NAP4 responds on cricoid pressure
Hi folks. Over Easter there was a bit of a chat on FOAMEd forums about cricoid pressure. Someone suggested I contact the NAP4 editors and ask for their comment on this issue. So I did.
I have permission from the editors who I communicated with to publish their statement.
The NAP4 editors who collectively responded to my question are : T Cook, N Woodall and C Frerk
Dr Tim Cook
Royal United Hospital, Bath
Joint Lead for the 4th National Anaesthesia Audit
Dr Nick Woodall
Co-Audit Lead, 4th National Audit Project (NAP4)
Dr Chris Frerk
Northampton General Hospital, Northampton
Okay what follows now is my original email and then their response.
Dear editors of the NAP4 publicationI am a prehospital and retrieval medicine doctor with the Royal Flying Doctor Service of Australia.I also run a medical blog, prehospitalmed.comLately my colleagues and I have been having a debate about the role of cricoid pressure in rapid sequence intubation in the prehospital and ED settingsWe often cite the NAP4 as a reference work in regard to its recommendation to use cricoid pressure as standard of care in RSI.Here is a recent post on a colleagues blog site, describing the opposition to use of cricoid pressureI was wondering if you would comment on this debate and whether you still believe cricoid pressure is the standard of care for RSI?thanks for helping if you canDr Minh Le CongRFDS Cairns and Mt Isa, Queensland, Australia
Hi Dr Le Cong,
We have discussed the issue of cricoid pressure and the NAP4 report. I hope you will find our views helpful.
The NAP4 report does not specifically endorse cricoid force though as it does support the need for rapid sequence induction (RSI) this is largely implied. Aspiration accounted for more than half of anaesthesia cases
resulting in deaths or brain damage. Amongst the contributory factors identified in review of these cases was a failure to use recognised techniques designed to lessen the risk of aspiration when risk factors existed. Amongst those recognised techniques would be RSI. In the UK RSI is generally taken to include the use of cricoid force.
We did emphasise that where cricoid force is employed it should be performed by those who are trained and practiced in it.
Correctly applied cricoid force is unlikely to worsen view at laryngoscopy and may even improve it. It should not impede mask ventilation (but may reduce gastric inflation). Incorrectly applied cricoid force leads to
difficult laryngoscopy, airway obstruction and a risk of failed mask ventilation.
The editorial by Vanner and Asai (Anaesthesia 1999) remains one of the best pieces of writing on the topic and is recommended reading. It recommends use of cricoid pressure (3kg) as a component of RSI. If direct laryngoscopy is difficult it recommends reducing then releasing cricoid pressure whilst simultaneously performing direct laryngoscopy with a suction catheter in hand to deal with regurgitation should this occur. These methods seek to maximise the potential benefits of this manoeuvre whilst minimising the potential hazards.
One important additional comment is that videolaryngoscopy has a potentially important role in RSI. VL – with a remote screen- enables all those involved in the induction (anaesthetist, assistant and others) to see the ease of laryngoscopy, the view of laryngoscopy and the impact of cricoid force. It is likely that use of VL at RSI improves teamwork – but again published evidence of that we believe is lacking.
In NAP4 we stated
NAP 4 has identified several cases where the omission of RSI , although there were strong indications for its use, was followed by patient harm, or death from aspiration. There were no cases where cricoid force was reported to lead to major complications. Rapid sequence induction with cricoid force does not provide 100% protection against regurgitation and aspiration of gastric contents, but remains the standard for those patients at risk. Recommendation: On balance, rapid sequence induction should continue to be taught as a standard technique for protection of the airway. Further focused research might usefully be performed to explore its efficacy, limitations and also explore the consequences of its omission.