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Cricoid Pressure Provides Incomplete Esophageal Occlusion Associated with Lateral Deviation: A Magnetic Resonance Imaging Study

      Abstract

      Background

      Cricoid pressure is a routine component of rapid sequence induction and is designed to reduce the risk of reflux and its associated morbidity. Recent studies have raised questions regarding the efficacy of cricoid pressure in terms of changes in the pharyngeal and esophageal anatomy.

      Objective

      This current descriptive study was designed to observe the anatomical effect of cricoid pressure on the occlusion of esophageal lumen in conscious volunteers using magnetic resonance imaging (MRI).

      Methods

      We quantitatively assessed esophageal patency before and during application of cricoid pressure in 20 awake volunteers utilizing MRI.

      Results

      Target cricoid pressure was achieved in 16 of 20 individuals, corresponding to a mean percentage reduction in cricovertebral distance of 43% (range 25–80%). Cricoid pressure was applied incorrectly in 4 (20%) individuals as evidenced by no change in the cricovertebral distance. Incomplete esophageal occlusion was seen in 10 of 16, or 62.5% (95% confidence interval 35–85%) of individuals when appropriate cricoid pressure was applied. Incomplete esophageal occlusion was always associated with a lateral deviation of the esophagus. None of the 6 subjects with complete occlusion had esophageal deviation during the appropriate application of cricoid pressure.

      Conclusion

      Effective application of cricoid pressure by an experienced operator frequently resulted in lateral deviation of the esophagus and incomplete occlusion of esophageal lumen. Reliance on cricoid pressure for esophageal occlusion requires further evaluation utilizing functional studies.

      Keywords

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      References

        • Auroy Y.
        • Benhamou D.
        • Pequignot F.
        • Jougla E.
        • Lienhart A.
        Survey of anaesthesia-related mortality in France: the role of aspiration of gastric contents.
        Ann Fr Anesth Reanim. 2009; 28: 200-205
        • Ufberg J.W.
        • Bushra J.S.
        • Karras D.J.
        • Satz W.A.
        • Kueppers F.
        Aspiration of gastric contents: association with prehospital intubation.
        Am J Emerg Med. 2005; 23: 379-382
        • Mort T.C.
        Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts.
        Anesth Analg. 2004; 99: 607-613
        • Thibodeau L.G.
        • Verdile V.P.
        • Bartfield J.M.
        Incidence of aspiration after urgent intubation.
        Am J Emerg Med. 1997; 15: 562-565
        • Sellick B.A.
        Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia.
        Lancet. 1961; 2: 404-406
        • Dutton R.P.
        • McCunn M.
        Anesthesia for trauma.
        in: Miller R.D. Miller’s anesthesia. Churchill Livingstone/Elsevier, Philadelphia2005: 2451-2495
        • Marx J.A.
        • Hockberger R.S.
        • Walls R.M.
        • Adams J.
        • Rosen P.
        In: Airway. Rosen’s emergency medicine: concepts and clinical practice.
        Mosby/Elsevier, Philadelphia2006 (2–26)
        • Smith K.J.
        • Dobranowski J.
        • Yip G.
        • Dauphin A.
        • Choi P.T.
        Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging.
        Anesthesiology. 2003; 99: 60-64
        • Smith C.E.
        • Boyer D.
        Cricoid pressure decreases ease of tracheal intubation using fibreoptic laryngoscopy (WuScope System).
        Can J Anaesth. 2002; 49: 614-619
        • Ellis D.Y.
        • Harris T.
        • Zideman D.
        Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis.
        Ann Emerg Med. 2007; 50: 653-665
        • Rice M.J.
        • Mancuso A.A.
        • Gibbs C.
        • Morey T.E.
        • Gravenstein N.
        • Deitte L.A.
        Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant.
        Anesth Analg. 2009; 109: 1546-1552
        • Ovassapian A.
        • Salem M.R.
        Sellick’s maneuver: to do or not do.
        Anesth Analg. 2009; 109: 1360-1362
        • Lerman J.
        On cricoid pressure: "may the force be with you.
        Anesth Analg. 2009; 109: 1363-1366
        • Neilipovitz D.T.
        • Crosby E.T.
        No evidence for decreased incidence of aspiration after rapid sequence induction.
        Can J Anaesth. 2007; 54: 748-764
        • Garrard A.
        • Campbell A.E.
        • Turley A.
        • Hall J.E.
        The effect of mechanically-induced cricoid force on lower oesophageal sphincter pressure in anaesthetised patients.
        Anaesthesia. 2004; 59: 435-439