A multicentre prospective cohort study of the accuracy of conventional landmark technique for cricoid localisation using ultrasound scanning

Abstract

Cricoid pressure is employed during rapid sequence induction to reduce the risk of pulmonary aspiration. Correct application of cricoid pressure depends on knowledge of neck anatomy and precise identification of surface landmarks. Inaccurate localisation of the cricoid cartilage during rapid sequence induction risks incomplete oesophageal occlusion, with potential for pulmonary aspiration of gastric contents. It may also compromise the laryngeal view for the anaesthetist. Accurate localisation of the cricoid cartilage therefore has relevance for the safe conduct of rapid sequence induction. We conducted a multicentre, prospective cohort study to determine the accuracy of cricoid cartilage identification in 100 patients. The cranio-caudal midpoint of the cricoid cartilage was identified by a qualified anaesthetic assistant using the conventional landmark technique and marked. While maintaining the patient in the same position, a second mark was made by identifying the midpoint of the cricoid cartilage using ultrasound scanning. The mean (SD) distance between the two marks was 2.07 (8.49) mm. In 41% of patients the midpoint was incorrectly identified by a margin greater than 5 mm. This error was uniformly distributed both above and below the midpoint of the cricoid cartilage. The Pearson correlation coefficient of this error with respect to body mass index was 0.062 (p = 0.539) and with age was -0.020 (p = 0.843). There were also no significant differences in error between male and female patients. Identification of cricoid position using a landmark technique has a high degree of variability and has little correlation with age, sex or body mass index. These findings have significant implications for the safe application of cricoid pressure in the context of rapid sequence induction.

Surface anatomical landmarks or ultrasound for cricoid pressure application – a reply

“…We thank Zeidan et al. for their interest in our study that has demonstrated the limitations of landmark‐guided localisation of the cricoid cartilage . We agree with Zeidan et al., as we had explicitly stated in the manuscript, that effective cricoid pressure is multifactorial.…”

An international survey about rapid sequence intubation of 10,003 anaesthetists and 16 airway experts

“…Although individual patient adjustment emerges as modern clinical practice, only when mastery in all RSI variants is achieved can the practitioner truly safely individualise patient care [30]. Although it might be reasonable to individualise the choice of pharmacological agents with consideration of their sideeffects, there is good evidence otherwise that without regular training, cricoid force might not be applied correctly [31,32]. Surveyed experts were much more consistent in avoiding the supine position and cricoid force use for RSI.…”

“…Nonetheless, this popularity varied between the countries of respondents. For example, it was less is good evidence otherwise that without regular training, cricoid force might not be applied correctly[31,32]. Surveyed experts were much more consistent in avoiding the supine position and cricoid force use for RSI.Surveyed experts agreed that trainees should always be closely supervised during RSI, but this would have important implications for departments, personnel and training.…”

Sellick maneuver assisted real-time to achieve target force range in simulated environment—A prospective observational cross-sectional study on manikin

“…https://doi.org/10.1371/journal. pone.0227805 skill taught to trainee anesthetists and assessed for competency in the United Kingdom and Ireland [4]. Today, cricoid pressure remains a relevant maneuver in clinical practice and deserves more studies to better understand it and to improve its performance by operators.…”