Cricoid Pressure Provides Incomplete Esophageal Occlusion Associated with Lateral Deviation: A Magnetic Resonance Imaging Study

Advances in foetal anaesthesia

Nowadays, widespread antenatal ultrasound screenings detect congenital anomalies earlier and more frequently. This has sparked research into foetal surgery, offering treatment options for various conditions. These surgeries aim to correct anomalies or halt disease progression until after birth. Minimally invasive procedures can be conducted under local anaesthesia (with/without maternal sedation), while open mid-gestational procedures necessitate general anaesthesia. Anaesthesia serves to prevent maternal and foetal pain, to provide immobilization, and to optimize surgical conditions by ensuring uterine relaxation. As early as 12 weeks after conception, the foetus may experience pain. Thus, in procedures involving innervated foetal tissue or requiring foetal immobilization, anaesthetic drugs can be administered directly to the foetus (intramuscular or intravenous) or indirectly (transplacental) to the mother. However, animal studies have indicated that exposure to prenatal anaesthesia might impact foetal brain development, translating these findings to the clinical setting remains difficult.

Efficacy of Cricoid Pressure Application during Esophagogastroduodenoscopy in Patients with Poor Gastric Wall Extension

INTRODUCTION

Esophagogastroduodenoscopy (EGD) requires adequate air infusion. However, cases of poor gastrointestinal wall extension due to frequent eructation have been reported. Sufficient gastrointestinal wall extension can be achieved by applying cricoid pressure during EGD. Herein, we evaluated the frequency of cases with poor gastrointestinal wall extension and the efficacy and safety of applying cricoid pressure during EGD.

METHODS

This interventional study included patients who underwent EGD between January 2020 and December 2020 at the JA Akita Koseiren Yuri Kumiai General Hospital. Cases wherein folds of the greater curvature of the upper gastric body were not sufficiently extended during EGD were considered to have poor gastrointestinal wall extension. In such cases, air infusion was performed while applying cricoid pressure. This procedure was considered effective when gastric wall extension was achieved.

RESULTS

A total of 2,000 patients were enrolled and underwent upper gastrointestinal endoscopy; however, five were excluded because of upper gastrointestinal tract stenosis. Observation of gastric wall extension of the greater curvature in the upper gastric body with normal air insufflation was difficult in 113 (5.7%) cases. Applying cricoid pressure was effective in 93 (82.3%) patients with poor gastric wall extension. Sufficient gastric wall extension was achieved within an average of 12.8 s in cases where cricoid pressure application was effective. No adverse events were associated with cricoid pressure application.

CONCLUSIONS

Cricoid pressure application for patients with poor gastric wall extension during EGD is useful for ensuring a sufficient field of view during observation of the gastric body.

A noninferiority trial comparing left paratracheal pressure versus cricoid pressure on tracheal intubation conditions using the Pentax Airway Scope

There are no studies evaluating the effect of left paratracheal pressure (PP) on difficulty of intubation using Pentax Airway Scope (Pentax), so we conducted this study to show that PP was not inferior to cricoid pressure (CP) in intubation time using the Pentax. Patients aged 19-70 years, with an American Society of Anesthesiologists physical status 1 or 2, and undergoing otorhinolaryngological, gynecological surgery, and cholecystectomy at a single university hospital were enrolled. Intubation was performed using the Pentax under PP or CP of 30 N. The primary outcome was intubation time, and the secondary outcomes were tube advancement difficulty and glottis view. The mean difference in intubation time (PP group - CP group) was - 4.19 s (95% CI - 8.24 to - 0.15), which was within the non-inferiority margin of 6.5 s, thus proving non-inferiority of the PP compared with the CP group. However, the score for tube advancement difficulty was significantly lower in the PP group than in the CP group (p = 0.02). PP did not prolong the intubation time and showed comparable intubation conditions to CP in intubation using the Pentax. Therefore, PP may be a good alternative maneuver to prevent gastric regurgitation during intubation using the Pentax.

Effect of Paratracheal Pressure on the Glottic View During Direct Laryngoscopy: A Randomized Double-Blind, Noninferiority Trial

BACKGROUND

Cricoid pressure has been used as a component of the rapid sequence induction and intubation technique. However, concerns have been raised regarding the effectiveness and safety of cricoid pressure. Paratracheal pressure, a potential alternative to cricoid pressure to prevent regurgitation of gastric contents or aspiration, has been studied to be more effective to cricoid pressure in preventing gastric insufflation during positive pressure ventilation. However, to adopt paratracheal compression into our practice, adverse effects including its effect on the glottic view during direct laryngoscopy should be studied. We conducted a randomized, double-blind, noninferiority trial comparing paratracheal and cricoid pressures for any adverse effects on the view during direct laryngoscopy, together with other secondary outcome measures.

