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Published on: January 17, 2011
Cricoid Pressure During Induction for Tracheal Intubation in Critically Ill Children: A Report From National
Taiki Kojima1, Ilana Harwayne-Gidansky2, Asha N Shenoi3
1Center for Simulation, Advanced Education and Innovation, Children's Hospital of Philadelphia, Philadelphia, PA.
Insights
Cricoid pressure, used to prevent regurgitation during pediatric intubation, was not associated with reduced events in critically ill children. Further research is needed to confirm its effectiveness in specific scenarios.
Area of Science:
- Pediatric Critical Care Medicine
- Airway Management
- Patient Safety
Background:
- Cricoid pressure is a common practice to prevent regurgitation during tracheal intubation in pediatric intensive care units (PICUs).
- Limited clinical data exist to support its efficacy in children, particularly those who are critically ill.
Purpose of the Study:
- To evaluate the association between the use of cricoid pressure and the occurrence of regurgitation during tracheal intubation in critically ill children.
- To analyze the impact of cricoid pressure on regurgitation rates in a multicenter pediatric airway quality improvement registry.
Main Methods:
- Retrospective cohort study involving 7,825 tracheal intubations across 35 PICUs.
- Multivariable logistic regression and propensity score-matched analyses were used to assess the association between cricoid pressure and regurgitation.
- Data were collected from July 2010 to December 2015 for children under 18 years undergoing direct laryngoscopy.
Main Results:
- Regurgitation occurred in 1.4% of cases (106/7,825).
- Unadjusted analysis showed a higher rate of regurgitation with cricoid pressure (1.9% vs 1.2%).
- Multivariable analysis found no significant association (adjusted OR, 1.57; P = 0.054), but a sensitivity analysis indicated a higher regurgitation rate with cricoid pressure (adjusted OR, 1.01; P = 0.036).
Conclusions:
- Cricoid pressure use during induction and mask ventilation prior to tracheal intubation in critically ill children was not associated with a lower regurgitation rate.
- Further studies are required to determine if cricoid pressure is effective for specific indications and with proper technique.
- Current practice does not demonstrate a clear benefit of cricoid pressure in reducing regurgitation events in this population.
Objectives:
Cricoid pressure is often used to prevent regurgitation during induction and mask ventilation prior to high-risk tracheal intubation in critically ill children. Clinical data in children showing benefit are limited. Our objective was to evaluate the association between cricoid pressure use and the occurrence of regurgitation during tracheal intubation for critically ill children in PICU.
Design:
A retrospective cohort study of a multicenter pediatric airway quality improvement registry.
Settings:
Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand).
Patients:
Children (< 18 yr) with initial tracheal intubation using direct laryngoscopy in PICUs between July 2010 and December 2015.
Interventions:
None.
Measurements And Main Results:
Multivariable logistic regression analysis was used to evaluate the association between cricoid pressure use and the occurrence of regurgitation while adjusting for underlying differences in patient and clinical care factors. Of 7,825 events, cricoid pressure was used in 1,819 (23%). Regurgitation was reported in 106 of 7,825 (1.4%) and clinical aspiration in 51 of 7,825 (0.7%). Regurgitation was reported in 35 of 1,819 (1.9%) with cricoid pressure, and 71 of 6,006 (1.2%) without cricoid pressure (unadjusted odds ratio, 1.64; 95% CI, 1.09-2.47; p = 0.018). On multivariable analysis, cricoid pressure was not associated with the occurrence of regurgitation after adjusting for patient, practice, and known regurgitation risk factors (adjusted odds ratio, 1.57; 95% CI, 0.99-2.47; p = 0.054). A sensitivity analysis in propensity score-matched cohorts showed cricoid pressure was associated with a higher regurgitation rate (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; p = 0.036).
Conclusions:
Cricoid pressure during induction and mask ventilation before tracheal intubation in the current ICU practice was not associated with a lower regurgitation rate after adjusting for previously reported confounders. Further studies are needed to determine whether cricoid pressure for specific indication with proper maneuver would be effective in reducing regurgitation events.
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