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Invited Commentary
January 2019

Is 30 Newtons of Prevention Worth a Pound of a Cure?—Cricoid Pressure

Author Affiliations
  • 1University of Maryland School of Medicine, Baltimore
JAMA Surg. 2019;154(1):18. doi:10.1001/jamasurg.2018.3590

Aspiration remains one of the most dreaded complications of endotracheal intubation. To mitigate the risk of aspiration in patients who are at high risk, rapid sequence induction (RSI) is used with an anesthetic and short-acting neuromuscular blocking agent. Cricoid pressure (the Sellick maneuver) has frequently been used for physically preventing aspiration.

Recognizing the lack of clinical trials that demonstrate clinically relevant beneficial outcomes, the use of cricoid pressure during RSI has been debated over the past decade.1-3 Regarding efficacy, although cricoid pressure is often not performed appropriately (ie, applying 30 newtons of pressure in the proper location), most studies demonstrate that cricoid pressure may prevent gastric insufflation by occluding the esophagus and postcricoid hypopharynx.4,5 However, other studies have suggested that cricoid pressure may displace the esophagus laterally or decrease lower esophageal sphincter pressure, thus increasing the risk of regurgitation.6 In addition, cricoid pressure may worsen the laryngoscopic view, further providing equipoise for studying its effectiveness.

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