Learning to apply effective cricoid pressure using a part task trainer

Cricoid Pressure: Contradictory Evidence Regarding a Standard Practice

The purpose of applying cricoid pressure is to prevent pulmonary aspiration of regurgitated gastric contents during airway management in mask-ventilated patients who are at risk of aspiration. Providers may apply cricoid pressure during induction and intubation if they expect a difficult intubation or if the patient has a high risk for regurgitation. Although the application of cricoid pressure has been accepted as a standard practice worldwide, controversy persists because pulmonary aspiration can occur even when cricoid pressure is applied. The perioperative nurse should have thorough knowledge of the anatomy of the upper respiratory and gastrointestinal tracts, be able to demarcate the surface landmarks of the neck, and be skilled in applying cricoid pressure properly and safely. This article discusses cricoid pressure in the context of safe airway management as well as the perioperative nurse's role as an assistant to the anesthesia professional when applying cricoid pressure.

The Knowledge of Health Professionals About the Application of Cricoid Pressure in a Low-Income Country: A Single-Center Survey Study

BACKGROUND

The application of cricoid pressure requires good knowledge and practice of health professionals who are working in operation theatres to prevent pulmonary aspiration. This study aims to assess the application of cricoid pressure knowledge and practice in health professionals who are working in the operation theatres.

METHODS

This survey-based study was conducted in health care professionals who are working in the operation theatre of Debre Tabor Comprehensive Specialized Hospital from November 1 to December 1, 2020. A structured checklist was used to collect data regarding the knowledge and practice of the application of cricoid pressure.

RESULTS

A total of 43 health professionals who are working in the operation theaters were involved in this study with a response rate of 81%. The correct anatomic position of cricoid cartilage was not identified in 67% of nurses. We found that 78% of anesthetists did not use the nasogastric tube for decompression, and 83% of them complain of difficult intubation during the application of cricoid pressure.

CONCLUSION

Health care professionals who are working in operation theatres had poor knowledge and practice in the application of cricoid pressure.

Sellick maneuver assisted real-time to achieve target force range in simulated environment-A prospective observational cross-sectional study on manikin

A force sensor system was developed to give real-time visual feedback on a range of force. In a prospective observational cross-section study, twenty-two anaesthesia nurses applied cricoid pressure at a target range of 30–40 Newtons for 60 seconds in three sequential steps on manikin: Group A (step 1 blinded, no sensor), Group B (step 2 blinded sensor), Group C (step 3 sensor feedback). A weighing scale was placed below the manikin. This procedure was repeated once again at least 1 week apart. The feedback system used 3 different colours to indicate the force range achieved as below target, achieve target, above target. Significantly higher proportion of target cricoid pressure was achieved with the use of sensor feedback in Group C; 85.9% (95%CI: 82.7%-88.7%) compared to when blinded from sensor in Group B; 31.3% (95%CI: 27.4–35.4%). Cricoid force achieved blind (Group B) exceeded force achieved with feedback (Group C) by a mean of 8.0 (95%CI: 5.9–10.2, p<0.0001) and 6.2 (95%CI:4.1–8.3, p< 0.0001) Newtons in round 1 and 2 respectively. Weighing scale read lower than corresponding force sensor by a mean of 8.4 Newtons (95% CI: 7.1–9.7, p<0.0001) in group B and 5.8 Newtons (95% CI: 4.5–7.1, p<0.0001) in Group C. Force sensor visual feedback system enabled application of reproducible target cricoid pressure with less variability and has potential value in clinical use. Using weighing scale to quantify and train cricoid pressure requires a review. Understanding the force applied is the first step to make cricoid pressure a safe procedure.

