“The Effective Application Of Cricoid Pressure” Essay Samples
Breathing is one of the main processes that sustain life. The termination of it, even for a short time, leads to the rapid demise of the body from oxygen deficiency - hypoxia. 'Cricoid pressure is a vital skill that should be performed during resuscitation with bag and mask and emergency tracheal intubation' (Hein, Owen, 2005). The virtuos skills, which are required to ensure the airway, are the integral part of the skills of every anesthesiologist. The anatomy of the upper respiratory tract, equipment and procedures of the airway management, as well as the complications of laryngoscopy, intubation and extubation are shown in this research paper (Walton, Pearce, 2000). The patient’s safety is directly dependent on the understanding of each of these issues. The successful conduct of mask ventilation, Sellick’s maneouvre, tracheal intubation and regional anesthesia of the larynx depends on the detailed knowledge of the anatomy of the respiratory tract, so the subject of the article is urgent and important from a practical point of view (Hein, Owen, 2005). Nevertheless, quite a large number of scientific works suggests that even the correct application of the cricoid pressure can harm the health of the patient. This work is focused on the study and analysis of the effectiveness of the cricoid pressure.
The article was found via the electronic search of Cardiff University online databases. The databases that were used are CINAHL, Ovid Medline, and PubMed. The search limitations were the articles from 2007 to 2014. The keywords which were used are the followings: ‘Sellick’s manoeuvre,’ ‘cricoid,’ ‘cricoid pressure.’
The chosen study is the review, which briefly outlines the history of cricoid pressure, when and why it should be performed, and how it can be taught effectively. The authors deal with the historical aspects of cricoid pressure, the explanation of the cricoid pressure the authors also answer the question how to perform cricoid pressure and note the possible contradictions to cricoid pressure. However, authors fail to stop in details on the ineffective performing of the cricoid pressure and the negative consequences of this manoeuvre in practice.
Additionally, the authors fail to show the statistic data concerning the negative and effective results of the Sellick’s maneouvre, thus, it can not be concluded undoubtedly the considering by the authors of the ethical requirements of the studied issue. The presentation of the findings or results is very important, because the goal of conducting research is to deliver the information to others in order to be understood and applied (Barash, 2009). The main finding of the investigation is that the application of cricoid pressure method stops the gastric regurgitation when reaching the lungs at the time of intubation. If the Sellik manoeuvre is done correctly, it can help to reach the correct location of the tracheal tube (Walton, Pearce, 2000).
The regurgitation of gastric contents is a frequent complication of the endotracheal intubation. This complication is dangerous, firstly because of the significant difficulties for intubation and the risk of suffocation; secondly, if it is managed to avoid asphyxiation, the regurgitation is fraught with the development of aspiration pneumonitis or aspiration pneumonia (Barash, 2009). The most frequent regurgitation and aspiration of gastric contents occurs in the obstetric practice, emergency medicine, and in abdominal interventions (Salem, Sellick, Elam, 1974). For the prevention of regurgitation there are many methods, but none of them do guarantee the absolute success, that is, the risk of this complication is always present (Maltby, Beriault, 2002). The cricoid pressure must be used in all patients with the risk of regurgitation (Maltby, Beriault, 2002).
However, the cricoid pressure, also known by the eponymous name of the Sellick manoeuvre is used by anaesthetists during the direct laryngoscopy in patients with ‘full stomac’ (Maltby, Beriault, 2002). The assistant presses a ring-thyroid cartilage, thereby compressing the input area in the esophagus and prevents the stomach contents into the mouth and trachea (Walton, Pearce, 2000). This maneuver is very simple and effective means of preventing regurgitation and aspiration pneumonitis (Walton, Pearce, 2000). The application of cricoid pressure method stops the gastric regurgitation when reaching the lungs at the time of intubation (Salem, Sellick, Elam, 1974). If the Sellik manoeuvre is done correctly, it can help to reach the correct location of the tracheal tube (Walton, Pearce, 2000). The application of cricoid pressure method is also recommended for ventilation with a mask for the cardiopulmonary resuscitation to reduce the bloating and spit further (Salem, Sellick, Elam, 1974). Many publications report that patients are at risk due to the improper performance of the cricoid pressure by the professional doctors (Clayton, Vanner, 2002). Overly vigorous application of the cricoid pressure method can seriously alter the anatomy of the pharynx and larynx. Thus, the issue of the effectiveness and possible negative consequences of the cricoid pressure method is very relevant and practical for the study (Clayton, Vanner, 2002).
