1. Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), MD., DA., DNB, MD (Acu), Dip. Diab.DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi Medical college and research institute, puducherry, India

2.   Sellick --  Its all about aspiration  Isnt it ??

3.   Incidence : 1 in 3000  Emergency – 1 in 600  More common in ASA IV  Solution possible ??  RSI with preoxygenation with sellick manouver Aspiration

4.   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

5.   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

6.   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

7.  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

8.  Full cartilage – cricoid

9.   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

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11.  Three fingers

12.   Prevent aspiration  Full stomach, diabetes, pregnancy, obese  Inflate lungs when unable to intubate Indications

13.   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 ??

14.   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

15.   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

16.   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 ?!

17.   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 ??

18.   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 ??

19.   Single handed A) B)  Double handed A) B) Types

20.   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

21.   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

22.   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

23.   Cricoid pressure  Increases the tone of the upper esophageal sphincter and decreases the tone of the lower esophageal sphincter  Probable pharyngeal receptors GER

24.   Conflicting  Correct application improves  Single handed cricoid pressure improves laryngoscopy  Wrong pressure, direction – difficult laryngoscopy  Jabalameli et al, turgeon et al CP and laryngoscopy

25.   Oxygenation without aspiration  Difficult to intubate  LMA  Position pressure direction change Sellick and CICV

26.   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

27.   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

28.  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

29.   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

30.   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

31.   Definition  Application – force  Techniques  Indications  Contraindications  complications Summary

32.   A simple technique  Properly learnt can prevent morbidity  NO gadgets necessary Why not sellick ??

33.  Thank you