MCRDR Knowledge-Based 3D Dialogue Simulation in Clinical Training and Assessment

Dialogue-based simulation is a real-world practice technique for medical and clinical education that provides students with an opportunity to train using hands-on experiences without putting actual patients being put at risk. In this paper, a 3D interactive dialogue-based training and assessment system that supports the detailed development of clinical trial competency for medical students in a distributed virtual environment was proposed. For clinical training, MCRDR-based natural language understanding to realize the semantic representation of written dialog from the most relevant inference results was applied, and on the basis of this, a convolutional neural network model was also used to make the generated inference more exact and reliable. For clinical assessment, the dialogue-driven competency method was used to encompass medical knowledge, communication skill as well as professionalism skill based on the collected dialogue information. Finally, the potential of the created system was demonstrated with several clinical cases. The preliminary results indicate that the system demonstrates the potential of providing efficient training and flexible assessment, while saving time, improving practical skills and making students more confident.

Analysis of cricoid pressure application: anaesthetic trainee doctors vs. nursing anaesthetic assistants

BACKGROUND AND OBJECTIVE

To evaluate the ability of anaesthetic trainee doctors compared to nursing anaesthetic assistants in identifying the cricoid cartilage, applying the appropriate cricoid pressure and producing an adequate laryngeal inlet view.

METHODS

Eighty-five participants, 42 anaesthetic trainee doctors and 43 nursing anaesthetic assistants, were asked to complete a set of questionnaires which included the correct amount of force to be applied to the cricoid cartilage. They were then asked to identify the cricoid cartilage and apply the cricoid pressure on an upper airway manikin placed on a weighing scale, and the pressure was recorded. Subsequently they applied cricoid pressure on actual anaesthetized patients following rapid sequence induction. Details regarding the cricoid pressure application and the Cormack-Lehane classification of the laryngeal view were recorded.

RESULTS

The anaesthetic trainee doctors were significantly better than the nursing anaesthetic assistants in identifying the cricoid cartilage (95.2% vs. 55.8%, p=0.001). However, both groups were equally poor in the knowledge about the amount of cricoid pressure force required (11.9% vs. 9.3% respectively) and in the correct application of cricoid pressure (16.7% vs. 20.9% respectively). The three-finger technique was performed by 85.7% of the anaesthetic trainee doctors and 65.1% of the nursing anaesthetic assistants (p=0.03). There were no significant differences in the Cormack-Lehane view between both groups.

CONCLUSION

The anaesthetic trainee doctors were better than the nursing anaesthetic assistants in cricoid cartilage identification but both groups were equally poor in their knowledge and application of cricoid pressure.

[Analysis of cricoid pressure application: anaesthetic trainee doctors vs. nursing anaesthetic assistants]

BACKGROUND AND OBJECTIVE

To evaluate the ability of anaesthetic trainee doctors compared to nursing anaesthetic assistants in identifying the cricoid cartilage, applying the appropriate cricoid pressure and producing an adequate laryngeal inlet view.

METHODS

Eighty-five participants, 42 anaesthetic trainee doctors and 43 nursing anaesthetic assistants, were asked to complete a set of questionnaires which included the correct amount of force to be applied to the cricoid cartilage. They were then asked to identify the cricoid cartilage and apply the cricoid pressure on an upper airway manikin placed on a weighing scale, and the pressure was recorded. Subsequently they applied cricoid pressure on actual anaesthetized patients following rapid sequence induction. Details regarding the cricoid pressure application and the Cormack-Lehane classification of the laryngeal view were recorded.

RESULTS

The anaesthetic trainee doctors were significantly better than the nursing anaesthetic assistants in identifying the cricoid cartilage (95.2% vs. 55.8%, p=0.001). However, both groups were equally poor in the knowledge about the amount of cricoid pressure force required (11.9% vs. 9.3% respectively) and in the correct application of cricoid pressure (16.7% vs. 20.9% respectively). The three-finger technique was performed by 85.7% of the anaesthetic trainee doctors and 65.1% of the nursing anaesthetic assistants (p=0.03). There were no significant differences in the Cormack-Lehane view between both groups.

CONCLUSION

The anaesthetic trainee doctors were better than the nursing anaesthetic assistants in cricoid cartilage identification but both groups were equally poor in their knowledge and application of cricoid pressure.