The need for the application of cricoid pressure
In cases where there is a real threat to life, it is necessary to apply the measures aimed at restoring or functioning of the vital systems, or at the complete replacement (temporary or permanent) of the functions of these systems by the artificial means (Barash, 2009). The examples of these activities include the restoration of airway and artificial ventilation; restoration of the heart and circulatory optimization; hemodialysis and other extracorporeal methods of purification (Walton, Pearce, 2000).
Restoration the respiratory tract patency
The cause of impaired patency of the upper respiratory tract, preventing the flow of air into the lungs, it may be the retraction of tongue, mucus, sputum, vomit, blood, swelling, laryngo- and bronchospasm (Maltby, Beriault, 2002). The obstruction can be complete or partial. For the restoration the respiratory tract patency in patients who are unconscious, it is needed to quickly and consistently perform the following manipulation: to put the patient on his back on a hard surface, to tilt the head back, open his mouth and push the lower jaw forward (Koziol, Cuddleford, Moos, 2000). Intubation is a method of temporary artificial mean for the mechanical ventilation during the intensive care (Koziol, Cuddleford, Moos, 2000). Tracheal intubation (irrigation or nasotracheal) blindly or using a laryngoscope is relatively easy to perform with full relaxation of the muscles of the lower jaw and the elimination of laryngeal reflexes (Maltby, Beriault, 2002).
During the applying laryngoscopy and intubation, it is used the ‘classic’ or ‘improved’ position, proposed by Jackson (1913). The difference between them lies in the fact that in the ‘classic’ position the head is sharply straighten, while in the ‘improved’ position the head is raised on the pillow height of 8-10 cm, and therefore, it does not require such expressed its extension (Koziol, Cuddleford, Moos, 2000). Laryngoscopy and tracheal intubation are performed after induction of anesthesia, usually followed by the depolarizing muscle relaxants (listenon, miorelaksin, ditilin). To prevent the vagal reflexes premedication should include atropine (Owen, Follows , Reynolds, Burgess, Plummer, 2002). From the start of induction of anesthesia to the laryngoscopy it should be carried out the oxygen inhalation, and after the administration of muscle relaxant it should be carried the assisted ventilation through a mask using breathing apparatus (Clayton, Vanner, 2002).
Sellick manoeuvre is a temporary compression of the esophagus by cricoid cartilage compression (Maltby, Beriault, 2002). Due to compression of the esophagus it prevents the flow of the contents from the stomach into the throat (Meek, Gittins, Duggan, 1999).
Cricoid is the only one of the cartilage of the trachea, which has a form of the completely closed ring (Smith, Dobranowski, Yip, Dauphin, Choi, 2003). After preoxygenation and performing of the cricoid pressure it should be injected the anesthetic and muscle relaxant, it also should be intubated the trachea; and the cuff should be immediately inflated (Escott, Owen, Strahan Plummer, 2003). To be sure in the correct position of the endotracheal tube, it is needed to check the symmetry of auscultation of breath and to measure the carbon dioxide in the exhaled air (Meek, Gittins, Duggan, 1999). The Sellick manoeuvre could be terminated only after the correct location of the endotracheal tube (Herman, Carter, Van Decar, 1996). Patients who have assumed difficulties with intubation may require intubation of the spontaneous breathing (Smith, Dobranowski, Yip, Dauphin, Choi, 2003). This technique is applicable in the presence of a light guide or fiberoptic bronchoscope intubation. The patient’s comfort is achieved by the use of sedation and local anesthesia (Escott, Owen, Strahan Plummer, 2003).
