Episode 4: Aspiration, RSI, and Cricoid Pressure Controversies

airway management Oct 01, 2019

Episode Summary

In this episode of the APEX Live Anesthesia Podcast we talk about the effort that goes into identifying and preventing aspiration and the controversies that surround RSI and cricoid pressure. We take a look at past research and opinions that have shaped the way we manage the prevention of aspiration, and what current research and opinion tells us now.


What You'll Learn

  • What is the history of aspiration prophylaxis?
  • What are risk factors for aspiration?
  • What does current evidence and opinion say about the administration of prophylactic medication for aspiration?
  • Should ventilation be performed during rapid sequence induction?
    Is cricoid pressure really effective?


Supplemental Materials


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Recommended Resources

  1. Driver BE et al. Drug Order in Rapid Sequence Intubation. Acad Emerg Med. 2019 Mar 4. doi: 10.1111/acem.13723.
  2. Masashi O, et al. The effectiveness of rapid sequence intubation (RSI) versus non-RSI in emergency department: an analysis of multicenter prospective observational study. Int J Emerg Med. 2017; 10:1.
  3. Nagelhout JJ. AANA journal course. Update for nurse anesthetists. Aspiration prophylaxis: is it time for changes in our practice? AANA J. 2003 Aug;71(4):299-303.
  4. Algie CM et al. Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation (Review). Cochrane Database Syst Rev. 2015 Nov 18;(11):CD011656.
  5. Boet S. et al. Cricoid pressure provides incomplete esophageal occlusion associated with lateral deviation: a magnetic resonance imaging study. J Emerg Med. 2012; 42: 606-11.
  6. Ehrenfeld, JM, et al. Modified RSI and Intubation: A survey of United States Current Practice. Anesth Analg. 2012 Jul; 115(1): 95-101.
  7. Schlesinger, S, Blanchfield, D. Modified rapid sequence induction of anesthesia: A survey of current clinical practice. AANA J. 2001; 69(4): 291-298. 
  8. Sajayan, A, et al. Current practice of rapid sequence induction of anaesthesia in the UK - a national survey. Br J Anaesth. 2016 Sept; suppl 1: 169-174.
  9. Zeidan, AM, et al. The effectiveness of cricoid pressure for occluding the esophageal entrance in anesthetized and paralyzed patients: An experimental and observational glidescope study. Anesth Analg 2014; 118:580–6. 
  10. Rice, MJ, et al. Cricoid pressure results in compression of the postcricoid hypopharynx: The esophageal position is irrelevant. Anesth Analg. 2009; 109: 1546-52.
  11. Kei J . et al. Using ultrasonography to assess the effectiveness of cricoid pressure on esophageal compression. J Emerg Med. 2017; 53: 236-40. 
  12. Trethewy CE, et al. Ideal cricoid pressure is biomechanically impossible during laryngoscopy. Acad Emerg Med. 2018 Jan;25(1):94-98.
  13. Lee D, et al. A multicenter prospective cohort study of the accuracy of conventional landmark technique for cricoid localization using ultrasound scanning. Anaesthesia. 2018: Oct;73(10):1229-1234.
  14. Salem MR, et al. Which Is the Original and Which Is the Modified Rapid Sequence Induction and Intubation? Let History Be the Judge! Anesth Analg. 2013: an;116(1):264-5.
  15. Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecol. 1946;52:191–205.
  16. Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of Anesthesia. Lancet. 1961;2:404–6.
  17. Stept WJ, & Safar P. Rapid induction-intubation for prevention of gastric-content aspiration. Anesth & Analg. 1970 Jul-Aug;49(4):633-6.
  18. Roberts RB & Shirley MA. Reducing the risk of acid aspiration during cesarean section. Anesth & Analg. 1974 Nov-Dec;53(6):859-68.
  19. Salem MR, et al. Cricoid Pressure Controversies: Narrative Review. Anesthesiology. 2017 Apr;126(4):738-752.
  20. Falyar CR et al. Clinical Application of Point-of-Care Ultrasound Gastric Examination in the Management of an ASA Class 3E Patient: A Case Report. AANA J. 2018 Oct; 86(5):379-82.
  21. Schuller PJ et al. Response to bispectral index to neuromuscular block in awake volunteers. Brit J Anaesth. 2015 Jul;115 Suppl 1:i95-i103.


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Podcast music by Eino Toivanen, kongano.com


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