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Cricoid pressure in emergency rapid sequence induction
  1. John Butler, Consultant,
  2. Ayan Sen, Clinical Fellow
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; s.carley1btinternet.com

    Abstract

    A short cut review was carried out to establish cricoid pressure reduced aspiration during rapid sequence induction (RSI) of anaesthesia. A total of 241 papers were identified using the reported search, of which three represented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. There is little evidence to support the widely held belief that the application of cricoid pressure reduces the incidence of aspiration during a rapid sequence intubation.

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    Report by John Butler, ConsultantChecked by Ayan Sen, Clinical Fellow

    Three part question

    In [patients undergoing emergency RSI] does [cricoid pressure] reduce the [incidence of aspiration of gastric contents/ morbidity/mortality]?

    Clinical scenario

    You are about to perform an RSI in a 26 year old man with a severe head injury. You have been told that the gentleman has consumed a significant amount of alcohol in the last three hours. The nurse asks you whether application of cricoid pressure will stop him aspirating.

    Search strategy

    Medline 1950 to July 2005 via OVID; Embase 1988 to July 2005 via OVID: [{Sellick’s manoeuvre.mp} OR {Cricoid pressure.mp} OR/cricoid pressure] LIMIT to HUMAN and ENGLISH and ABSTRACTS. Cochrane Database of Systematic Reviews 2005.

    Search outcome

    Medline: 241 papers in total of which 3 papers were relevant to the question (table 2). Embase: 119 citations, no new references found. Cochrane: No new papers found.

    Table 2

    Comment(s)

    Cricoid pressure has been described as the “linchpin of rapid sequence induction” and has become widely accepted as the standard of practice during anaesthesia in the UK and USA. However, it is not widely used in some continental countries. Although it is a simple manoeuvre there have been concerns about its safety and efficacy. Opinion on its use varies widely from those who believe it should remain the standard of care to those who urge for re-evaluation of the technique. Concern has been expressed that cricoid pressure may interfere with airway management, obscuring the laryngeal view and creating difficulties in passing the endotracheal tube. This may lead to a failure of airway tecniques and subsequent morbidity and mortality. The evidence presented in this review suggests that none of the papers confirm the perceived clinical benefit of cricoid pressure in reducing the incidence of aspiration during an emergency RSI.

    It will be interesting to see whether a technique that is now so widely engrained in anaesthetic practice will ever be submitted to a more rigorous evaluation.

    CLINICAL BOTTOM LINE

    There is little evidence to support the widely held belief that the application of cricoid pressure reduces the incidence of aspiration during a rapid sequence intubation.

    Report by John Butler, ConsultantChecked by Ayan Sen, Clinical Fellow

    References

    View Abstract

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