Editorial
Sellick maneuver revisited
A nesthetists the world over are obsessed with the fear of
Downloaded from http://journals.lww.com/joac by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
gastric regurgitation and pulmonary aspiration. Cricoid
pressure is widely used to prevent this problem during
induction of anesthesia and tracheal intubation, especially in
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 08/10/2023
emergency and full stomach situations.
Much before the anesthetists realized the usefulness of this
technique, vertical pressure applied on the cricoids cartilage
was used by Dr. Monro during resuscitation of victims of
drowning.[1] Thereafter in 1774, Dr. W. Cullen described
this as “a means of preventing gastric distension during lung
inflation.”[1]
Almost 200 years later the efficacy of the technique was
described and popularized by Brian A. Sellick in 1961.[2]
He provided radiological evidence that the cricoid pressure
occludes the esophageal lumen at the level of 5th cervical
vertebra. He further demonstrated that the cricoid pressure was
effective in preventing gastric regurgitation. With the cricoid
pressure in place, there was no run up of saline introduced in
the esophagus from a height of 100 cm in a patient undergoing
gastro-oesophagectomy.[3] “Sellick’s maneuver” as the cricoid
pressure came to be called, rapidly replaced the other means of
preventing regurgitation and aspiration such as the use of awake
intubation, inhaled induction and RSII with 40° head up tilt.[4]
Some questions, however, remained unanswered — how much
pressure, in which direction, and the best possible time to start
applying the pressure. More evidence regarding its efficacy was
also needed at that time to accept its universal usage.
Later on, it was recommended that a pressure be applied
directly backwards on the cricoid cartilage and to begin with
it should be a “light pressure” of about 10 Newton while the
patient is still awake. The same was to be gradually increased
to about 30-40 Newton as the patient lost consciousness.[5] The
efficacy of cricoid pressure was re-confirmed by Rice et al.,
who demonstrated that in human volunteers, application of
Access this article online
Quick Response Code:
Website:
www.joacc.com
DOI:
10.4103/2249-4472.143872
Journal of Obstetric Anaesthesia and Critical Care / Jul-Dec 2014 / Vol 4 | Issue 2
cricoid pressure, irrespective of the direction of pressure,
directly backwards or backwards and lateral, pushes both the
cricoid and the hypopharynx immediately behind the cricoid,
together as a unit, either against the vertebrae or against the
longus colli muscles. In both situations the hypopharynx gets
occluded.[6]
The technique was soon modified and applied to situations,
in which the glottis could not be visualized during direct
laryngoscopy, and another name assigned to this technique —
backwards, upwards and right pressure (BURP) applied on the
thyroid cartilage. BURP maneuver too is popular to this date
and a useful technique for tracheal intubation.[7,8]
Despite wide spread acceptance and use, the efficacy and
reliability of cricoid pressure were again questioned around the
turn of the millennium. The main reasons being that some cases
of regurgitation and aspiration were reported even with the
cricoid pressure in place.[9] Reports of esophageal rupture, and
nausea and vomiting associated with cricoid pressure further
strengthened the case against the use of cricoid pressure.[10]
The technique of cricoid pressure was indeed even blamed for
some incidents of “inability to mask ventilate”, failure of tracheal
intubation and correct laryngeal mask airway placement.[11,12]
In the recent past many doubts have been raised for the validity
of the efficacy of cricoid pressure, as reviews have shown
that there is no evidence of reduced incidence of pulmonary
aspiration of gastric contents after cricoid pressure.[13-15]
With no evidence that cricoid pressure prevents pulmonary
aspiration, and reports of increased morbidity directly
attributed to the use of cricoid pressure, is it logical to continue
the use of cricoid pressure? Avoidance of positive pressure
ventilation during apnea after injection of a muscle relaxant
prior to tracheal intubation in patients with full stomach
ensures there is no gastric distension with oxygen or anesthetic
gases, minimizing the chances of regurgitation and resultant
aspiration. A large number of anesthesiologists no longer use
suxamethonium to facilitate tracheal intubation, thus avoiding
the potential rise in intra-gastric pressure attributed to this
muscle relaxant which could further increase the incidence of
gastric aspiration.