METHODS

In total, 140 adult patients undergoing general anesthesia randomly received paratracheal pressure (paratracheal group) or cricoid pressure (cricoid group) during anesthesia induction. The primary end point was the incidence of deteriorated laryngoscopic view, evaluated by modified Cormack-Lehane grade with a predefined noninferiority margin of 15%. Secondary end points included percentage of glottic opening score, ease of mask ventilation, change in ventilation volume and peak inspiratory pressure during mechanical mask ventilation, ease of tracheal intubation, and resistance encountered while advancing the tube into the glottis. The position of the esophagus was assessed by ultrasound in both groups to determine whether pressure applied to the respective area would be likely to result in esophageal compression. All secondary outcomes were tested for superiority, except percentage of glottic opening score, which was tested for noninferiority.

RESULTS

Paratracheal pressure was noninferior to cricoid pressure regarding the incidence of deterioration of modified Cormack-Lehane grade (0% vs 2.9%; absolute risk difference, -2.9%; 95% confidence interval, -9.9 to 2.6, P <.0001). Mask ventilation, measured on an ordinal scale, was found to be easier (ie, more likely to have a lower score) with paratracheal pressure than with cricoid pressure (OR, 0.41; 95% confidence interval, 0.21-0.79; P = .008). The increase in peak inspiratory pressure was significantly less in the paratracheal group than in the cricoid group during mechanical mask ventilation (median [min, max], 0 [-1, 1] vs 0 [-1, 23]; P = .001). The differences in other secondary outcomes were nonsignificant between the groups. The anatomical position of the esophagus was more suitable for compression in the paratracheal region, compared to the cricoid cartilage region.

CONCLUSIONS

Paratracheal pressure was noninferior to cricoid pressure with respect to the effect on glottic view during direct laryngoscopy.

A survey of self-reported use of cricoid pressure amongst Australian and New Zealand anaesthetists: Attitudes and practice

We conducted a survey of Australian and New Zealand anaesthetists designed to quantify self-reported use of cricoid pressure (CP) in patients presumed to be at risk of gastric regurgitation, and to ascertain the underlying justifications used to support individual practice. We aimed to identify the perceived benefits and harms associated with the use of CP and to explore the potential impact of medicolegal concerns on clinical decision-making. We also sought to ascertain the views of Australian and New Zealand anaesthetists on whether recommendations relating to CP should be included in airway management guidelines. We designed an electronic survey comprised of 15 questions that was emailed to 981 randomly selected Fellows of the Australian and New Zealand College of Anaesthetists (ANZCA) by the ANZCA Clinical Trials Network on behalf of the investigators. We received responses from 348 invitees (response rate 35.5%). Of the 348 respondents, 267 (76.9%) indicated that they would routinely use CP for patients determined to be at increased risk of gastric regurgitation. When asked whether participants believed the use of CP reduces the risk of gastric regurgitation, 39.8% indicated yes, 23.8% believed no and 36.3% were unsure. Of the respondents who indicated that they routinely performed CP, 159/267 (60%) indicated that concerns over the potential medicolegal consequences of omitting CP in a patient who subsequently aspirates was one of the main reasons for using CP. The majority (224/337; 66%) of respondents believed that recommendations about the use of CP in airway management guidelines should include individual practitioner judgement, while only 55/337 (16%) respondents believed that routine CP should be advocated in contemporary emergency airway management guidelines.

The Knowledge of Health Professionals About the Application of Cricoid Pressure in a Low-Income Country: A Single-Center Survey Study

BACKGROUND

The application of cricoid pressure requires good knowledge and practice of health professionals who are working in operation theatres to prevent pulmonary aspiration. This study aims to assess the application of cricoid pressure knowledge and practice in health professionals who are working in the operation theatres.

METHODS

This survey-based study was conducted in health care professionals who are working in the operation theatre of Debre Tabor Comprehensive Specialized Hospital from November 1 to December 1, 2020. A structured checklist was used to collect data regarding the knowledge and practice of the application of cricoid pressure.

RESULTS

A total of 43 health professionals who are working in the operation theaters were involved in this study with a response rate of 81%. The correct anatomic position of cricoid cartilage was not identified in 67% of nurses. We found that 78% of anesthetists did not use the nasogastric tube for decompression, and 83% of them complain of difficult intubation during the application of cricoid pressure.