Effectiveness of cricoid pressure in preventing gastric aspiration during rapid sequence intubation in the emergency department: study protocol for a randomised controlled trial

Background

Cricoid pressure is considered to be the gold standard means of preventing aspiration of gastric content during Rapid Sequence Intubation (RSI). Its effectiveness has only been demonstrated in cadaveric studies and case reports. No randomised controlled trials comparing the incidence of gastric aspiration following emergent RSI, with or without cricoid pressure, have been performed. If improperly applied, cricoid pressure increases risk to the patient. The clinical significance of aspiration in the emergency department is unknown. This randomised controlled trial aims to; 1. Compare the application of the 'ideal" amount of force (30 - 40 newtons) to standard, unmeasured cricoid pressure and 2. Determine the incidence of clinically defined aspiration syndromes following RSI using a fibrinogen degradation assay previously described.

Methods/design

212 patients requiring emergency intubation will be randomly allocated to either control (unmeasured cricoid pressure) or intervention groups (30 - 40 newtons cricoid pressure). The primary outcome is the rate of aspiration of gastric contents (determined by pepsin detection in the oropharyngeal/tracheal aspirates or treatment for aspiration pneumonitis up to 28 days post-intubation). Secondary outcomes are; correlation between aspiration and lowest pre-intubation Glasgow Coma Score, the relationship between detection of pepsin in trachea and development of aspiration syndromes, complications associated with intubation and grade of the view on direct largyngoscopy.

Discussion

The benefits and risks of cricoid pressure application will be scrutinised by comparison of the incidence of aspiration and difficult or failed intubations in each group. The role of cricoid pressure in RSI in the emergency department and the use of a pepsin detection as a predictor of clinical aspiration will be evaluated.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611000587909

Deepening the theoretical foundations of patient simulation as social practice

Simulation is a complex social endeavor, in which human beings interact with each other, a simulator, and other technical devices. The goal-oriented use for education, training, and research depends on an improved conceptual clarity about simulation realism and related terms. The article introduces concepts into medical simulation that help to clarify potential problems during simulation and foster its goal-oriented use. The three modes of thinking about reality by Uwe Laucken help in differentiating different aspects of simulation realism (physical, semantical, phenomenal). Erving Goffman's concepts of primary frames and modulations allow for analyzing relationships between clinical cases and simulation scenarios. The as-if concept by Hans Vaihinger further qualifies the differences between both clinical and simulators settings and what is important when helping participants engage in simulation. These concepts help to take the social character of simulation into account when designing and conducting scenarios. The concepts allow for improved matching of simulation realism with desired outcomes. It is not uniformly the case that more (physical) realism means better attainment of educational goals. Although the article concentrates on mannequin-based simulations that try to recreate clinical cases to address issues of crisis resource management, the concepts also apply or can be adapted to other forms of immersive or simulation techniques.

Cricoid Pressure in Emergency Department Rapid Sequence Tracheal Intubations: A Risk-Benefit Analysis

Cricoid pressure is considered an integral part of patient safety in rapid sequence tracheal intubation and emergency airway management. Cricoid pressure is applied to prevent the regurgitation of gastric contents into the pharynx and subsequent aspiration into the pulmonary tree. This review analyzes the published evidence supporting cricoid pressure, along with potential problems, including increased difficulty with tracheal intubation and ventilation. According to the evidence available, the universal and continuous application of cricoid pressure during emergency airway management is questioned. An awareness of the benefits and potential problems with technique allows the practitioner to better judge when cricoid pressure should be used and instances in which it should be removed.

Practice makes perfect? Evaluation of cricoid pressure task training for use within the algorithm for rapid sequence induction in critical care

OBJECTIVE

To assess task training in cricoid pressure application suitable for incorporation into the algorithm for rapid sequence induction in acute care.

METHOD

A blinded prospective direct observational study of 110 critical care staff of two hospitals in regional New South Wales. Each participant was instructed to apply blinded cricoid force within the target range of 30-40 N to a cricoid model mounted on a weighing scale and the result recorded. After up to 3 min of unblinded practice without coaching on the same model a repeat blinded application of force was recorded. The pre- and post-intervention results were compared.

