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JAMA Surgery Jan 2019The use of cricoid pressure (Sellick maneuver) during rapid sequence induction (RSI) of anesthesia remains controversial in the absence of a large randomized trial. (Comparative Study)
Comparative Study Randomized Controlled Trial
IMPORTANCE
The use of cricoid pressure (Sellick maneuver) during rapid sequence induction (RSI) of anesthesia remains controversial in the absence of a large randomized trial.
OBJECTIVE
To test the hypothesis that the incidence of pulmonary aspiration is not increased when cricoid pressure is not performed.
DESIGN, SETTING, AND PARTICIPANTS
Randomized, double-blind, noninferiority trial conducted in 10 academic centers. Patients undergoing anesthesia with RSI were enrolled from February 2014 until February 2017 and followed up for 28 days or until hospital discharge (last follow-up, February 8, 2017).
INTERVENTIONS
Patients were assigned to a cricoid pressure (Sellick group) or a sham procedure group.
MAIN OUTCOMES AND MEASURES
Primary end point was the incidence of pulmonary aspiration (at the glottis level during laryngoscopy or by tracheal aspiration after intubation). It was hypothesized that the sham procedure would not be inferior to the cricoid pressure. The secondary end points were related to pulmonary aspiration, difficult tracheal intubation, and traumatic complications owing to the tracheal intubation or cricoid pressure.
RESULTS
Of 3472 patients randomized, mean (SD) age was 51 (19) years and 1777 (51%) were men. The primary end point, pulmonary aspiration, occurred in 10 patients (0.6%) in the Sellick group and in 9 patients (0.5%) in the sham group. The upper limit of the 1-sided 95% CI of relative risk was 2.00, exceeding 1.50, failing to demonstrate noninferiority (P = .14). The risk difference was -0.06% (2-sided 95% CI, -0.57 to 0.42) in the intent-to-treat population and -0.06% (2-sided 95% CI, -0.56 to 0.43) in the per protocol population. Secondary end points were not significantly different among the 2 groups (pneumonia, length of stay, and mortality), although the comparison of the Cormack and Lehane grade (Grades 3 and 4, 10% vs 5%; P <.001) and the longer intubation time (Intubation time >30 seconds, 47% vs 40%; P <.001) suggest an increased difficulty of tracheal intubation in the Sellick group.
CONCLUSIONS AND RELEVANCE
This large randomized clinical trial performed in patients undergoing anesthesia with RSI failed to demonstrate the noninferiority of the sham procedure in preventing pulmonary aspiration. Further studies are required in pregnant women and outside the operating room.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT02080754.
Topics: Anesthesia; Cricoid Cartilage; Double-Blind Method; Female; Humans; Intubation, Intratracheal; Laryngoscopy; Length of Stay; Male; Middle Aged; Operative Time; Pneumonia, Aspiration; Pressure; Treatment Outcome
PubMed: 30347104
DOI: 10.1001/jamasurg.2018.3577 -
Anesthesiology Apr 2017Since cricoid pressure was introduced into clinical practice, controversial issues have arisen, including necessity, effectiveness in preventing aspiration, quantifying... (Review)
Review
Since cricoid pressure was introduced into clinical practice, controversial issues have arisen, including necessity, effectiveness in preventing aspiration, quantifying the cricoid force, and its reliability in certain clinical entities and in the presence of gastric tubes. Cricoid pressure-associated complications have also been alleged, such as airway obstruction leading to interference with manual ventilation, laryngeal visualization, tracheal intubation, placement of supraglottic devices, and relaxation of the lower esophageal sphincter. This review synthesizes available information to identify, address, and attempt to resolve the controversies related to cricoid pressure. The effective use of cricoid pressure requires that the applied force is sufficient to occlude the esophageal entrance while avoiding airway-related complications. Most of these complications are caused by excessive or inadequate force or by misapplication of cricoid pressure. Because a simple-to-use and reliable cricoid pressure device is not commercially available, regular training of personnel, using technology-enhanced cricoid pressure simulation, is required. The current status of cricoid pressure and objectives for future cricoid pressure-related research are also discussed.
