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Australasian Anaesthesia 2011 - Australian and New Zealand ...

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70 <strong>Australasian</strong> <strong>Anaesthesia</strong> <strong>2011</strong>Cricoid pressure: is there any evidence? 71PRESENCE OF A NASOGASTRIC TUBESellick originally proposed that a nasogastric (N/G) tube should be removed prior to the application of CP. Hethought that it interfered with oesophageal compression <strong>and</strong> made the lower <strong>and</strong> upper oesophageal sphinctersincompetent. This is supported by the clinical view that a N/G tube breaches the integrity of the lower oesophagealsphincter <strong>and</strong> acts as a capillary tube encouraging regurgitation, particularly in a case of upper gastrointestinalobstruction with raised intragastric pressure with the N/G occluded proximally. However, this is challenged bystudies which show that the efficacy of CP is enhanced by the presence of a N/G tube because it occupies thepart of the oesophagus not obliterated by CP, the raised intragastric pressure can be decreased with suction priorto the application of CP, <strong>and</strong> that this pressure reduction is maintained if the N/G tube’s proximal end is left openduring induction <strong>and</strong> the application of CP.18. Patel PN. Effect of education on the application of Cricoid pressure during Rapid sequence Induction. DifficultAirway Society Meeting, Cheltenham UK 2010.19. Smith KJ; Dobransowski J, Yip G et al. Cricoid pressure displaces the oesophagus: an observational studyusing magnetic resonance imaging. Anesthesiology. 2003; 99(1):66-64.20. Toumadre J, Chassard D, Berrada KR et al. Cricoid pressure decreases lower oesophageal sphincter tone.Anesthesiology. 1997; 86(1):7-9.21. Vanner R. A presentation at the Difficult Airway Society Meeting, Cheltenham UK 2010.SUMMARYThere is little evidence to support the view that the application of CP reduces the incidences of aspiration. Thereis a growing body of literature questioning the efficacy of CP. Effective or not it is likely to remain st<strong>and</strong>ard practicebecause its efficacy can’t be disproven <strong>and</strong> there may not be a better option.The majority of the data on aspiration ignores post operative <strong>and</strong> intraoperative aspiration, of which there arelimited data.<strong>New</strong> guidelines have been proposed for the application of CP:1. the patient should be placed with a 200 head up tilt; this will make pre oxygenation more effective <strong>and</strong> willmake intubation easier <strong>and</strong> decrease the pressure applied to prevent regurgitation;2. is to be maintained during pre oxygenation;3. if there is a poor laryngoscopic view during intubation then CP should be released;4. should be released to allow insertion of a laryngeal mask. 21REFERENCES1. Thwaites AJ, Rice CP, Smith I. Rapid sequence Induction: a questionaaire survey of its routine conduct <strong>and</strong>continued management during failed intubation. <strong>Anaesthesia</strong>. 1999; 54(4):376-381.2. Brimacoombe J, Berry A. Cricoid pressure. Can J Anaesth. 1997;44(4):414-425.3. Neillipovitz DT, Crosby ET. No evidence for decreased incidence of aspiration after rapid sequence induction.Can J Anaesth. 2007;54(9):748-764.4. Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia.Lancet. 1961; 2:404-406.5. Mendelson CL. The aspiration of stomach contents into the lungs during obstetrical anaesthesia. AmericanJ Obs Gynae. 1946;52:191-204.6. Warner MA, Warner ME, Weber JG. Clinical significance of pulmonary aspiration during the peri operative period.Anesthesiology. 1993; 78(1):56-62.7. Maltby JR, Beriault MT. Science, pseudoscience <strong>and</strong> Sellick. Can J Anaesth. 2002;49(5):443-447.8. Lienhart A, Auroy Y, Pequiqriot F et al. Survey of anaesthesia- related mortality in France. Anaesthiology. 2006;105(6):1087-1097.9. Vanner R. The aspiration problem. In Calder I, Pearce A. eds. Core topics in Airway management. CambridgeUK; Cambridge University Press, <strong>2011</strong>.10. Engelhardt T, Webster N. Pulmonary aspiration of gastric contents in anaesthetics. BJA. 1999; 83(3):453-460.11. Palmer JHM, Ball DR. The effect of cricoid pressure on the cricoid cartilage <strong>and</strong> vocal cords: an endoscopicstudy in anaesthetised patients. <strong>Anaesthesia</strong>. 2000; 55(3):263-268.12. Cook T. Cricoid pressure: Are two h<strong>and</strong>s better than one? <strong>Anaesthesia</strong>. 1996; 51(4):365-368.13. Yentis S. The effects of single h<strong>and</strong>ed <strong>and</strong> bimanual Cricoid pressure on the view at laryngoscopy. <strong>Anaesthesia</strong>.1997; 52(4):332-335.14. Vanner R, Clarke P, Moore WJ et al. Effect of neck support on the view at laryngoscopy. <strong>Anaesthesia</strong>.1997; 52(9):896-900.15. Howells YH, Chamney Ar, Wraight WJ. The application of Cricoid pressure: assessment <strong>and</strong> survey of itspractice. <strong>Anaesthesia</strong>. 1983; 38(5):457-460.16. Morris J, Cook TM. Rapid sequence induction: a national survey of practice. <strong>Anaesthesia</strong>. 2001; 56(11):1090-1097.17. Meek T, Gittins N, Duggan J. Cricoid Pressure: Knowledge <strong>and</strong> performance amongst anaesthesia assistants.<strong>Anaesthesia</strong>. 1999; 54(1):59-62.

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