However, the excessive sedation, as well as an overdose of local anesthetics, may negate the own protective reflexes of the patient (Ovessapian, Salem, 2009). Thus, the maintaining of a certain level of consciousness and the adequate local anesthesia of the respiratory tract above the epiglottis ensures the patient safety during the intubation (Smith, Ladak, Choi, Dobranowski, 2002). Nevertheless, the endotracheal intubation can not guarantee the complete prevention of aspiration. The content may pass inflated or poorly inflated cuff (Australian Resuscitation Council, 2005). Children up to 8 years old are not recommended to be used with the tube with cuff, so getting of the contents of the pharynx to the trachea is an ordinary phenomenon (Smith, Ladak, Choi, Dobranowski, 2002).
The average length of hospitalization is 21 days, and most of that time the patient spends in the ICU (Australian Resuscitation Council, 2005). Often, in patients it is developed the complications from pneumonia and bronchiolitis spasm to ARDS, lung abscess and empyema (Smith, Ladak, Choi, Dobranowski, 2002).
Cricoid pressure is recommended in all cases. As soon as the patient loses consciousness, the sister- anesthesiologist presses the cricoid, squeezing between the trachea and esophagus spine (Smith, Dobranowski, Yip, Dauphin, Choi, 2003). This procedure should not be performed with two fingers, palm edge, etc. If the cricoid pressure is done correctly, the trachea is fixed between the thumb and middle finger, and cricoid pressure is carried by the forefinger (Ovessapian, Salem, 2009). The adequate pressure needs to be 3-4 kg. In practical guidance it is stresses that in order to develop the necessary skills it is needed to train this skill it special mannequin (Escott, Owen, Strahan Plummer, 2003).
A very significant force required to perform this technique in some patients leads to the flexing of head in otlanto-occipital joint (Smith, Dobranowski, Yip, Dauphin, Choi, 2003). This makes it very difficult to perform the laryngoscopy and tracheal intubation. In such cases, the sister by second free hand should support the patient's neck from behind to prevent the bending of it (Haslam, Parker, Duggan, 2005). However, in some cases, difficulties in intubation are saved, and then it is needed to renounce the use of cricoid pressure (Haslam, Parker, Duggan, 2005). The risk of aspiration and regurgitation decreases in the appointment of the appropriate premedication, conducting pre-oxygenation and rapid sequence induction of anesthesia, at refusal of manual the ventilation and at extubation only after the recovery of consciousness (Smith, Dobranowski, Yip, Dauphin, Choi, 2003).
Properly conducted cricoid pressure make it easier the intubating and prevents the ingress of belching and stomach contents into the lungs of the patient (Haslam, Parker, Duggan, 2005). It is recommended to press the cricoid during the mask ventilation during CPR. The control unit with timer continuously informs about the right or wrong hand position and the force of pressure on the cricoid (Smith, Ladak, Choi, Dobranowski, 2002).
Diverticulum of the cervical esophagus can also be difficult for the anesthesiologist and increase the risk of anesthesia (Moynihan, et.al, 1993). With the large diverticulum, it is accumulated the contents (food weight, saliva), which may serve as a source of aspiration (Palmer, Ball, 2000). During the narrowing of the esophagus, its neck area can be expanded; the esophageal wall can be thickened (Ovessapian, Salem, 2009). These changes may cause the fact that by cricoid pressure it is impossible to reliably prevent aspiration: diverticulum or advanced esophagus can not be effectively blocked by pressure on the cartilage of the larynx (Palmer, Ball, 2000).
Aspiration syndrome may occur especially difficult because of the fact that the contents of a diverticulum or extended esophagus has a special consistency (sometimes resembles thick cream) (Moynihan, et.al, 1993). The injection of such mass into the bronchi can not suck or remove through the bronchoscope (Ovessapian, Salem, 2009). Only the active lavage of the bronchi using a special bronchoscope can improve the condition of the respiratory system and eliminate the severe violations of ventilation (Palmer, Ball, 2000).
Taking into account the above mentioned risks and complications, it is recommend the following procedure of the anesthesiologist’s actions. Before the operation it is necessary to assess the location, size and content of the diverticulum (or spread of the esophagus), the anatomical features of the esophagus (Palmer, Ball, 2000). The anesthetist should be present at the X-ray examination and should participate while esophagoscopy (Mac, Palmer, Ball, 2000). Under the control of the screen it should be assessed the feasibility and effectiveness of pressing of the esophagus by the cricoid pressure (Hartsilver, Vanner, 2000).