RESULTS

At the pre-intervention stage, 22 participants (20%) applied initial pressure within the target range, increasing to 57 (52%) at the post-intervention stage (chi(2) = 24.19, d.f. = 1, P < 0.01; odds ratio [OR] = 0.23; 95% confidence interval [CI] 0.12-0.44). The post-intervention results show a significant improvement in the number of participants achieving the target range in both nursing (chi(2) = 20.42, d.f. = 1, P < 0.01; OR = 0.18; 95% CI 0.08-0.42) and medical subgroups (chi(2) = 4.68, d.f. = 1, P = 0.03; OR = 0.34; 95% CI 0.11-1.02). The number applying force sufficient to prevent regurgitation, that is 30 N or greater, rose from 71 to 97 (65% to 88%) (chi(2) = 17.02, d.f. = 1, P < 0.01; OR = 0.24; 95% CI 0.11-0.51). The number applying in excess of 44 N fell from 41 to 25 (37% to 21%) (chi(2) = 5.54, d.f. = 1, P < 0.02; OR = 2.02; 95% CI 1.08-3.81).

CONCLUSION

The application of cricoid force by critical care staff can be significantly improved by up to 3 min of practice on a simple task trainer.

Cricoid pressure: Assessment of performance and effect of training in emergency department staff

OBJECTIVES

(i) To evaluate the theoretical knowledge and practical skills of ED staff regarding the technique of cricoid pressure; (ii) to assess the efficacy of two methods of cricoid pressure training.

METHODS

Theoretical knowledge of participants was assessed by a pretraining questionnaire, and practical ability was assessed using a Flinders Meditech cricoid pressure trainer. Participants then received a brief period of theoretical instruction, and were allocated to two training groups. Group A received further training with the pressure trainer. Group B was provided with reading material. Practical ability was assessed again immediately and then 4-6 weeks later.

RESULTS

Seventy subjects were recruited. A total of 53% could identify the position of the cricoid cartilage, and 16% could identify the pressure required. The percentage achieving a correct position at baseline, immediately after training and after 4-6 weeks was 47%, 97% and 70% respectively in group A, compared with 61%, 86% and 74% respectively in group B, a non-significant difference between groups. The percentage achieving correct pressure at baseline, immediately after training and 4-6 weeks later was 38%, 88% and 67% respectively in group A, compared with 30%, 33% and 51% respectively in group B. The between-group difference was significant only immediately following training (P < 0.0001).

CONCLUSION

Theoretical knowledge and technique regarding cricoid pressure was poor among our ED staff. Both methods of training appeared to improve performance. The biofeedback group was more likely to apply correct pressure immediately after training. The effects of training diminished rapidly with time.

Simulators for use in anaesthesia

There are many simulators available for use in anaesthetic-related education and research. Those who wish to purchase a simulator or to establish a simulation facility face a daunting task in understanding the differences between simulators. Recent reviews have focused on narrower areas of simulation, such as airway management or basic life support, or on the application of simulators. It would be difficult to deal in detail with every simulator ever made for anaesthesia, but in the present review we cover the spectrum of currently available anaesthetic simulators, provide an overview of different types of simulator, and discuss a selection of simulators of particular interest, including some of historical significance and some examples of 'home made' simulators. We have found no common terminology amongst authors for describing or classifying simulators, and propose a framework for describing (or classifying) them that is simple, clear and applicable to any simulator.

Educating Nurses about Correct Application of Cricoid Pressure

ALTHOUGH THE APPLICATION of cricoid pressure is a technique that is performed almost daily in the OR, perioperative nurses may not be applying cricoid pressure correctly. THE PURPOSE of this quality improvement project was to develop an education program to assess perioperative nurses' skills and educate and train them regarding correct application of cricoid pressure. OF 51 PERIOPERATIVE NURSES who participated in a pretest, an education program, and a posttest, the number of participants who could apply the appropriate amount of pressure to the correct location increased from two (3.9%) on the pretest to 35 (68.6%) on the posttest.

