African study on cricoid pressure

The inventor of cricoid pressure. Possibly.

A colleague told me about a cricoid pressure paper I would otherwise have missed, since I don’t normally check out the International Journal of Obstetric Anaesthesia. This was a multicentre observational study in Malawi, in which 30 women (of 4891 general anaesthetics) vomited or regurgitated during induction of anaesthesia, in 24 of whom cricoid pressure was applied. 11 of the 77 deaths that occurred were associated with regurgitation, in 10 of which regurgitation contributed to the death. Nine of these 11 mothers who died had had cricoid pressure applied. The incidence of regurgitation was lower, but not significantly so, among those who did not have cricoid pressure applied. Not sure why it took nine years to publish this work.
 

BACKGROUND: Cricoid pressure is a routine part of rapid-sequence induction of general anaesthesia in obstetrics, but its efficacy in saving life is difficult to ascertain.
METHODS: As part of a prospective observational study of caesarean sections performed between January 1998 and June 2000 in 27 hospitals in Malawi, the anaesthetist recorded whether cricoid pressure was applied, the method of anaesthesia, the use of endotracheal intubation, the occurrence and timing of regurgitation and any other pre- or intra-operative complications. Logistic regression was used to assess the effect of cricoid pressure, type of anaesthetic and pre-operative complications on vomiting/regurgitation and death.
RESULTS: Data were collected for 4891 general anaesthetics that involved intubation. Cricoid pressure was applied in 61%; 139 women vomited or regurgitated, but only 30 on induction of anaesthesia, in 24 of whom cricoid pressure was applied. There were 77 deaths, 11 of which were associated with regurgitation, in 10 of which regurgitation contributed to the death. Nine of the 11 mothers had cricoid pressure applied. Only one died on the table, the rest postoperatively. All those who died had preoperative complications.
CONCLUSION: This study does not provide any evidence for a protective effect of cricoid pressure as used in this context, in preventing regurgitation or death. Preoperative gastric emptying may be a more effective measure to prevent aspiration of gastric contents.

Life-saving or ineffective? An observational study of the use of cricoid pressure and maternal outcome in an African setting
Int J Obstet Anesth. 2009 Apr;18(2):106-10

4 thoughts on “African study on cricoid pressure”

  1. thanks for the interesting paper, Cliff!
    Did Levitan put you onto this one?
    Problem with trying to research cricoid pressure is that everyone does it differently because we teach it poorly because we do not understand it very well at all.
    In other words it is a poorly taught and applied technique. no wonder we can;t prove it is an effective technique!
    Therein lies the problem. It is a technique that should work but it doesnt because we do it badly. the editorial to the Fenton paper is interesting as it shows how polarised people can get with this topic.
    tradition is hard to shift

  2. Hi Cliff
    I am at the ANZCA Airway conference right now in Coolum, Sunshine Coast. Today we had a lecture on cricoid pressure by a senior anaesthetist who basically outlined the complete lack of appropriate evidence for efficacy of cricoid pressure.
    I stood up and asked him if we should be encouraging prospective controlled trials on cricoid pressure and he said it would be unethical and he continues to use cricoid pressure because it is standard of care and would be medicolegally indefensible not to. it seems we are going around in circles with this issue..no one prepared to give it up but no one prepared to properly study the technique despite everyone admitting there is not much evidence to support its use.
    talked to the sugammadex rep today…$450 per vial for a box of 10..can’t buy less than one box..ouch!
    Paediatric LMA supreme sizes have come to Australia only last week..you would like this conference Cliff. There was a prehospital German anaesthetist talking about how they use the Bonfils rigid intubating scope on retrievals..its a bit like the Levitan scope only longer!

  3. Since there are RCTs on cricoid pressure going on in the USA and Australia, it’s apparent that ethical review committees / IRBs don’t agree that it would be unethical to study this area of clear equipoise.

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