CONCLUSION

Health care professionals who are working in operation theatres had poor knowledge and practice in the application of cricoid pressure.

Maternal cardiac arrest

PURPOSE OF REVIEW

The review is intended to serve as a practical clinical aid for the clinician called to maternal cardiac arrest.

RECENT FINDINGS

Anesthesia complications comprise an important cause of maternal cardiac arrest in developed countries Also predominant are hemorrhage and infections. Recent in-depth reports highlight fractionated care for pregnant women with cardiac and also probably neurological comorbidities. Pathology reports reveal a prevalence of thromboembolic phenomena that is higher than previously assumed but still rare. These are accompanied by particularly high mortality rates. The presenting rhythms of cardiac arrest which differ from most cardiac arrest populations, suggest the need for further in-depth investigation of both the causes and management of these cases. Despite these, outcomes are far better than those of most arrests. Key differences in treatment include are consideration of early airway management and possible medication complications. Pulseless electrical activity and VF should always alert to the possibility of hemorrhage. Echocardiography can diagnose thromboembolism. Also different are the need for Left uterine displacement and early delivery within after 4-5 min of initiation of resuscitation effort in cases with suspected compromise of the venous return or a poor likelihood of a good maternal outcome.

SUMMARY

Maternal cardiac arrest should be managed similarly to other adult cardiac arrests. At the same time its unique reversible causes require a different form of thought regarding diagnosis and treatment during the code.

Pressure measurement in the upper esophagus during cricoid pressure: A high-resolution solid-state manometry study

BACKGROUND

The use of cricoid pressure is controversial, and its ability to occlude the esophagus has been questioned. In this study, high-resolution solid-state manometry was used to analyze pressure changes in the upper esophagus from cricoid pressure during modified rapid sequence induction. This is a secondary analysis of data from a previous study.

METHODS

Seventeen healthy volunteers participated in a double-blind, randomized, placebo-controlled, cross-over study with primary aim to compare differences in the barrier pressure on the lower esophageal sphincter during rapid sequence induction with or without alfentanil. Standardized cricoid pressure of 30 N was applied 2 minutes after propolipid injection and held for 15 seconds and pressures in the esophagus were measured.

RESULTS

Cricoid pressure resulted in a pressure increase of 127 ± 98 mmHg (95% CI: 73-182) (placebo) and 123 ± 74 mmHg (95% CI: 84-162) (alfentanil) at the level of the upper esophageal sphincter (UES), compared to baseline. The pressure difference around the UES compared to the proximal esophagus during cricoid pressure application was 165 ± 100 mmHg (placebo) and 159 ± 87 mmHg (alfentanil) (mean ± 1 SD).

CONCLUSION

This study using high-resolution solid-state manometry under clinically relevant conditions shows that 30 N cricoid pressure generates high pressure in the area of the UES, far exceeding the levels previously considered necessary to prevent regurgitation. Additional studies are needed to clarify the effectiveness of cricoid pressure in preventing passive regurgitation before it is rejected as a part of rapid sequence induction.

Cardiac arrest in pregnancy

Cardiac arrest in pregnancy is a rare and frightening event. Although not every obstetrician will encounter cardiac arrest in pregnancy during their career, it is imperative to be prepared to manage this acute emergency. The management is particularly complex due to maternal physiologic changes from pregnancy and the simultaneous management of two patients, the mother and fetus. In 2010, the American Heart Association released their first scientific statement on guidelines for management of cardiac arrest in pregnancy that has since been updated in 2015. All providers who care for pregnant patients should be aware of these guidelines and ready to manage cardiac arrest in pregnancy because correct and timely interventions can affect real world outcomes.

Cricoid Pressure Controversies

Since cricoid pressure was introduced into clinical practice, controversial issues have arisen, including necessity, effectiveness in preventing aspiration, quantifying the cricoid force, and its reliability in certain clinical entities and in the presence of gastric tubes. Cricoid pressure–associated complications have also been alleged, such as airway obstruction leading to interference with manual ventilation, laryngeal visualization, tracheal intubation, placement of supraglottic devices, and relaxation of the lower esophageal sphincter. This review synthesizes available information to identify, address, and attempt to resolve the controversies related to cricoid pressure. The effective use of cricoid pressure requires that the applied force is sufficient to occlude the esophageal entrance while avoiding airway-related complications. Most of these complications are caused by excessive or inadequate force or by misapplication of cricoid pressure. Because a simple-to-use and reliable cricoid pressure device is not commercially available, regular training of personnel, using technology-enhanced cricoid pressure simulation, is required. The current status of cricoid pressure and objectives for future cricoid pressure–related research are also discussed.