Topics: Airway Obstruction; Cricoid Cartilage; Humans; Intubation, Intratracheal; Pneumonia, Aspiration; Pressure; Reproducibility of Results
PubMed: 28045709
DOI: 10.1097/ALN.0000000000001489 -
Emergency Medicine Journal : EMJ Mar 2017Propensity score methodology is being increasingly used to try and make inferences about treatments when randomised trials are either impossible or not conducted and the...
Propensity score methodology is being increasingly used to try and make inferences about treatments when randomised trials are either impossible or not conducted and the only data are from observational studies. This paper reviews the basis of propensity scores and the current state of knowledge about them. It uses and critiques a current paper in the to illustrate the methodology.
Topics: Cricoid Cartilage; Emergency Medicine; Humans; Pressure; Propensity Score; Research Design; Treatment Outcome; Vomiting
PubMed: 28143814
DOI: 10.1136/emermed-2016-206542 -
Multimedia Manual of Cardiothoracic... Dec 2022The treatment of benign subglottic stenoses can be challenging. It requires an experienced multidisciplinary team. It is important to define the aetiology, severity and...
The treatment of benign subglottic stenoses can be challenging. It requires an experienced multidisciplinary team. It is important to define the aetiology, severity and number/types of any pretreatments of the stenosis. Short-term symptom relief can be achieved with endoscopic techniques; however, this relief comes at the price of a high likelihood of restenosis, which often is more severe than the original stenosis. Successful long-term treatment of subglottic stenosis can be achieved by surgical resection in most cases. Cricotracheal resection is the established standard technique to treat subglottic stenosis. In patients with advanced disease, it can be extended by a dorsal mucosectomy, a lateral cricoplasty or a partial anterior laryngeal split in order to remove the entire diseased area. In this video tutorial, we describe a modification of cricotracheal resection. In this technique for an extended resection, the cricoid arch is partially preserved. In addition to restoring sufficient airway width, this modification has the advantage that the cricothyroid joint remains intact. Therefore, the reduction in the pitch and volume of the voice associated with the standard resection techniques is avoided.
Topics: Humans; Constriction, Pathologic; Trachea; Tracheal Stenosis; Laryngostenosis; Cricoid Cartilage; Treatment Outcome
PubMed: 36534064
DOI: 10.1510/mmcts.2022.104 -
Acta Otorhinolaryngologica Italica :... Dec 2022
Review
Topics: Humans; Laryngeal Neoplasms; Cricoid Cartilage; Chondrosarcoma
PubMed: 36654516
DOI: 10.14639/0392-100X-N1912 -
Scandinavian Journal of Trauma,... May 2013An emergency cricothyrotomy is the last-resort in most airway management protocols and is performed when it is not possible to intubate or ventilate a patient. This... (Review)
Review
BACKGROUND
An emergency cricothyrotomy is the last-resort in most airway management protocols and is performed when it is not possible to intubate or ventilate a patient. This situation can rapidly prove fatal, making it important to identify the best method to establish a secure airway. We conducted a systematic review to identify whether there exists superiority between available commercial kits versus traditional surgical and needle techniques.
METHODS
Medline, EMBASE and other databases were searched for pertinent studies. The inclusion criteria included manikin, animal and human studies and there were no restrictions regarding the professional background of the person performing the procedure.
RESULTS
In total, 1,405 unique references were identified; 108 full text articles were retrieved; and 24 studies were included in the review. Studies comparing kits with one another or with various surgical and needle techniques were identified. The outcome measures included in this systematic review were success rate and time consumption. The investigators performing the studies had chosen unique combinations of starting and stopping points for time measurements, making comparisons between studies difficult and leading to many conflicting results. No single method was shown to be better than the others, but the size of the studies makes it impossible to draw firm conclusions.
CONCLUSIONS
The large majority of the studies were too small to demonstrate statistically significant differences, and the limited available evidence was of low or very low quality. That none of the techniques in these studies demonstrated better results than the others does not necessarily indicate that each is equally good, and these conclusions will likely change as new evidence becomes available.
