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The Clinical Use of Cricoid Pressure

First, Do No Harm

Zdravkovic, Marko MD*,†; Rice, Mark J. MD; Brull, Sorin J. MD, FCARCSI (Hon)§

doi: 10.1213/ANE.0000000000004360
Patient Safety: PDF Only
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Application of cricoid pressure (CP) during rapid sequence induction and intubation sequence has been a “standard” of care for many decades, despite limited scientific proof of its efficacy in preventing pulmonary aspiration of gastric contents. While some of the current rapid sequence induction and intubation guidelines recommend its use, other international guidelines do not, and many clinicians argue that there is insufficient evidence to either continue or abandon its use. Recently published articles and accompanying editorials have reignited the debate on the efficacy and safety of CP application and have generated multiple responses that pointed out the various (and significant) limitations of the available evidence. Thus, a critical discussion of available data must be undertaken before making a final clinical decision on such an important patient safety issue. In this review, the authors will take an objective look at the available scientific evidence about the effectiveness and safety of CP in patients at risk of pulmonary aspiration of gastric contents. We suggest that current data are inadequate to impose clinical guidelines on the use of CP because we acknowledge that currently there is not, and there may never be, a method to prevent aspiration in all patients. In addition, we reiterate that a universally accepted medical-legal standard for approaching the high-risk aspiration patient does not exist, discuss the differences in practice between the US and international practitioners regarding use of CP, and propose 5 recommendations on how future studies might be designed to obtain optimal scientific evidence about the effectiveness and safety of CP in patients at risk for pulmonary aspiration.

From the *Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Maribor, Slovenia

Faculty of Medicine, University of Maribor, Maribor, Slovenia

Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee

§Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, Florida.

Accepted for publication June 27, 2019.

Funding: None.

Conflicts of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Sorin J. Brull, MD, FCARCSI (Hon), Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 4500 San Pablo Rd, Jacksonville, FL 32224. Address e-mail to sjbrull@me.com.

© 2019 International Anesthesia Research Society
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