Time to change thinking on ‘cricoid pressure’

April 22, 2014 by  
Filed under All Updates

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.

Cliff

Comments

13 Responses to “Time to change thinking on ‘cricoid pressure’”

  1. Minh Le Cong on April 22nd, 2014 05:29

    thankyou Cliff. I dont think anyone should be sued for choosing not to use cricoid pressure. in a perfect world I dont think anyone should be sued full stop.

    In our world it does happen and I agree we need to change things

    so lets work on changing the guidelines, setting new standards, doing more education and research.

    yours in good faith always

    Minh

  2. Hon Liang on April 22nd, 2014 09:43

    Dear Cliff,

    I am writing in support of your opinion with regards to cricoid pressure. As an anaesthetist, I have yet to be convinced of its utility: it hampers some intubations and fail to prevent regurgitation in others. The argument that it is standard of care cannot be supported. It might work in selected cases with patients in the correct position, with correct anatomy and correct application of pressure but these are far and few between.

    As an intensivist called to the wards for emergency difficult airways on numerous occasions, I have secured airways simply by asking the helpful and enthusiastic assistant to ease up on their applied cricoid pressure. I believe those patients experienced more harm than benefit of cricoid pressure. I find the avoidance of over zealous BVM ventilation by junior staff to be far more important in preventing regurgitation.

    Dogma gets to live another day unfortunately. Perhaps your eminence and sphere of influence have gone against you this time! I would love that you kept the page up on your blog. Maybe re-worded but with the same information. At least, dogma won’t have complete victory.

    Cheers,
    HL

  3. Chris Cresswell on April 22nd, 2014 13:55

    It’s a shame the original post was deleted.
    It was witty and clever.
    It is sad that others didn’t see it that way.
    There’s a future medical market: sense of humour transplants.
    Keep up the good work Cliff
    Illegitimis non carborundum

  4. John Mackenzie on April 24th, 2014 08:30

    Sorry I missed the original post Cliff, apologies of this has been mentioned. Interesting that in a number of algorithms we have “remove cricoid pressure” when things start to go wrong. We remove to improve position and view .
    Yet the rest of the algorithm and checklist is driving to best position, preparation,equipment at the outset.
    Do the strong proponents of CP feel its still good to have something up your sleeve.

  5. Ed Valentine on April 24th, 2014 20:00

    Hi Cliff,

    Totally agree with your views on cricoid pressure during RSI and it’s something that I long ago abandoned performing.

    On many occasions I’ve watched people struggle to intubate whilst cricoid is being applied and all the problems immediately resolve once cricoid is removed (even when cricoid pressure is being applied by someone ‘experienced’).

    In the pre-hospital setting and Resus, I think it’s even more likely that cricoid will be incorrectly applied – adrenaline levels are high and performance often gets impaired.

    Have to say I didn’t find your initial posting offensive at all – especially when taken in the way it was intended!

    All the best – keep lysing the dogma!!

    Ed

  6. Alessandro on April 25th, 2014 10:22

    Hi Cliff

    I’m an Intensive Care Paramedic with NSW Ambulance. I came across to your blog and I can’t stop reading and listening to the great articles and podcasts you created.I just want to acknowledge how much of an inspiration you are for other clinicians and thank you for being so much passionate about teaching others. You are doing such a fantastic job, we are very lucky to have people like you in our organisation.

    Kind regards
    Alessandro

  7. Cliff on April 25th, 2014 16:28

    Wow that’s very kind of you to say Alessandro. I’m really glad I can help.

  8. Tim Leeuwenburg on April 26th, 2014 12:18

    Cliff (and other FOAMites) – I am putting finishing touches to a summary article seeking consensus position on RSI in the critical patient, acknowledging not just CP but other inconsistencies and lack of standardisation in how RSI is performed.

    Input welcome from the FOAMed community. Await the email…

  9. Tim on April 29th, 2014 05:20

    Dear Cliff,

    when some people get upset because of questioning medical dogmas for good reasons… that’s actually a good sign! We run a little website here in the west of Ireland (bijc.org) and have posted some backup for you. Change won’t happen if you don’t challenge things… so keep going!

    Best regards from the green island, Tim

  10. Cliff on May 2nd, 2014 20:15

    Thank you Tim. I enjoyed your post and agree with the balanced summary of the issues. It can be found here

  11. Cliff on May 2nd, 2014 20:18

    Thanks Tim
    I’m still in hospital in the UK recovering from an acute illness. Not caught up on email yet but I know John Hinds had proposed a similar approach, ie. publishing a consensus review of RSI & CP as applied to critical care outside the OR
    Cliff

  12. Nicholas Aujalay on May 2nd, 2014 23:20

    Hey
    I guess I have missed out on the debate here, have not used cricoid pressure over the last 10 years for either kids or adults, but this is the way I was thought in residency and by Rich Levitan etc. So one more vote against cricoid pressure from me!
    Cheers
    Nicholas

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