Time to change thinking on ‘cricoid pressure’
I don’t like cricoid pressure. Some people do. There is insufficient evidence that it is of any benefit. There is some consistent evidence that it worsens laryngoscopic view.
In my clinical practice of critical care in and out of hospital, I can’t afford to risk delaying the securing of my patients’ airways with a procedure in which in my view the risks of harm outweigh any unproven chance of benefit.
I had erroneously thought after many online ‘debates’ that the critical care community had settled on a compromise – if you want to use it great, just take it off if it’s causing a problem. If you don’t want to use it, then that’s equally fine.
However a Google Plus conversation last week ignited a storm! There was a suggestion that cricoid pressure represented a ‘standard of care’, and that not to use it in a critical care intubation would potentially invite legal proceedings, catalysed by colleagues prepared to testify against those of us who have carefully weighed the balance of evidence and selected what we feel is the best approach for our patients.
I wrote a post to challenge the very thinking that what might be considered a ‘standard of care’ in elective anaesthesia in some guidelines should ever be applied to a critical care airway. I proposed a tongue in cheek change of terminology to emphasis what we know about cricoid pressure in the critically ill: that it can delay intubation, distort and compress the airway, and move rather than compress the oesophagus (although I concede the latter point may be irrelevant in terms of CP’s proposed mechanism).
Some people got upset. I reworded the post and added a big fat disclaimer to avoid any perception of ad hominen attack. I wanted to attack and ridicule the procedure, not its proponents. I still got attacked using some bizarrely offensive comparisons by people you would expect to know better. It got ugly.
The combination of support by some people I hold in very high regard and a currently crazy schedule (I’ve been in the UK for three hours having just travelled from Australia) meant the post stayed up for a while until I could consider the feedback. I still haven’t read it all. But I’ve read enough.
I respect the people I disagree with. I respect absolutely their right to hold different views from my own. But I don’t respect all their views, and I don’t necessarily think people have a right not to be offended by my views. However if the WAY I EXPRESS those views causes UNNECESSARY offence I have to reconsider my message.
The science around cricoid pressure is there in the literature. The arguments that it can acceptably be discarded in critical care are powerful. If we need a new acronym it doesn’t need to be one that can be pronounced and construed in a way different to that which I’d envisaged. As Dr Brent May so insightfully put: ‘You can’t emphasise a syllable on Twitter‘.
I want to thank EVERYONE who provided constructive feedback on and off social media. I apologise unreservedly to anyone offended by the post. It’s gone. The battle against unthinking enforcement of a potentially harmful technique goes on, but the unwitting offence of innocent parties is not an acceptable consequence. I will try to be more intelligent in subsequent debate.