Cricoid Pressure Controversies

Abstract

Since cricoid pressure was introduced into clinical practice, controversial issues have arisen, including necessity, effectiveness in preventing aspiration, quantifying the cricoid force, and its reliability in certain clinical entities and in the presence of gastric tubes. Cricoid pressure–associated complications have also been alleged, such as airway obstruction leading to interference with manual ventilation, laryngeal visualization, tracheal intubation, placement of supraglottic devices, and relaxation of the lower esophageal sphincter. This review synthesizes available information to identify, address, and attempt to resolve the controversies related to cricoid pressure. The effective use of cricoid pressure requires that the applied force is sufficient to occlude the esophageal entrance while avoiding airway-related complications. Most of these complications are caused by excessive or inadequate force or by misapplication of cricoid pressure. Because a simple-to-use and reliable cricoid pressure device is not commercially available, regular training of personnel, using technology-enhanced cricoid pressure simulation, is required. The current status of cricoid pressure and objectives for future cricoid pressure–related research are also discussed.

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

“…Reported cricoid pressure applied were found to be inappropriate and variable in the technique used and the amount of force exerted [6][7][8]10,12,21)]. Even after training, reported retention of cricoid pressure skill ranged from 1 week to 3 months [7,12,22,23]. Knowledge [9,10,23] of recommended cricoid force was also found to be inappropriate and inadequate in previous studies.…”

“…We recognize that discussing cricoid force alone does not address all the controversies that surrounds its use and effectiveness, it is however the first step towards enhancing the performance of cricoid pressure. While a recent review called for training of personnel using technology enhanced cricoid pressure simulation [22]. We proposed the use of technology to enhance cricoid pressure by providing real time objective feedback.…”

The influence of different patient positions during rapid induction with severe regurgitation on the volume of aspirate and time to intubation: a prospective randomised manikin simulation study

“…Supporters of the supine position contend that the anaesthetist’s familiarity with this position will accelerate endotracheal intubation and that research has provided convincing evidence that regurgitation in the supine position can be prevented as long as cricoid pressure is applied properly [21].…”

Effect of cricoid pressure on the glottic view and intubation with king vision® video laryngoscope

“…In the recent times, CP application has been a topic of debate. [14] This is because the effective use of CP requires that the applied force is sufficient to occlude the esophageal entrance while avoiding airway obstruction leading to interference with manual ventilation, laryngeal visualization, and tracheal intubation. [15] In this context, the use of VLS during RSI of anesthesia is gaining importance, and thus, independent evaluation of each VLS with CP requires to be established.…”

“…Different cricoid forces may have to be used depending on the scenario as in children, obese, use of head up position, preanesthetic nasogastric tube in situ and with use of VLS. [1425] Zeidan et al showed the median cricoid force for female is 18.7 N (95% confidence interval 17.1–20.3) and 30.8 N (95% confidence interval 28.15–33.5) for males suggesting that median force necessary to occlude esophageal entrance to prevent regurgitation is less in women. [26] Oh et al showed that CP with increasing force resulted in a worse laryngeal view with Pentax AWS.…”