Cricoid pressure (CP), otherwise termed Sellick’s maneuver, is a somewhat controversial technique used in anesthesia during intubation. The technique seeks to mitigate the risk of aspiration, which occurs when patients inhale gastric contents into their lungs (1). By pushing down on the cricoid cartilage, located in the middle and center of the neck, the technique aims to occlude the esophagus, the canal that connects the throat to the stomach, and thereby prevent the regurgitation of gastric contents (2). Although cricoid pressure has been in use in anesthesia since its popularization in the 1960’s, the safety and efficacy of the method have been contested in recent years (2).
The modern-day use of cricoid pressure in anesthesia is most commonly attributed to the British anesthesiologist Dr. Brian Aruthur Sellick. In 1961, he published a seminal paper outlining the technique’s use in preventing aspiration during anesthesia induction, one of the biggest concerns in the field at the time (3). His study involved 26 patients, of whom 23 experienced no regurgitation before, during, or after receiving cricoid pressure (3). The technique quickly gained popularity and became an integral part of rapid sequence induction (RSI). Additionally, it has been used for patients with GERD.
In the operating room, an anesthetic technician with no other assigned duties aside from assisting with intubation is responsible for the application of cricoid pressure. Cricoid pressure involves several aspects that must be performed correctly in order to be effective. First, and most importantly, the assistant must be able to locate the cricoid cartilage that surrounds the trachea (5). A thumb and middle finger are placed on either side, while the index finger is placed directly on top in order to apply the pressure (6). The timing of the application of pressure is crucial, along with making sure the force is neither too soft nor too hard. It is recommended to use around 30 N, which is considered enough force to compress the esophagus (5).
The large body of literature regarding cricoid pressure does not provide definitive data for or against its use in anesthesia. Although CP can prevent aspiration, it remains unclear if it does so reliably. Some research has shown concerns that the use of cricoid pressure risks deviating the esophagus and deforming the cartilage (7). Many of the concerns surrounding the use of CP largely stem from the fact that it is still manually performed by clinicians. As it is a delicate technique, this leaves room for potential human errors that could harm the patient. Some suggest that engineering a biomedical device to perform CP would ease many of the concerns (7).
Cricoid pressure, while historically an important part of the patient safety movement in anesthesia, is a technique that has faced increased scrutiny in recent years. Anesthesiologists must weigh the potential benefits against the risks and remain aware of data-driven guidelines on its use.
References
- Dunn, Debra. “Cricoid Pressure: Contradictory Evidence Regarding a Standard Practice.” AORN Journal 115, no. 5 (April 27, 2022): 423–36. https://doi.org/10.1002/aorn.13666.
- Tessarolo, Ella, Hatem Alkhouri, Nicholas Lelos, Pooria Sarrami, and Sally McCarthy. “Review Article: Effectiveness and Risks of Cricoid Pressure during Rapid Sequence Induction for Endotracheal Intubation in the Emergency Department: A Systematic Review.” Emergency Medicine Australasia 34, no. 4 (May 16, 2022): 484–91. https://doi.org/10.1111/1742-6723.13993.
- Sellick, B.A. “Cricoid Pressure to Control Regurgitation of Stomach Contents during Induction of Anaesthesia.” The Lancet 278, no. 7199 (August 1, 1961): 404–6. https://doi.org/10.1016/s0140-6736(61)92485-0.
- Ramaiah, Ramesh, Joshua C Stewart, and Sanjay Bhananker. “Rapid-Sequence Intubation and Cricoid Pressure.” International Journal of Critical Illness and Injury Science 4, no. 1 (January 1, 2014): 42. https://doi.org/10.4103/2229-5151.128012.
- Owen, H., V. Follows, K. J. Reynolds, G. Burgess, and J. Plummer. “Learning to Apply Effective Cricoid Pressure Using a Part Task Trainer.” Anaesthesia 57, no. 11 (October 22, 2002): 1098–1101. https://doi.org/10.1046/j.1365-2044.2002.02836.x.
- Nickson, Chris. “Cricoid Pressure.” Life in the Fast Lane • LITFL, July 1, 2024. https://litfl.com/cricoid-pressure/.
- Salem, M. Ramez, Arjang Khorasani, Ahed Zeidan, and George J. Crystal. “Cricoid Pressure Controversies.” Anesthesiology126, no. 4 (December 31, 2016): 738–52. https://doi.org/10.1097/aln.0000000000001489.