Download - Cricolol by John Hinds at smaccGOLD
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Cricoid Pressure
John Hinds
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Conflict of interest
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Conflict of interest
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My nefarious plan
• Get invited to International conference in sunny climate
• Captive audience
• Sell you this fabulous new product!
Cricolol
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Appraising drugs and therapies
• Steroids in Spinal Cord injury• Activated Protein C• Starch solutions• Therapeutic hypothermia in OOHCA
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Cricolol: Early development
• Herbal remedy by Seamus O’Monroe in 1774
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Cricolol: Early development
• Rebranded by Seamus O’Sellick in 1961– 26 patients– Single hospital observational study– Non-randomised– Non-standardised – Dose was guessed
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Administration
• Dedicated assistant during RSI
• 10mg before induction• 30mg during induction
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Administration
• Dedicated assistant during RSI
• 10mg before induction• 30mg during induction
• Exact dose in syringe is unknown
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How much is in the ampoule?
105 trained perioperative nurses
• 5% correct dose
• No correlation between knowledge of correct dose and actual dose given
(Seamus O’Kozial et al, AORN J 2000)
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A half century of Evidence
No randomised controlled trials showing benefit.
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B.S.E.’s• Quite good at making it difficult to pass
nasogastric tubes
• Quite good for nice pictures in healthy volunteers having MRI scans
• Some nonsense with Dye
• Seems OK in dead bodies
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Any problems?
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Makes Airway management more difficult
• Airway compression in 81% (O’Smith et al, Anaesthesiology. 2003)
• Airway obstruction in 56%(O’Hartsilver, Anaesthesia, 2000)
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Reduces success with the tube
• Worsens laryngeal view in 29%(O’Levitan et al, Anal Emerg Med 2006)
• Makes intubation process more difficult(O’Allman KG. J Clin Anesth 1995)
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Increases vomiting and regurgitation
• Lowers oesophageal sphincter tone and increases regurgitation
O’Garrad et al, Anaesthesia 2004
O’Chassard et al, Can J Anaesth 1996
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Narrow therapeutic window
• Dose of 30mg recommended– No idea what’s in the ampoule
• You might break the airway(O’ Heath et al, Br J Anaesth 1996)
• Oesophagus might explode if dose exceeds 44mg
(O’ Ralph, O’ Wareham, Anaesthesia 1991)
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Cricolol
• Evidence in well powered clinical trials– None.– Some BSE data
• Evidence of side effects includes:– Airway collapse in most patients– Complete airway obstruction in half of patients– Increased difficulty of intubation– Physical harm
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Cricoid Pressure
3 pet hates of mine
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“I use Cricoid Pressure…
I can just take it off if the airway is difficult”
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Sellick
• Cricoid on for induction…
… off at laryngoscopy
• Resulted in the highest reported incidence of gastric regurgitation, ever.
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Beware the “Trained assistant”
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“Can I PLEASE have Cricoid?!”
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“Can I PLEASE have Cricoid?!”
“Well if you tell me what cupboard it’s in I’ll get it”
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“I don’t believe in Cricoid Pressure…
but I’m afraid to not use it because of Guidelines”
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Difficult Airway Society
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Difficult Airway Society
• “Written guidelines should exist in each department to cover a number of common or serious airway problems”
• “An individual practitioner can make a judgement about which equipment/technique to use, and is quite entitled to use any”
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“I have to follow the Guidelines”
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“Befehl ist Befehl”
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Godwin’s Law
“As an online discussion grows longer,
the probability of a comparison involving Nazis or Hitler approaches 1”
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Vote for Cricoid Pressure
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Vote for Cricoid Pressure
• An Idiot.
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Vote for Cricoid Pressure
• An Idiot.
• A Nazi.
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Cricolol !
30mg Suppository!
“For all the good it does, you might as well just stick it up your Arse”