Presentation on theme: "Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), MD., DA., DNB, MD (Acu), Dip. Diab.DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi Medical college."— Presentation transcript:
Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), MD., DA., DNB, MD (Acu), Dip. Diab.DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi Medical college and research institute, puducherry, India
Sellick -- Its all about aspiration Isnt it ??
Incidence : 1 in 3000 Emergency – 1 in 600 More common in ASA IV Solution possible ?? RSI with preoxygenation with sellick manouver Aspiration
Monro In 1774, concerning the recovery of persons “drowned and seemingly dead,” the use of Cricoid pressure by Dr. Monro was referred to as a means of preventing gastric distension during inflation of the lungs. History
In 1961 Dr. Brian Arthur Sellick Cricoid pressure must be exerted by an assistant. Before induction, the cricoid is palpated and lightly held between the thumb and second finger; as anaesthesia begins, pressure is exerted on the cricoid cartilage mainly by the index finger. Sellick in 1961
a conscious patient can tolerate moderate pressure without discomfort but as soon as consciousness is lost, firm pressure can be applied without obstruction of the patient's airway. Pressure is maintained until intubation and inflation of the cuff of the endotracheal tube is complete." In 1961 Dr. Brian Arthur Sellick
The maneuver consisted of “occlusion of the upper esophagus by backward pressure on the cricoid ring against the bodies of cervical vertebrae to prevent gastric contents from reaching the pharynx. Neck extended --- Sellick original
Full cartilage – cricoid
confirmed the value of CP in preventing saline (run into the esophagus from a height of 100 cm H2O) from reaching the pharynx in a patient undergoing gastroesophagectomy emphasized that the lungs can be ventilated by intermittent positive pressure and that CP can prevent inflation of the stomach during positive pressure ventilation Original sellick
Prevent aspiration Full stomach, diabetes, pregnancy, obese Inflate lungs when unable to intubate Indications
The cricoid cartilage should be fixed between digits and then pressed backwards at a force of 30 newtons. How this 30 newtons ?? CP substitutes for the loss of tone in the cricopharyngeus, nature’s normal defense mechanism What is the pressure ??
Nose pain; applying pressure on one’s own nose until pain is felt has been suggested Neck pain; pressure on one’s own cricoid that prevents swallowing 20 N Syringe and plunger Scales – 3 Kg Cricoid yoke; a padded yoke conforming to the external radius of a cricoid cartilage attached to a hand-held strain gauge to assist in applying a measured consistent pressure over the cricoid cartilage. Training
Cricoid pressure trainer; encompasses realistic patient anatomy with realtime feedback on technique. The user is able to view the direction, duration and amount of force applied to the neck of the manikin Skill lab
Cricoid pressure should not be confused with optimal external laryngeal manipulation (OELM) or backward upward right pressure (BURP) on the thyroid cartilage which is used to improve visualisation of the vocal cords when intubating. There is no priority for prevention of aspiration Don’t confuse ?!
Moderate pressure and site-- to be done before induction Increase pressure Immediate loss of consciousness Till cuff inflation Too much pressure earlier ?? When to give ??
the current recommendation is to apply 10 N when a patient is awake, and increase the force to 30 N once the patient loses consciousness What is new ??
Single handed A) B) Double handed A) B) Types
A) Single- handed cricoid pressure: downward pressure with index finger over the cricoid cartilage, thumb and middle finger each side. B) Single - handed cricoid pressure: downward pressure with index and middle finger over cricoid cartilage, the heel of hand over sternum. Single handed
Bimanual cricoid pressure: technique A with another hand behind the neck, preventing flexion during laryngoscopy. Bimanual cricoid pressure (contra-cricoid cuboid): with a pillow (size 27×10×5 cm) behind the hand. Bimanual
The stomach contracts every 20 seconds with pressure increases to as much as 50 cm H2O; It can accommodate up to1500 ml. Fasted patients may have 200 ml of gastric fluid. The lower oesophageal sphincter (LES) is competent to about 30 cm H2O if normal. The difference between LES pressure and gastric pressure is the “barrier pressure ” GER
Cricoid pressure Increases the tone of the upper esophageal sphincter and decreases the tone of the lower esophageal sphincter Probable pharyngeal receptors GER
Conflicting Correct application improves Single handed cricoid pressure improves laryngoscopy Wrong pressure, direction – difficult laryngoscopy Jabalameli et al, turgeon et al CP and laryngoscopy
Oxygenation without aspiration Difficult to intubate LMA Position pressure direction change Sellick and CICV
NG tube Sellick originally advised to remove NG tube before cricoid pressure. But it has been established that NG tube does not impede cricoid pressure No problem in – 1. esophageal compression 2 stomach can be deflated Sellick and nasogastric tube
Trauma to anterior neck Unstable C Spine injury Patient actively vomiting risk of oesophageal rupture Limited number of rescuers POSSIBLE CONTRA-INDICATIONS TO CRICOID PRESSURE
intubation is made difficult Esophageal barrier pressure decrease MAP and HR increase Aspiration Cricoid fracture nausea and vomiting -- Esophageal rupture 4 minutes of application of cricoid pressure at 30 newtons can lead to arm fatigue and subsequent incorrect technique Complications
The application of cricoid pressure in the paediatric population has been shown to prevent insufflation of gas into the stomach during face mask ventilation In pediatrics
the postcricoid hypopharynx moved with the cricoid ring as an anatomic unit. Termed as Cervical esophagus Is it part of the esophagus ?? MRI in 24 volunteers performed with and without CP in sniffing, neutral, and extended head positions