cricoid pressure: are we really doing it right? nichole m. doyle, md university of kansas som...
TRANSCRIPT
Cricoid Pressure: Are We Really Doing it Right?
Nichole M. Doyle, MD
University of Kansas SOM Wichita
4/14/2011
Cricoid Study Design• 143 Anesthesiolgists, Residents,CRNA’s, OR Staff and RT’s•Pre-didactic questionairre•Simulated RSI/Emergent intubation•Short power point presentation•Allowed to practice on simulator• Returned 2 months later for repeat testing
Questionnaire• Yrs of experience• Formal training• How cricoid pressure was learned• Indications and Contraindications for
CP• When is CP released• How many Newtons should be applied• What is a Newton• Did person feel adequately trained
Results From Questionnaire
• 100% found the didactic training beneficial
• 99% of participants found the simulation beneficial
• 55% of participants learned to apply cricoid pressure from observation or OJT
• 72% had not received formal training
Results from Questionnaire Cont.
• 20% incorrectly believed primary function was to improve visualization
• 7% Knew the proper amount of pressure to apply
• 11% Knew what a Newton was• 67% Felt inadequately trained
Results From Simulation• Correct Location Improved from 45%-
88%• Correct amount of pressure before LOC
improved from 68%-74%• Correct amount of pressure after LOC
improved from 3%-56%• Drop in Pressure during DL decreased
from 100% to 29%• Cricoid pressure released appropriately
increased from 94%-98%
Cricoid Pressure• Pressure applied to cricoid cartilage
with goal of occluding hypopharynx and prevent aspiration
• Still controversial but still a medicolegal standard of care
• Cricoid cartilage is used because it’s the only complete ring
• Often confused with BURP procedure
Technique Using the thumb and index finger on either side of
the cricoid cartilage apply 10 Newtons of pressure directly backwards prior to induction of anesthesia
Increase pressure to 30 Newtons upon loss of consciousness
Maintain pressure until position of endotracheal tube is confirmed by breath sounds and permission is given by intubating personnel
10 Newtons is the force of gravity on an object with a mass of approx 1kg
Therefore approx 2-3lbs for awake pts and approx 7lbs-10lbs for unconscious pts
Indications
• Code/Emergent Intubation• Full Stomach/Recent Meal• Delayed gastric emptying
• Trauma, acute abdomen• Incompetent lower esophageal
sphincter• Hiatal hernia, pregnancy, severe
symptomatic GERD
Contraindications
• Suspected cricotracheal injury• Active vomiting• Unstable cervical spine injuries• Foreign body in upper airway• Tracheotomy
Complications• Cricoid Pressure may….
• Interfere with ventilation• Make passage of ETT difficult• Alter laryngeal visualization
• Esp at pressures > 40 N• In awake pts has promoted vomiting• Esophageal rupture• Decreased lower esophageal sphincter
tone• Cricoid Cartilage fracture
BURP Procedure• BURP (Backward, upward, rightward,
procedure)• Is done with the objective of improving
view of intubator during direct laryngoscopy
• Pressure applied to thyroid cartilage• Much less pressure than what is
applied during application of cricoid pressure
Final Points• Pressure amounts given are for adults• Release cricoid pressure if it interferes with
ventilation or visualization• Maintain constant pressure after LOC occurs
until ETT position confirmed• BURP and cricoid pressure are different
maneuvers with different goals• Training improves location and amount of
pressure applied• Participants felt more comfortable applying
CP after teaching
THANK YOU
Questions?
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