In my personal experience, a large number of my anesthesia
colleagues are apprehensive about the correct application of
57
 Kohli: Sellick maneuver
cricoid pressure while it is being applied. It is not uncommon
to manipulate the larynx while cricoid pressure is being applied
and often incorrectly applied pressure makes intubation difficult.
In this era of “evidence based medicine” and “protocols,” it
is high time the anesthetists gave a serious thought to the
Downloaded from http://journals.lww.com/joac by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
continued teaching and practice of this technique.
Pramod Kohli
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 08/10/2023
Department of Anaesthesiology, Lady Harding Medical College,
New Delhi, India
Address for correspondence: Prof. Pramod Kohli,
Department of Anaesthesiology, Lady Harding Medical College,
New Delhi, India.
E-mail: pramodkohli@hotmail.com
REFERENCES
1. Cullen W. A Letter to Lord Cathcart Concerning the Recovery of Persons
Drowned and Seemingly Dead. London: Printed for J. Murray; 1776.
2. Sellick BA. Cricoid pressure to control regurgitation of stomach contents
during induction of anaesthesia. Lancet 1961;2:404-6.
3. Sellick BA. The prevention of regurgitation during induction of
anaesthesia. In: Proceedings of the First European Congress of
Anaesthesiology, Vienna. Vol. 1. World Federation of Societies of
Anaesthesiologists; 1962. p. 89.
4. Snow RG, Nunn JF. Induction of anaesthesia in the foot-down position
for patients with a full stomach. Br J Anaesth 1959;31:493-7.
58
5. Wraight WJ, Chamney AR, Howells TH. The determination of an effective
cricoid pressure. Anaesthesia 1983;38:461-6.
6. Rice MJ, Mancuso AA, Gibbs C, Morey TE, Gravenstein N, Deitte LA.
Cricoid pressure results in compression of the postcricoid hypopharynx:
The esophageal position is irrelevant. Anesth Analg 2009;109:1546-52.
7. Takahata O, Kubota M, Mamiya K, Akama Y, Nozaka T, Matsumoto H,
et al. The efficacy of the “BURP” maneuver during a difficult laryngoscopy.
Anesth Analg 1997;84:419-21.
8. Knill RL. Difficult laryngoscopy made easy with a “BURP”. Can J Anaesth
1993;40:279-82.
9. Schwartz DE, Matthay MA, Cohen NH. Death and other complications
of emergency airway management in critically ill adults. A prospective
investigation of 297 tracheal intubations. Anesthesiology 1995;82:367-76.
10. Vanner RG, Pryle BJ. Regurgitation and oesophageal rupture with cricoid
pressure: A cadaver study. Anaesthesia 1992;47:732-5.
11. Palmer JH, Ball DR. The effect of cricoid pressure on the cricoid
cartilage and vocal cords: An endoscopic study in anaesthetised patients.
Anaesthesia 2000;55:263-8.
12. Aoyama K, Takenaka I, Sata T, Shigematsu A. Cricoid pressure impedes
positioning and ventilation through the laryngeal mask airway. Can J
Anaesth 1996;43:1035-40.
13. Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department
rapid sequence tracheal intubations: A risk-benefit analysis. Ann Emerg
Med 2007;50:653-65.
14. Neilipovitz DT, Crosby ET. No evidence for decreased incidence of
aspiration after rapid sequence induction. Can J Anaesth 2007;54:748-64.
15. Lerman J. On cricoid pressure: “May the force be with you”. Anesth
Analg 2009;109:1363-6.
Cite this article as: Kohli P. Sellick maneuver revisited. J Obstet Anaesth
Crit Care 2014;4:57-8.
Source of Support: Nil, Conflict of Interest: None declared.
Journal of Obstetric Anaesthesia and Critical Care / Jul-Dec 2014 / Vol 4 | Issue 2