Policy

The Sellick Manoeuvre: maybe you’re doing it wrong…

I was NEVER going to write a post about cricoid pressure (it didn’t appear at all in “101 Tips for Anaesthetic Nurses”).
It always seemed so…fundamental to practice as an Anaesthetic nurse that there was nothing left to say. Recent controversies in relation to the application of cricoid pressure in the #FOAMed world left me appreciating that this wasn’t the case, especially as the arguments presented didn’t seem to address all the shades of gray…

 

The Sellick Manoeuvre, better known as “Cricoid Pressure”, was first described in 1961 by Dr Brian Sellick in a paper titled Cricoid pressure to control regurgitation of stomach contents during induction of anesthesia – preliminary communication.

The application of pressure to the cricoid cartilage was advocated by Sellick following use of the technique on 26 “high risk” patients during induction and intubation. In 23 cases, no signs of aspiration or regurgitation of gastric contents was found at all during intubation, and in 3 cases regurgitation of gastric contents followed the release of cricoid pressure.

In 1961 there was routine use of high tidal volumes (greater than 10ml/kg), trendelenberg (head down) positioning during intubation, and use of barbituate anaesthesia. (The original “planes of anaesthesia” model described the physiological effects of inhaled ether and was easily modified when barbituates came into practice. With current pharmacology practice has changed so much that neither physiological model has much relevance).

For the next 40 years, the Sellick Manoeuvre was accepted practice in Anaesthetics, Intensive Care and Emergency particularly for non-fasted patients or during rapid sequence intubations. This is despite changes to the practice of anaesthesia (and intubation techniques).

However, in the early 2000’s, some aspects of the use of the Sellick Manoeuvre were found to be not as simple as first thought.

Damage to the cricoid, lateral movement of the oesophagus (not posterior occlusion as intended) and triggering of reflexative relaxation of the lower oesophageal sphincter causing regurgitation may all be physiological responses to the application of the Sellick Manoeuvre (Yao, Fontes and Malhotra, 2012).

Not to mention the difficulty in visualisation of the glottis for the laryngoscopist as a result of mobilisation of the larynx, with associated reduction in first-pass intubation.

In fact, a related technique called BURP (Backward, Upward, Rightward Pressure) was developed to improve visualisation of the glottis and therefore improve the incidence of first-pass intubation.

 
(This man has some serious manoeuvres, but they’re not right either)
 

There has been controversy recently within the #FOAM world in relation to the routine application of the Sellick Manoeuvre during intubation and the evidence for or against. Much of the obvious preferences centre around the difficulty in obtaining first-pass intubation due to impaired visualisation. As the chance of aspiration from gastric regurgitation from all causes is reduced by successful intubation, improving the glottic view is the focus of this blog.

The prevailing thought-leader opinion seems to be passionately and firmly in the belief that the use of cricoid pressure is not justified in routine clinical practice. Opinion had been divided into “tribes”: eg. use of the Sellick Manoeuvre may be justified in anaesthesia, but not in intensive care or emergency. Interestingly, College Fellowship exams of all three colleges require that the Sellick Manoeuvre be applied (or at least considered) for intubation scenarios.

Academia (somewhat more staid than #FOAM) seems firmly out to lunch on the matter. Several sources suggest the use of the Sellick Manoeuvre can neither be recommended nor discouraged, citing benefits, drawbacks, and unknowns.

So where does that leave us?

Before throwing the baby out with the bath water, it might be good to look at what the Sellick Manoeuvre actually involves.

Importantly, Sellick’s description of the technique specifies that pressure should be applied via the index finger, after the cricoid carilage has been palpated between the thumb and the 2nd finger (Sellick, 1961: 405). The original Sellick article does not specify which hand should be used or on which side of the patient the person applying pressure should stand. The thumb and two finger technique was the method I was taught, using the right hand (I’m very left handed), standing on the patient’s right.

The Sellick Manoeuvre was one of the first things I learned as a junior Anaesthetic nurse.I was taught by an Anaesthetic nurse, not by an Anaesthetist. Successful demonstration of Cricoid Pressure during a rapid sequence induction was the end point of my preceptorship in Anaesthetics (after a shift and a half).

Looking after the airway is ultimately the Anaesthetist’s responsibility, but it is also the primary reason for the Anaesthetic nurse’s role. If you ask them during their more honest moments, most Anaesthetic nurses will tell you that they don’t really work that hard for their wages. Except during emergencies such as difficult airways. It’s what they have to know, in order to appropriately do, and when.

Over time I have had many opportunities to apply cricoid pressure during difficult airways for prolonged periods. When tired, it is natural to drag your hand (and the larynx) towards you. This can make a difficult airway harder. The last thing you want is to be responsible for a difficult airway. This is your incentive to communicate with the laryngoscopist, to find out what the view of the larynx is like, to make adjustments.

