Sellick maneuver

Dr. S. Parthasarathy 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

Three fingers

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

Definition Application – force Techniques Indications Contraindications complications

Summary

A simple technique Properly learnt can prevent

morbidity

NO gadgets necessary

Why not sellick ??

Thank you