Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia

Abstract

The use of cricoid pressure (Sellick maneuver) during rapid sequence induction (RSI) of anesthesia remains controversial in the absence of a large randomized trial.OBJECTIVE To test the hypothesis that the incidence of pulmonary aspiration is not increased when cricoid pressure is not performed.DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, noninferiority trial conducted in 10 academic centers. Patients undergoing anesthesia with RSI were enrolled from February 2014 until February 2017 and followed up for 28 days or until hospital discharge (last follow-up, February 8, 2017). INTERVENTIONSPatients were assigned to a cricoid pressure (Sellick group) or a sham procedure group.MAIN OUTCOMES AND MEASURES Primary end point was the incidence of pulmonary aspiration (at the glottis level during laryngoscopy or by tracheal aspiration after intubation). It was hypothesized that the sham procedure would not be inferior to the cricoid pressure. The secondary end points were related to pulmonary aspiration, difficult tracheal intubation, and traumatic complications owing to the tracheal intubation or cricoid pressure. RESULTSOf 3472 patients randomized, mean (SD) age was 51 (19) years and 1777 (51%) were men. The primary end point, pulmonary aspiration, occurred in 10 patients (0.6%) in the Sellick group and in 9 patients (0.5%) in the sham group. The upper limit of the 1-sided 95% CI of relative risk was 2.00, exceeding 1.50, failing to demonstrate noninferiority (P = .14). The risk difference was −0.06% (2-sided 95% CI, −0.57 to 0.42) in the intent-to-treat population and −0.06% (2-sided 95% CI, −0.56 to 0.43) in the per protocol population. Secondary end points were not significantly different among the 2 groups (pneumonia, length of stay, and mortality), although the comparison of the Cormack and Lehane grade (Grades 3 and 4, 10% vs 5%; P <.001) and the longer intubation time (Intubation time >30 seconds, 47% vs 40%; P <.001) suggest an increased difficulty of tracheal intubation in the Sellick group.CONCLUSIONS AND RELEVANCE This large randomized clinical trial performed in patients undergoing anesthesia with RSI failed to demonstrate the noninferiority of the sham procedure in preventing pulmonary aspiration. Further studies are required in pregnant women and outside the operating room.

Advancing emergency airway management practice and research

“…Although cricoid pressure had been used to reduce the risk of aspiration during intubation, it may be unnecessary to undertake RSI safely . Likewise, there is no concrete evidence on the use of the backward, upward, rightward pressure (BURP) method to improve the glottis view during intubation …”

The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice

“…Therefore, facemask ventilation should only be performed gently in the event of critical arterial oxygen desaturation . In order to maximise first‐pass success and not compromise optimal ventilation (if needed), cricoid force should not be performed, unless there are other indications . Apnoeic oxygenation is recommended to prevent desaturation , ideally with low‐flow nasal oxygenation during tracheal intubation attempts.…”

An international survey about rapid sequence intubation of 10,003 anaesthetists and 16 airway experts

“…The incidence of pulmonary aspiration is thought to be between 0.01% and 0.04% [4,12]. This rises to 0.5% and 2.8% for RSIs conducted in and outside of the operating theatre, respectively [10,13]. These incidences are greater than the incidence of a failure to oxygenate scenario, which is estimated to be 0.002% of all general anaesthetics [4,14].…”