Cricoid Pressure

John Hinds

Conflict of interest

Conflict of interest

My nefarious plan

• Get invited to International conference in sunny climate

• Captive audience

• Sell you this fabulous new product!

Cricolol

Appraising drugs and therapies

• Steroids in Spinal Cord injury• Activated Protein C• Starch solutions• Therapeutic hypothermia in OOHCA

Cricolol: Early development

• Herbal remedy by Seamus O’Monroe in 1774

Cricolol: Early development

• Rebranded by Seamus O’Sellick in 1961– 26 patients– Single hospital observational study– Non-randomised– Non-standardised – Dose was guessed

Administration

• Dedicated assistant during RSI

• 10mg before induction• 30mg during induction

Administration

• Dedicated assistant during RSI

• 10mg before induction• 30mg during induction

• Exact dose in syringe is unknown

How much is in the ampoule?

105 trained perioperative nurses

• 5% correct dose

• No correlation between knowledge of correct dose and actual dose given

(Seamus O’Kozial et al, AORN J 2000)

A half century of Evidence

No randomised controlled trials showing benefit.

B.S.E.’s• Quite good at making it difficult to pass

nasogastric tubes

• Quite good for nice pictures in healthy volunteers having MRI scans

• Some nonsense with Dye

• Seems OK in dead bodies

Any problems?

Makes Airway management more difficult

• Airway compression in 81% (O’Smith et al, Anaesthesiology. 2003)

• Airway obstruction in 56%(O’Hartsilver, Anaesthesia, 2000)

Reduces success with the tube

• Worsens laryngeal view in 29%(O’Levitan et al, Anal Emerg Med 2006)

• Makes intubation process more difficult(O’Allman KG. J Clin Anesth 1995)

Increases vomiting and regurgitation

• Lowers oesophageal sphincter tone and increases regurgitation

O’Garrad et al, Anaesthesia 2004

O’Chassard et al, Can J Anaesth 1996

Narrow therapeutic window

• Dose of 30mg recommended– No idea what’s in the ampoule

• You might break the airway(O’ Heath et al, Br J Anaesth 1996)

• Oesophagus might explode if dose exceeds 44mg

(O’ Ralph, O’ Wareham, Anaesthesia 1991)

Cricolol

• Evidence in well powered clinical trials– None.– Some BSE data

• Evidence of side effects includes:– Airway collapse in most patients– Complete airway obstruction in half of patients– Increased difficulty of intubation– Physical harm

Cricoid Pressure

3 pet hates of mine

“I use Cricoid Pressure…

I can just take it off if the airway is difficult”

Sellick

• Cricoid on for induction…

… off at laryngoscopy

• Resulted in the highest reported incidence of gastric regurgitation, ever.

Beware the “Trained assistant”

“Can I PLEASE have Cricoid?!”

“Can I PLEASE have Cricoid?!”

“Well if you tell me what cupboard it’s in I’ll get it”

“I don’t believe in Cricoid Pressure…

but I’m afraid to not use it because of Guidelines”

Difficult Airway Society

Difficult Airway Society

• “Written guidelines should exist in each department to cover a number of common or serious airway problems”

• “An individual practitioner can make a judgement about which equipment/technique to use, and is quite entitled to use any”

“I have to follow the Guidelines”

“Befehl ist Befehl”

Godwin’s Law

“As an online discussion grows longer,

the probability of a comparison involving Nazis or Hitler approaches 1”

Vote for Cricoid Pressure

Vote for Cricoid Pressure

• An Idiot.

Vote for Cricoid Pressure

• An Idiot.

• A Nazi.

Cricolol !

30mg Suppository!

“For all the good it does, you might as well just stick it up your Arse”