IRIS Cricoid Pressure Trial & Deimplementation (Journal Club)

Journal Club Article: Birenbaum, A., Hajage, D., Roche, S., Ntouba, A., Eurin, M., Cuvillon, P., … & Menut, R. (2018). Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia: The IRIS Randomized Clinical Trial. JAMA Surgery.

Background: 

Cricoid pressure or Sellick’s maneuver (first described by Dr. Sellick in the 1960’s) aims to reduce the risk of regurgitation. The technique involves the application of pressure over the cricoid cartilage with the thumb and 1-2 additional fingers, to to occlude the esophagus and prevent regurgitation of stomach contents into the upper airway.

Study Aim:

Does the cricoid pressure prevent pulmonary aspiration in patients undergoing rapid sequence induction of anesthesia?

Study Design:

A randomized, double-blind, noninferiority trial conducted across 10 academic centers. Patients undergoing anesthesia with rapid sequence intubation (RSI) were enrolled from February 2014 until February 2017 and followed up for 28 days or until hospital discharge. 3472 patients were assigned to cricoid pressure (Sellick group) or a sham procedure group. Mean age was 51 years and 51% were men. Inclusion: all adults; Exclusion: pregnancy.

Key Results: 

Primary measure of pulmonary aspiration, occurred in 10 patients (0.6%) in the Sellick group and in 9 patients (0.5%) in the sham group.

Secondary Measures:

  • No significant difference in pneumonia, length of stay and mortality.
  • The Cricoid (Sellick maneuver) group had significantly longer intubation time (median, 27 vs. 23 seconds).
  • Longer intubation time >30 seconds, Cricoid 47% vs Sham 40%; P <.001.
  • Comparison of the Cormack and Lehane grade (Grades 3 and 4) in Cricoid (10%) vs Sham (5%; P <.001).
  • All suggests an increased difficulty of tracheal intubation in the Cricoid (Sellick) group.

Summary: 

Investigators summary: “the results failed to demonstrate the noninferiority of a sham procedure in preventing pulmonary aspiration compared with the cricoid pressure. Mortality, pneumonia, and length of stay did not differ significantly between groups, and differences in intubation time and laryngoscopic exposure suggest more difficulties in the Sellick group”.

Nursing Clinical Questions:

  • Is cricoid pressure needed if there is no harm prevention and gives inferior views of the airway?
  • This study population was in theatre, can the results be transferred into the pre-hospital, ED or ICU populations (and in pregnancy)?
  • Should nurses use the evidence base to encourage the deimplementation of ‘ritualistic’ practice? See below in Deimplementation Resources.
  • Should nurses just refuse to perform a non-evidence based procedure?

Additional Resources:

Recommended Viewing on Cricoid: Cricolol by John Hinds on Vimeo.

Deimplementation Resources

Rogers, E. M. (1995) Diffusion of innovations. (5th ed.) Simon and Schuster, New York, USA. [summary article]

Nursing Education Network. (2017) Deimplementation of Practice.

Nursing Education Network. (2016) Human Centred Design.

 

 

 

 

 

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