Acute Intraoperative Pulmonary Aspiration

Acute intraoperative aspiration is a potentially fatal complication with significant associated morbidity. Patients undergoing thoracic surgery are at increased risk for anesthesia-related aspiration, largely due to the predisposing conditions associated with this complication. Awareness of the risk factors, predisposing conditions, maneuvers to decrease risk, and immediate management options by the thoracic surgeon and the anesthesia team is imperative to reducing risk and optimizing patient outcomes associated with acute intraoperative pulmonary aspiration. Based on the root-cause analyses that many of the aspiration events can be traced back to provider factors, having an experienced anesthesiologist present for high-risk cases is also critical.

The use of cricoid pressure during rapid sequence induction in trauma patients – UK and European practice compared

Introduction

There is ongoing debate and conflicting evidence surrounding the place of cricoid pressure (CP) as part of a rapid sequence induction (RSI) of anaesthesia. This study investigated the current use of CP during trauma RSI and compared reported practice in the UK with the rest of Europe.

Methods

An anonymised, web-based survey was sent to all clinicians registered as European Trauma Course instructors.

Results

CP use was reported by 83.1% of UK respondents and 39.4% from the rest of Europe, with an overall reported use of 49.8%. Anaesthetists use CP less commonly (35.6%) than clinicians from other specialties (63.6%). The most common reason given for not using CP (76.7%) was a perceived lack of evidence of effectiveness.

Conclusion

Generally the use of CP appears to be in decline with only half of all clinicians reporting to use it; however it remains much more commonly used in the UK than the rest of Europe.

Cardiac Arrest in Pregnancy

This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.

Rapid-sequence intubation and cricoid pressure

Airway management is the most important clinical skill for anesthesiologist, emergency physician, and other providers who are involved in oxygenation and ventilation of the lungs. Rapid-sequence intubation is the preferred method to secure airway in patients who are at risk for aspiration because it results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis). Application of cricoid pressure (CP) for patients undergoing rapid-sequence intubation is controversial. Multiple specialty societies have recommended that CP is not effective in preventing aspiration; rather it may worsen laryngoscopic view and impair bag-valve mask ventilation. Some experts think that CP should be applied in trauma and patients at risk for aspiration; however CP, if necessary, should be altered or removed to facilitate intubation.

Maternal cardiac arrest: a practical and comprehensive review

Cardiac arrest during pregnancy is a dedicated chapter in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care; however, a robust maternal cardiac arrest knowledge translation strategy and emergency response plan is not usually the focus of institutional emergency preparedness programs. Although maternal cardiac arrest is rare, the emergency department is a high-risk area for receiving pregnant women in either prearrest or full cardiac arrest. It is imperative that institutions review and update emergency response plans for a maternal arrest. This review highlights the most recent science, guidelines, and recommended implementation strategies related to a maternal arrest. The aim of this paper is to increase the understanding of the important physiological differences of, and management strategies for, a maternal cardiac arrest, as well as provide institutions with the most up-to-date literature on which they can build emergency preparedness programs for a maternal arrest.

The duration of fibre-optic intubation is increased by cricoid pressure. A randomised double-blind study

BACKGROUND

In some categories of patients, a rapid sequence induction using a fibre-optic method may be indicated. The aim of the present study was to examine the effect of cricoid pressure (CP) on the duration of fibre-optic intubation. The hypothesis was that CP would prolong the intubation time.

METHODS

The study was a randomised, double-blind, cross-over study. The patients were intubated twice, in a randomised way, using a flexible fibrescope once with and once without CP. The intubation time and the visualisation of the glottis were registered. If the intubation was not completed within 180 s, it was registered as failed. CP was standardised to a pressure of 30 N. The data are given as the mean (standard deviation) or median [interquartile] (range).

RESULTS

Fifty patients were included, with a mean age of 53 years (14.6) and mean body mass index of 26.4 (4.3). Three intubations without and 13 intubations with CP failed. The durations of intubation without and with CP were 59 s [53-79 s] (34-144 s) and 75 s [67-104 s] (43-179 s), respectively (P < 0.001).

CONCLUSION

The study showed that CP prolongs the duration of fibre-optic intubation in patients with Mallampati grades 1-2.