Since I started, I have seen a variety of Anaesthetists, Intensive Care and Emergency specialists and Senior Registrars demonstrate Cricoid Pressure to junior nurses and residents, or attempt to assist each other…

…and they don’t do it very well.

It’s kind of surprising. Anyone other than another Anaesthetic nurse seems to stand either side of the patient or uses either hand, or uses more digits than thumb and first two fingers. Some just…mash

The lack of practice, consistency and established communication between intubator and assistant mean that it is difficult to know if applying pressure to the cricoid is achieving anything.

It means it is difficult to know if the person applying pressure is moving the larynx laterally, or whether the patient has a deviated trachea.

It means it is difficult to know if the person applying cricoid pressure is applying enough or too much pressure (and the lack of standardisation in technique means it is near impossible to ever ascertain what too little or too much even means).

I’m not suggesting for a moment that there are arcane skills amongst Anaesthetic nurses that no-one else can learn. But I am suggesting that if a group of professionals perform something like the Sellick Manoeuvre repeatedly and as consistently as possible and we still don’t know if it helps or not…

 

Then have it both ways…

Assess the patient and the conditions. Is there another way? Do you and the person you ask to place pressure on the cricoid have the same expectations? Now is a good time to find out…

Put it on. Try it.

Assess the view. See the glottis? Left, right or anterior? Tell the person assisting.

If it helps, leave it on.

If it doesn’t help, you can always take it off.

 

 

 

 

 

 

Bhatia, N.; Bhagat, H.; Sen,I. (2014) Cricoid Pressure: Where do we stand? Journal of Anaesthesiology Clinical Pharmacology Jan-Mar; 30(1): 3–6.

Sellick, B.A. (1961) Cricoid pressure to control regurgitation of stomach contents during induction of anesthesia – preliminary communication. Lancet (2): 404-406 accessed via www.hneed.com/storage/Original%20Sellick%20Article%201961.pdf

Yao, F.F.; Fontes, M.L.; Malhotra, V. (2012) Intraoperative Management in Yao and Artusio’s Anesthesiology: Problem-Oriented Patient Management (7th Edition). Lippincott Williams & Wilkins. accessed via https://www.inkling.com/store/book/yao-artusio-anesthesiology-fonte-malhotra-7th

 

 

 

 

 

 

 

 

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“Public Hospitals could save $430m by getting nurses to do some doctor tasks: report” – My Thoughts

My eye was caught today by an article in on the ABC news website.

 

Public hospitals could save $430m by getting nurses to do some doctor tasks: report – ABC News (Australian Broadcasting Corporation)

 

The gist of the piece is that “routine” procedures can be easily carried out by nurses at less cost. The author suggests endoscopies, colonoscopies, and sedating patients for low risk procedures.

The author appears to be an economist and public policy academic. This perspective is the only one in current Australian culture that the report makes sense. The Grattan Institute (http://grattan.edu.au/about-us) states that “it is an independent policy think tank providingindependent, rigorous and practical solutions to some of the country’s most pressing problems.”

I don’t have issue with the article per se (although at no point has anyone thought to ask any nurses what they think…) but I am riled by some of the more obvious comments attached below.

None of the Users commenting actually seem to understand the point of the original report or what the people in the modern health system actually do.

 

 

 

Comments all seem to follow a small number of themes:

  1. Just plain bitchy (“… our definition of a colonoscopy was “six feet of fibre optics with an ar*ehole at each end” … Modern nurses are well qualified to replace the current proceduralists” – User discus49, retired anaesthetist) Let he who casts the first stone, sir. You’d know, maybe having been one of the ar*eholes at some point. And I hope I never worked with you.
  2. The “I nearly died from an anaesthetic and I’m not going to let a nurse near me” response. I’m not even going to address this User’s concerns directly, they obviously had a bad experience which has hopefully resolved. They do suggest that nurses “are not trained specialtists” and several other claims not bearing scrutiny. Although I guarantee that what ever happened it was not fixed by doctors alone.
  3. The “perhaps vocational training at a hospital level (as it was 25 years ago) would be a good way to save resources instead of insisting on degree level training” – User cynical wasp, no occupation listed) line of thought. This comment unfortunately represents a large proportion of the general population who don’t understand what we actually do.

Further comments reflect the original article’s assertation that the RN duties of bathing and feeding could be passed on to vocationally trained nursing assistants.

So I suppose what this post is really about is a rebuttal to the “let’s train nurses as we always have” mixed with some thoughts about why nurse sedationists are a bad idea in modern Australia. If neither of these topics interest you, please read something else (really, my opinions aren’t going to change yours…come back though, there’ll be something else later more your style…)

The obvious response is why do we let the public have a say regarding nurse education anyway? Other professions don’t do this. We tend to invite “consumers” onto our Nursing Boards of Registration (the now defunct QNC used to have two such representatives) and as nurses we engage the community with position statements from Nursing Colleges and policy organisations.