Before the start of anesthesia it should be prepared the necessary tools for the lavage of the bronchi and other events in the case of aspiration syndrome (Mehrotra, Paust, 1979). Immediately before anesthesia and surgery it is needed to try to empty the diverticulum by the thick gastric probe or via esophagoscopy (Hartsilver, Vanner, 2000). If its fails, and the character and changes diverticulum esophagus can not guarantee the reliable prevention of aspiration syndrome, then the cricoid pressure is recommended under the local anesthesia in the usual method or via fiberoptic as described above (Haslam, Parker, Duggan, 2005).
When diverticula are below the level of the larynx, in the absence of anatomical changes in the structure and location of the esophagus and when it can be expected that the Sellick manoeuvre is able to prevent aspiration, the patient is administered anesthesia in a conventional manner (premedication, the use of high-speed and muscle relaxant anesthetic when performing intubation) (Hartsilver, Vanner, 2000). After the tracheal intubation, it should be chosen the method and the patient should be anesthetized by the general rules (Moynihan, et.al, 1993).
Properly conducted cricoid pressure makes it easier the intubating and prevents the ingress of belching and stomach contents into the lungs of the patient, thus, in this case it is very effective measure (Hartsilver, Vanner, 2000). The rapid sequence induction includes optimal preoxygenation followed by an induction agent and listenon (Haslam, Parker, Duggan, 2005). Cricoid pressure should be carried out with the first signs of loss of consciousness. During the preoperative examination, the signs of possible difficulties with intubation/ventilation in the patient may not be revealed (Haslam, Parker, Duggan, 2005). Since the clinical evaluation of the respiratory tract is unreliable, it is needed a clear sequence of actions aimed at resolving of the unexpected difficulties encountered with intubation and mask ventilation. In this situation, the operation is not an emergency; failed intubation is an indication for the awakening of the patient (Hein, Owen, 2005).
If ventilation using a mask is effective, it should be continued to restore the spontaneous respiration (Hein, Owen, 2005). If ventilation is not effective, then the anesthesiologist has a few tricks to maintain the oxygenation (Fanning, 1970). This includes the use of various kinds of air ducts depending on the experience and availability of the anesthesiologist (Mac, Palmer, Ball, 2000). It is also possible the use of the laryngeal mask, which allows not only to maintain the respiratory tract patency, but also, if necessary, to perform the mechanical ventilation (Haslam, Parker, Duggan, 2005). At the same time, it should be noted that the laryngeal mask does not provide the complete respiratory tract patronage of gastric contents, so the cricoid pressure should be performed during the mechanical lung ventilation through the laryngeal mask (Hocking, Roberts, Thew, 2001).
If there is no laryngeal mask or the use of it is inefficient, as an emergency measure it can be used the trans-tracheal lung ventilation by the puncture of the cricoid membrane (Mac, Palmer, Ball, 2000). After the restoration of the spontaneous breathing, the patient is allowed to wake up and the further conduct of the operation is decided individually (Haslam, Parker, Duggan, 2005). It should be noted that in this situation, the priority is given to the preservation of life of the patient and in the case of obstetric operation the priority is given to the mother's life (Ovessapian, Salem, 2009). Before the intubation anesthesiologist must carefully inspect and palpate the mouth, nose, throat, neck and cervical spine, so as not to miss the traumatic injuries (Ovessapian, Salem, 2009). Only then the doctors should proceed to perform the aspiration of oropharyngeal sanitation, nasal passages, making it thoroughly, but gently, so as not to provoke the vomiting and aspiration syndrome (Mac, Palmer, Ball, 2000). Hence, the failure to accent on the negative consequences of the cricoid pressure, as well as of its improper application, despite its effectiveness, may harm the health of the patient and led to the unacceptable results.
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Barash, Paul (2009). Clinical Anesthesia (6th ed.). Lippencott Williams & Wilkins. p. 1223.
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