No European consensus – cricoid pressure during RSI

Cricoid pressure was first described by Brian Arthur Sellick in 1961. Since then, it has been an integral component of Rapid Sequence Induction (RSI) in the UK.

The merits of cricoid pressure have been the subject of lively debate for some time, since it is not entirely clear it provides any benefit. In addition, use of cricoid pressure has implications for tracheal intubation and insertion of supraglottic airways. It can also be poorly taught and poorly applied, leaving it unclear whether any issues are due to limitations with the technique itself, inadequate training, or it simply being too difficult to apply it correctly on a consistent basis even when well trained. However, in the 4th UK National Audit Project (NAP4), ‘Major complications of airway management in the UK’, there were no cases where cricoid force was reported as leading to major complications.

I therefore read with interest a ‘Survey on controversies in airway management among anaesthesiologists in the UK, Austria and Switzerland’, which, in one of three questions, asked 266 anaesthetists from three European countries ‘When do you use cricoid pressure?

96% of those surveyed from the UK confirmed they used cricoid pressure for RSI. No surprises there. The surprise was this was not replicated with the anaesthetists from Austria and Switzerland. Only 52% from Austria and 30% from Switzerland confirmed they used cricoid pressure for RSI. In addition, 40% of the Austrian anaesthetists and 49% of the Swiss replied they never used cricoid pressure.

Of course, the authors of this survey confirmed the limitations of their results, and expressed the hope that a large multi-national European study would be conducted to establish a broader picture of airway management habits in Europe.

So is the UK the last bastion of cricoid pressure in Europe? Looks like we will have to wait for the above mentioned survey to find out.

UK National Audit Projects – past, present and future

National Audit Project Four, or NAP4 as it is commonly known, which examined major complications of airway management in anaesthesia, emergency departments and intensive care, has been widely acknowledged as a milestone in airway management research. A seminal work, it was designed to determine what type and how often airway devices are used, how often major complications occur, what do they consist of and what can be learnt from them to reduce their frequency and consequences. In the opinion of many, this was an objective largely achieved.

Its legacy is not yet clear, but I would suggest it is not only the content of the report that has determined its success to date, but also the ease with which it can be accessed and how easy it is to navigate through it and find the information you need. Each of the main chapters has a quick summary, a review of what is already known, a case review, data analysis, discussion, and finally, clear learning points and recommendations. It has quickly become a constant and valued source of reference. In addition, those organisations involved with NAP4 are to be commended, not only for making the report itself easy to find and free to download, but also making available all the presentations from launch day, as well as podcasts of the lectures, available on the Royal College of Anaesthetists web-site.

It might be tempting to dismiss NAP4 as being of local UK interest only, but this would be a mistake, since many of the themes, results and conclusions, are likely to have a much wider, if not universal, interest and significance. Encouragingly, NAP4 has been the subject of international, as well as domestic lectures at key conferences since its publication. Notably, one of the authors of NAP4 was invited to give a presentation at the Society of Airway Management (SAM) annual conference in the USA in 2011. A challenge was issued to the audience, ‘dismiss the findings of NAP4 as not relevant to your (local, institutional, national) practice if you like……but please do not do so until you have collected robust data to show it is not relevant to your practice’.

With the high profile and success of NAP4, I was curious to know more about its predecessors and what the future might hold for the next series of reports. I was aware of NAP3, ‘Major Complications of Central Neuraxial Block in the UK’, but I was not aware of NAPs one and two. NAP1 examined the supervisory role of consultant anaesthetists, and NAP2, the place of mortality and morbidity review meetings. The report and findings for both can be downloaded from the Royal College of Anaesthetists web-site.

We already know NAP5 will report on ‘Accidental Awareness during General Anaesthesia’. The project was officially launched on 1st June, seeking notification of all reports of accidental awareness during general anaesthesia (AAGA) reported between 1st June 2012 and 31st May 2013. As with NAP4, every UK hospital has agreed to participate. The Clinical Lead for NAP5 is Prof Jaideep Pandit, who will work closely with Dr Tim Cook, the College Advisor for National Audit Projects.

The process of selecting the subject for NAP5 may have provided us with some clues as to the possible subjects for NAP6 and beyond. Among the topics proposed for NAP5 were ‘Anaphylaxis’, ‘Dental damage’, ‘Obesity – incidence and complications’, ‘Recovery Room complications’, ‘Tracheostomy: complications’ and ‘Post-operative nausea and vomiting’. All worthy subjects, but with the request for re-submissions for NAP6 unlikely for another 12 months, perhaps a new subject might come to prominence and prove irresistible. Time will tell.