Topics: Airway Management; Animals; Cricoid Cartilage; Emergency Medical Services; Humans; Laryngeal Cartilages; Manikins; Treatment Outcome
PubMed: 23725520
DOI: 10.1186/1757-7241-21-43 -
Cartilage Jul 2019The larynx sometimes requires repair and reconstruction due to cancer resection, trauma, stenosis, or developmental disruptions. Bioengineering has provided some... (Review)
Review
The larynx sometimes requires repair and reconstruction due to cancer resection, trauma, stenosis, or developmental disruptions. Bioengineering has provided some scaffolding materials and initial attempts at tissue engineering, especially of the trachea, have been made. The critical issues of providing protection, maintaining a patent airway, and controlling swallowing and phonation, require that the regenerated laryngotracheal cartilages must have mechanical and material properties that closely mimic native tissue. These properties are determined by the cellular and proteomic characteristics of these tissues. However, little is known of these properties for these specific cartilages. This review considers what is known and what issues need to be addressed.
Topics: Arytenoid Cartilage; Bioengineering; Cartilage; Cricoid Cartilage; Epiglottis; Female; Humans; Larynx; Male; Proteomics; Regenerative Medicine; Thyroid Cartilage; Tissue Engineering; Tissue Scaffolds; Trachea; Young Adult
PubMed: 29322878
DOI: 10.1177/1947603517749921 -
British Journal of Anaesthesia Aug 2014Advanced airway management is one of the most controversial areas of pre-hospital trauma care and is carried out by different providers using different techniques in... (Review)
Review
Advanced airway management is one of the most controversial areas of pre-hospital trauma care and is carried out by different providers using different techniques in different Emergency Medical Services systems. Pre-hospital anaesthesia is the standard of care for trauma patients arriving in the emergency department with airway compromise. A small proportion of severely injured patients who cannot be managed with basic airway management require pre-hospital anaesthesia to avoid death or hypoxic brain injury. The evidence base for advanced airway management is inconsistent, contradictory and rarely reports all key data. There is evidence that poorly performed advanced airway management is harmful and that less-experienced providers have higher intubation failure rates and complication rates. International guidelines carry many common messages about the system requirements for the practice of advanced airway management. Pre-hospital rapid sequence induction (RSI) should be practiced to the same standard as emergency department RSI. Many in-hospital standards such as monitoring, equipment, and provider competence can be achieved. Pre-hospital and emergency in-hospital RSI has been modified from standard RSI techniques to improve patient safety, physiological disturbance, and practicality. Examples include the use of opioids and long-acting neuromuscular blocking agents, ventilation before intubation, and the early release of cricoid pressure to improve laryngoscopic view. Pre-hospital RSI is indicated in a small proportion of trauma patients. Where pre-hospital anaesthesia cannot be carried out to a high standard by competent providers, excellent quality basic airway management should be the mainstay of management.
Topics: Airway Management; Anesthesia; Anesthetics; Cricoid Cartilage; Delivery of Health Care; Emergency Medical Services; Guidelines as Topic; Humans; Wounds and Injuries
PubMed: 25038153
DOI: 10.1093/bja/aeu205 -
International Journal of Pediatric... Sep 2022We reported the free hyoid bone reconstruction of the cricoid cartilage to treat LTS in children. This retrospective case series study included LTS children who... (Review)
Review
We reported the free hyoid bone reconstruction of the cricoid cartilage to treat LTS in children. This retrospective case series study included LTS children who underwent hyoid bone separation and T tube implantation. Thirty-four children were included. Twenty-five children were with good outcomes after free hyoid bone reconstruction of the cricoid cartilage. Specifically, the cure rate was 92.8% for the children with mixed stenosis, followed by 63.6% in children with glottis stenosis and 55.6% in children with subglottic stenosis. Free hyoid bone reconstruction of the cricoid cartilage for the management of LTS is feasible, with good outcomes and few complications.
Topics: Child; Constriction, Pathologic; Cricoid Cartilage; Humans; Hyoid Bone; Laryngostenosis; Neck Injuries; Retrospective Studies; Tracheal Stenosis; Treatment Outcome
PubMed: 35797923
DOI: 10.1016/j.ijporl.2022.111227