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Cricoid pressure and the law

The editorial by Turnbull et al. [1] advocates use of cricoid pressure by default for rapid sequence induction, but omitted mention of ‘any hint of difficulty in airway management’. Apart from the fact that no harm was highlighted in NAP 4 by cricoid pressure, all other evidence quoted by the authors opposes the use of cricoid pressure. My personal experience of a ‘can’t intubate, can’t oxygenate’ situation resulted directly from inappropriately-applied cricoid pressure. The guidelines at that time did not recommend release of cricoid pressure and so my requests to an assistant to relax the pressure were ignored. If cricoid pressure were to be introduced afresh today, the most optimistic conclusion would be that ‘further studies are needed before it can be recommended for universal adoption’. The recommendation that ‘cricoid pressure be used to satisfy the desires of some peers and the courts’ makes anaesthesia practice subjective rather than objective. In any case, the courts will go by available guidelines, which in turn must be evidence-based. Turnbull et al. have quoted evidence that cricoid pressure contributes to harm in the form of difficult airway management, failed intubation, vomiting and aspiration. There is also evidence that cricoid pressure is not effective in preventing aspiration, and absence of cricoid pressure does not cause harm. Patients in the original, small, non-randomised study by Sellick [2] were positioned head-down, and had variable induction and neuromuscular blockade regimens, which increased the likelihood of regurgitation. Current anaesthesia practice is different, and current guidelines should reflect current evidence.