest the upper part of the wind-pipe, that part which lies a little below the chin which from its prominence in men is vulgarly called Adam's Apple; by doing this the Gullet will be completely stopped up whilst the windpipe will be rendered more open to let air pass freely into the lungs."

burp maneuver
"BURP" Maneuver

The "BURP" maneuver consists of displacement of the larynx in 3 specific directions, posteriorly against the cervical vertebrae (Back), as far superior (Upward) as possible and slightly laterally to the right (Rightward Pressure).

In a Japanese study, both cricoid pressure and the "BURP" maneuver significantly improved laryngoscopic visualization, with the "BURP" maneuver being more effective.

Osamu Takahata, MD, Munehiro Kubota, MD, Keiko Mamiya, MD, et al. The Efficacy of the "BURP" Maneuver During a Difficult Laryngoscopy. Anesthesia Analgesia 1997:84:419-21

cricoid pressure references
Cricoid Pressure References
  • Brimacombe JR, Berry AM: Cricoid pressure. Can J Anaesth 1997; 44: 414-25
  • Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia: preliminary communication. Lancet. 1961; 2:404-406.
  • Wraight WJ, Chamney AR, Howells TH: The determination of an effective cricoid pressure. Anaesthesia 1983; 38: 461-6
  • Vanner RG, O'Dwyer JP, Pryle BJ, Reynolds F: Upper oesophageal sphincter pressure and the effect of cricoid pressure. Anaesthesia 1992; 47: 95-100
  • Salem MR, Wong AY, Fizzoti GF: Efficacy of cricoid pressure in preventing aspiration of gastric contents in paediatric patients. Br J Anaesth 1972; 44: 401-4
  • Salem MR, Joseph NJ, Heyman HJ, Belani B, Paulissian R, Ferrara TP: Cricoid compression is effective in obliterating the esophageal lumen in the presence of a nasogastric tube. Anesthesiology 1985; 63: 443-6
  • Vanner RG, Pryle BJ: Regurgitation and oesophageal rupture with cricoid pressure: A cadaver study. Anaesthesia 1992; 47: 732-5