Effectiveness of cricoid pressure in preventing gastric aspiration during rapid sequence intubation in the emergency department: study protocol for a randomised controlled trial

Trethewy, Christopher; Burrows, Julie; Clausen, Don; Doherty, Steven

doi:10.1186/1745-6215-13-17

Cited by 11 publications

(9 citation statements)

References 44 publications

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“…In emergency medicine, the efficiency of cricoid pressure to prevent aspiration still has to be documented 12. In addition, the use of cricoid pressure during emergent intubation might be associated with impaired laryngeal views 13.…”

Section: Discussionmentioning

confidence: 99%

Effect of cricoid pressure on laryngeal view during prehospital tracheal intubation: a propensity-based analysis

2016

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BackgroundThe benefit of cricoid pressure during tracheal intubation is still debated and, due to its potential negative impact on laryngeal views, its routine use is questioned. The goal of this study was to estimate its impact on laryngeal view. Methods All patients intubated in the prehospital setting were included. Three different propensity score (PS) models were used and compared in terms of the balance achieved between those patients who received cricoid pressure and those who did not. The PS model that optimised the balance was retained in order to estimate the relationship between cricoid pressure and the following outcomes: difficult laryngoscopy, intubation-related complications and difficult intubation. Results Among the 1195 patients included, 499 (41.7%) received cricoid pressure. The optimal PS included seven variables (cardiac arrest, altered neurological status, shock, respiratory distress, gender, obesity, patient's position). After PS matching, no significant risk difference (RD) in the rate of difficult laryngoscopy was found between the patients who received cricoid pressure and those who did not (RD=0.001, 95% CI −0.07 to 0.08, p=0.50). No significant difference was found in terms of difficult intubation (RD=0.06, 95% CI −0.13 to 0.25, p=0.28) and in terms of prevalence of complications, except for airway trauma that were more frequent in cricoid pressure group (RD=0.03, 95% CI 0.002 to 0.05, p=0.01). Conclusions No significant relationship was found between the use of cricoid pressure for prehospital intubation and difficult laryngoscopy. Cricoid pressure was found to be associated with more airway trauma. This finding could question its routine use.

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Section: Discussionmentioning

confidence: 99%

Effect of cricoid pressure on laryngeal view during prehospital tracheal intubation: a propensity-based analysis

2016

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“…This prospective, randomized trial compared two methods of CP application in patients undergoing RSI within the emergency departments (EDs) of two regional hospitals in NSW, Australia. The study protocol was registered (ACTRN12611000587909); full methodology was published and approved by the Hunter New England and the North Coast Area Health Service Human Research Ethics committees.…”

Section: Methodsmentioning

confidence: 99%

Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy

Trethewy

Doherty

Burrows

et al. 2017

Academic Emergency Medicine

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Objective: This study was a prospective, randomized controlled trial of rapid sequence intubation (RSI) with cricoid pressure (CP) within the emergency department (ED). The primary aim of the study was to examine the link between ideal CP and the incidence of aspiration.Method: Patients > 18 years of age undergoing RSI in the ED of two hospitals in New South Wales, Australia, were randomly assigned to receive measured CP using weighing scales to target the ideal CP range (3.060-4.075 kg) or control CP where the weighing scales were used, but the CP operator was blinded to the amount of CP applied during the RSI. A data logger recorded all CP delivered during each RSI. Immediately after intubation, tracheal and esophageal samples were taken and underwent pepsin analysis.Results: Fifty-four RSIs were analyzed (25 measured/29 control). Macroscopic contamination of the larynx at RSI was observed in 14 patients (26%). During induction (0-50 seconds), both groups delivered in-range CP. During intubation (51-223 seconds), laryngoscopy was associated with a reduction in mean CP below 3.060 kg in both groups. When compared, there was no statistically significant difference between the groups. For 11 patients, pepsin was detected in the oropharyngeal sample, while three were positive for tracheal pepsin. Seven patients (four control/three measured) were treated for clinical aspiration during hospitalization. As a result of the finding that neither group could maintain ideal range CP during laryngoscopy, the trial was abandoned.Conclusion: Laryngoscopy provides a counter force to CP, which is negated to facilitate tracheal intubation.The concept that a static 3.060 to 4.075 kg CP could be maintained during laryngoscopy and intubation was rejected by our study. Whether a lower CP range could prevent aspiration during RSI was not explored by this study. R apid sequence intubation (RSI) involves administration of anesthetic and neuromuscular blocking agents in rapid succession to facilitate endotracheal intubation.1 In a 1961 nonrandomized, uncontrolled case series, Sellick 2 described esophageal occlusion "by backwards pressure on the cricoid ring against the bodies of the cervical vertebrae" during RSI in 26 high-risk anesthetic cases. In three cases, release of the cricoid pressure (CP) after intubation was associated with immediate reflux into the pharynx of gastric and

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“…It involves the application of backward pressure on the cricoid cartilage with a force of between 30 and 40 N [1][2][3][4][5] in order to occlude the upper oesophagus (although latterly it has been suggested that a force of 20-30 N [6][7][8] might be more appropriate). Failure to secure the airway in this way may put the patient at risk of developing aspiration pneumonitis, bacterial pneumonia and or bronchial blockage [9].…”

Section: Introductionmentioning

confidence: 99%

“…Although ubiquitous, numerous studies have shown that knowledge and skills of cricoid pressure amongst anaesthetic and emergency department staff are still quite poor [8][9][10][28][29][30][31][32]. The main deficiencies lie in the practitioners' method of application and understanding of the correct amount of force to apply [8,30].…”

Section: Introductionmentioning

confidence: 99%

A cricoid cartilage compression device for the accurate and reproducible application of cricoid pressure

et al. 2014

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SummaryWe describe the development and laboratory assessment of a refined prototype tactile feedback device for the safe and accurate application of cricoid pressure. We recruited 20 operating department practitioners and compared their performance of cricoid pressure on a training simulator using both the device and a manual unaided technique. The device significantly reduced the spread of the applied force: average (SE) root mean squared error decreased from 8.23 (0.48) N to 5.23 (0.32) N (p < 0.001). The average (SE) upwards bias in applied force also decreased, from 2.30 (0.74) N to 0.88 (0.48) N (p < 0.01). Most importantly, the percentage of force applications that deviated from target by more than 10 N decreased from 18% to 7% (p < 0.01). The device requires no prior training, is cheap to manufacture, is single-use and requires no power to operate, whilst ensuring that the correct force is always consistently applied.

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Effectiveness of cricoid pressure in preventing gastric aspiration during rapid sequence intubation in the emergency department: study protocol for a randomised controlled trial

Cited by 11 publications

References 44 publications

Effect of cricoid pressure on laryngeal view during prehospital tracheal intubation: a propensity-based analysis

Effect of cricoid pressure on laryngeal view during prehospital tracheal intubation: a propensity-based analysis

Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy

A cricoid cartilage compression device for the accurate and reproducible application of cricoid pressure

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