The 50???ml syringe training aid should be utilized immediately before cricoid pressure application

OBJECTIVE

Cricoid pressure, applied during rapid sequence induction of anaesthesia, should be performed only by trained staff. Recommended training intervals vary from weekly to every 3 months, but this is unrealistic in day-to-day practice. Performance, when assessed, is often shown to be unacceptable before training. Unfortunately, most training aids are either expensive or unavailable. Assessment and training in previous studies was carried out on the same cricoid pressure simulator, introducing learning bias. In our study, we tested whether a 50 ml syringe utilized as a training aid immediately before the assessment of simulated rapid sequence induction on a different cricoid pressure simulator would improve staff performance.

METHODS

A total of 64 volunteers were randomly allocated into two equal groups. Group 1 (control group) was assessed on the cricoid pressure simulator only. Group 2 (training group) was pretrained to defined criteria using the 50 ml syringe. Next, the group was assessed on the cricoid pressure simulator.

RESULTS

A satisfactory force was applied in only 19% (6/32) of the control group, but in 47% (15/32) of the syringe pretrained group (P=0.03). Both groups applied, on average, excessive force.

CONCLUSION

Brief training with a 50 ml syringe will increase the likelihood of satisfactory force application during Sellick's manoeuvre. Applied to clinical practice, this will make cricoid pressure both more effective and reliable, and may improve patient safety. Therefore, the 50 ml syringe should be utilized before any clinical application of cricoid pressure.

Assessment of cricoid pressure application by emergency department staff

OBJECTIVE

To assess the accuracy of cricoid force applied by ED staff working in two hospitals based on the New South Wales central coast.

METHODS

A prospective, observational study of 38 doctors and 69 nurses working in the ED. Each staff member was asked to demonstrate cricoid pressure using a model based on a set of weighing scales. Five attempts were measured and a mean value calculated for each participant. Subgroup analysis was also performed for specific variables of interest.

RESULTS

Twenty-seven (25%) participants applied the target cricoid force. Of the 80 participants who were outside of the target range, 50 (63%) applied less than the target range and 30 (37%) applied more than the target range. No statistically significant difference was demonstrated for sex, age, qualification or years of experience and the ability to apply cricoid force within the target range. More candidates (27) applied the target range than those who correctly identified it (12). When methods of instruction were compared there was no difference between candidates with one and more than one modality of instruction (t-test: t (105) = -0.09, P = 0.9; 95% confidence interval [CI]-0.66-0.6) and the mean cricoid force applied. Those who had greater than one form of instruction applied correct cricoid force at the target range more often than those who had received only one form of instruction, this result was significant. (chi(2) = 4.24, d.f. = 1, P = 0.04; odds ratio = 2.6; 95% CI 1.03-6.41).

CONCLUSION

The application of cricoid force by ED staff participating in the present study is unreliable, often providing inadequate protection against regurgitation. Training using a model integrating the concept of force is recommended. The role of cricoid pressure in rapid sequence induction needs to be further investigated.

Applying cricoid pressure

This article discusses the literature surrounding the application of cricoid pressure during rapid sequence induction and suggests ways in which the training of this skill can be improved.

Cricoid pressure training: how useful are descriptions of force?

Cricoid pressure has been used for over 200 years. During that time, training in the technique has not changed greatly, despite the well-documented potential for complications if performed improperly. Typically, training relies on quantitative or qualitative descriptions such as "firm" pressure, a number of Newtons of force or equivalent force to that causing pain while pressing on the nose. This study tests the value of these descriptive methods in training to apply cricoid pressure. Fifty subjects were asked to apply cricoid pressure after receiving a description of the force required and again after having tested how much finger pressure on the bridge of their nose was required to cause discomfort. Initial force, force at 45 seconds, minimum force, and maximum force was recorded. The results were analysed using the Wilcoxon signed ranks test, which showed no significant difference in performance between the two types of training. One subject maintained pressure in the range of 25 to 35 Newtons for the entire 45 seconds of the first attempt but no subject performed this well on the second attempt. The use of qualitative and quantitative descriptors of the appropriate pressure does not appear useful in the training of the technique of cricoid pressure. Training incorporating force feedback is recommended.