In Response.

Abstract

We are indebted to Dr Khorasani et al1 for their comments on our manuscript, “The clinical use of cricoid pressure: first, do no harm.”2 It is a pleasure to correspond with clinicians (M.R.S.) who have worked directly with Dr Sellick. While the authors are correct in the “British” naming of digits, our main point was that clinicians apply cricoid pressure (CP) in a variety of (nonstandardized) ways; for instance, one of the authors (S.J.B.) was taught that appropriate application of CP during rapid induction and intubation sequence in obstetrics, obese patients, and those with a barrel chest included application of pressure using index finger (second digit) and middle finger (third digit) while the rest of the hand rested flat on the patient’s upper chest. This was done to allow more space for maneuvering the “stubby” (short) laryngoscope handle into optimal position for laryngoscopy and tracheal intubation. In nonobstetric (or nonobese) patients, CP was taught to be applied using thumb-index pressure. The overarching theme in our article2 was, and still is, that the technique of application of CP is highly variable in clinical practice and may affect its effectiveness. We also wholeheartedly agree that measurement of the CP force is important and preferred to estimation; this can best be accomplished using reliable devices, particularly because the target pressure on the cricoid ring is counteracted by laryngoscopy. We thank the authors for recommending the discussion of additional issues, such as the insertion of a gastric tube (GT), which also is not standardized in routine clinical practice. Management of GTs in patients at risk of pulmonary aspiration was superbly summarized previously by Dr Salem and colleagues1: “the GT should not be withdrawn and should be connected to suction during induction.” We cannot agree that “Patient positioning during CP is no longer a matter of dispute.”1 A recent international survey of over 10,000 anesthesiologists and airway experts revealed a high variability in patient positioning during rapid sequence induction.3 Both head-down and horizontal-supine positions are used frequently in clinical practice, likely due to the lack of high-quality evidence favoring a specific position. Because pulmonary aspiration still occurs in the head-up position despite the use of CP, proponents of the head-down positioning argue that any regurgitated material would flow out through the mouth and/or the patient’s nose rather than down the trachea. A recent manikin study found that the head-down tilt reduced the amount of aspirated fluid.4 We attempted to report a balanced review,2 and distanced ourselves from any beliefs or personal preferences; we emphasized key elements in future research, and the need for a universally accepted definition of pulmonary aspiration. Moreover, we pointed out the variability in practice across countries and continents. Indeed, it appears that the recent call for guidelines summarizing the “range of acceptable practices”3 should be seriously considered. We hope these (and other) discussions will generate renewed interest in the ubiquitous CP maneuver that was always intended to protect our patients from harm. Marko Zdravkovic, MDDepartment of Anaesthesiology, Intensive Care and Pain ManagementUniversity Medical Centre MariborMaribor, SloveniaFaculty of MedicineUniversity of MariborMaribor, Slovenia Mark J. Rice, MDDepartment of AnesthesiologyVanderbilt University Medical CenterNashville, Tennessee Sorin J. Brull, MD, FCARCSI (Hon)Department of Anesthesiology and Perioperative MedicineMayo Clinic College of Medicine and ScienceJacksonville, Florida[email protected]