— the EMCrit Crew (@emcrit) October 18, 2018
— Saint Emlyn's (@stemlyns) October 20, 2018
John Hinds' original talk about cricoid pressure from SMACC.
— mike hurley (@m1kehurley) October 18, 2018
So this week a large RCT from France was published in JAMA regarding cricoid pressure in RSI and no sooner did it hit twitter than the arguments and debating started as all airway related topics tend to do on that medium!
There is the camp of cautious supporters of Cricoid pressure, almost exclusively anaesthesia doctors who argue the study is underpowered and lacks statistical significance and that cricoid pressure is still an essential element of safe RSI especially in pregnant patients who were excluded from the trial.
And then there is the camp who do not support cricoid pressure or only sparingly support its use in fairly select case by case basis. The study showed no real difference between the sham vs trained cricoid pressure groups in terms of aspiration. Intubation times were longer in the real cricoid group.
So overall a brave effort by French colleagues to try to settle a long standing controversy regarding role of cricoid pressure in airway management. But it lacks the knockout punch to cricoid! However cricoid pressure looks like its on the ropes and struggling to stay up. There is still no real proof it prevents aspiration to any significant degree and consistently has been shown in several studies to make airway management more difficult. So we are left with a somewhat tasteless compromise position of applying cricoid pressure and removing it if difficulty in airway management without really knowing if cricoid pressure actually does the job we want it to : prevent aspiration!Reality is many of us including anaesthesia doctors who criticise the French study, admit we are already abandoning routine cricoid pressure use in RSI. Select use in pregnant patients is really a flip of the coin as to what benefit it has above and beyond other measures taken to reduce aspiration risk, like use of suxamethonium for fast paralysis and minimisation of time to secure trachea with cuffed ETT.
So what dp I do? I havent routinely used cricoid pressure for over 5 yrs in RSI. If I have a high risk case for aspiration like bowel obstruction, I’ll place a gastric drain first. Other measures like head up intubation, deliberately intubating the oesophagus first, these are all things to try to reduce risk of aspiration. Dr Ducanto’s SALAD technique to deal with massive stomach regurgitation is another new technique to help here, placing special large bore suction catheter into oesophagus to continuously drain it during intubation.
What about pregnant women? Here is a special high risk situation as hormonal changes and the gravid uterus pushing up on diaphragm all make risk of regurgitation and gastric stasis much higher.Like with bowel obstruction, try to place a gastric drain ASAP and empty stomach. Sometimes for ultra emergency c section you might not have time to do this so I can understand the thinking in using routine cricoid pressure in these situations as its easy to apply. However there is a tradeoff and its consistently shown in all studies of cricoid pressure. It makes airway management harder, especially intubation and placement of a LMA. If you have to remove it to secure airway you fall back to exactly the same risk of regurgitation you had before you applied it. So really what logically are you doing? You really are gambling that cricoid pressure will NOT make airway management difficult and at same time, protect from regurgitation. And sure thats probably what happens at least half of the time. Now here this issue I believe is often in training/skill to apply cricoid pressure. This is often poorly done and non standardised and has been shown to make airway management harder if its not done to a standardised technique. So its an even extra gamble if you dont know if your assistant can apply cricoid pressure consistently well. TO my mind thats a whole lot of gambling and in my opinion better to refocus the defence against regurgitation on other measures, like positioning, suction techniques like SALAD and being really prepared to handle massive regurgitation during intubation.