Variable application and misapplication of cricoid pressure

In 1961, Sellick described a three-finger technique of cricoid pressure used to prevent gastric regurgitation during induction of anesthesia. The "Sellick maneuver" is now used worldwide. The authors have observed great variability in the application of cricoid pressure by health care providers and have suspected that misapplication occurs. The objectives of this observational study were to determine how many different techniques of cricoid pressure were being used and to identify the reasons for such variability of technique.

During a 30-month period, the authors observed 32 health care providers applying cricoid pressure at five hospitals. The technique and the professional degree of the person performing the maneuver were recorded. We also reviewed five national courses that provide airway management training to determine which technique of cricoid pressure was being taught.

Ten different techniques of cricoid pressure were identified in 32 observations. We identified cases in which pressure was mistakenly applied to the thyroid cartilage and sternocleidomastoid muscles. The original three-finger Sellick technique was rarely used (3 of 32). A review of five national training courses revealed that none provide specific cricoid pressure training.

This observational study demonstrates that there is great variability in the application of cricoid pressure, identifying 10 different techniques in 32 observations. Misapplication does occur with possible patient harm. We suggest four possible reasons for this variability of technique. The authors use the three-finger cricoid pressure technique as originally described by Sellick and thought that this technique is effective, easy to teach, and safely keeps the fingers in the midline of the cricoid cartilage.