In doing so we may educate a percentage of the population regarding the reality of modern healthcare and nurses place within it, but I believe that is the absolute minority. I feel that the vast majority of society only meet nurses when they find themselves in the unfortunate position of needing nursing care.

So should we go back to the old days of signing our (mostly female) young adults over to a regime of residential curfews, administration spies and vocation (read task focused) based training? Should we remove the rights of junior nurses to go “out” for social events (on own time) without the employers permission? Should we leave them without the ability to advocate for their patients, subservient to the requirements of the medical profession, with all the job satisfaction of knowing that if they keep going and achieve another poor pleb will come and relieve them of the burden of the bedpan?

Rather than answer in the manner in which I normally would (No! with references)…

Would we ever expect that surgeons give responsibility for their education back to barbers?

Would we ever expect that in order to save money, the health system sack all the anaesthetists in favour of good, strong sticks for patients to bite?

Would we ever expect that modern dentistry return to the “everything can be fixed with a good extraction” days of the past?

I could go on…(architects? airline pilots? rocket scientists?)

 

Society has changed. Nursing has changed. There is no real correlation between “what a doctor used to need to know and what a nurse needs to know now” but the body of knowledge involved in both professions does intersect and cover the same ground. One complements the other, not replaces it.

Nurses do and will likely always look after the patient as a person in an attempt to return that person to the best functional state they can achieve. That does involve feeding, and toileting, and bathing. These aren’t things that can always be passed off to another with vocational training. They are further opportunities to assess, to look closely, and they may be the only time available to do so. The fact that these things are not done is not always an indictment on the nurse but a comment on the current conditions in which we work: doing more with less.

The public perception that the nurse is more interested in completing the paperwork (computerised or not) couldn’t be further from the truth to the average nurse. Most could easily have gone for an administration job (without night shift) if that is what they wanted to do. The paperwork is devoted to justifying the hours costed for staffing the ward, and ultimately the costs spent by government in looking after the patient.

Part of my thinking in working in my chosen specialities was the potential for the nurse practitioner role in anaesthetics: the nurse anaesthetist. As alluded to by the Grattan Institute’s report and the ABC article, the role does exist in several countries. One of the prime impediments to adopting such a role in Australia is one of culture.

In the US, nurses have administered anaesthetics (or anesthetics, in American) since the earliest surgeries. Medicine only took responsibility for sedation relatively recently, in the 1960’s or thereabouts (with few exceptions, the people administering drugs to patients during surgery in M*A*S*H* were nurses).

In Australia we followed the English model. Thus doctors have always had responsibility of anaesthesia, and even the anaesthetic nurse role is defined by hospital policy rather than codified by any particular legislation (ANZCA, the College of Anaesthetists recommend that a staff person be provided by the hospital to assist the anaesthetist as required, they shall not be answerable to the surgeon, and shall have 18months ‘suitable’ educational preparation).

In practice, this means that the anaesthetic assistant is a former wardsperson, or some one off the street, or any other background deemed to have satisfied the 18 month rule (no specification is made of what the 18 months should include). Or if you are lucky, the hospital has a preference for Registered Nurses, with their Bachelor of Nursing (3 years) and a Graduate Certificate in Anaesthetic Nursing (1 year). This still isn’t an “I’m better than you are” argument: I can train an anaesthetic nurse in a shift and a half (that was all I recieved at the time) but it’ll take about two years before you really know what you’re doing.

After all that, I could keep someone asleep during surgery whilst the Anaesthetist went to the toilet, I could anticipate, I could intubate and assess, I was handy in an emergency, understood and could administerl all the medications, all the things you would want in an assistant. Once I came to ICU I learned a lot more, all relevant. I have all the experience I need to apply to a US-style program (they call them Certified Registered Nurse Anaesthetists, or CRNA’s).

The US model requires the equivalent of a Masters degree preparation, AFTER the background and preparation and education I currently have. I could do that. But I won’t. Even if we followed the Grattan Institute’s ideas and adopted the system here.

The CRNA model requires supervision. It has been a part of the system since the beginning and the nurses undertake ALL anaesthetics during ALL the procedures a hospital offers. All of them. Patients aren’t always given the choice, and the literature shows there is not a difference in the care from a nurse as from a doctor.

We simply do not have that culture in Australia. Nursing has an image problem (as demonstrated by the comments above indicating a lack of understanding with the staus quo) and the public likely won’t accept nurses in the role (imagine the outcry!!!)

As a child of cost cutting measures, the CRNA model in Australia would be a hard pill to swallow. There are not enough training positions for the doctors, never mind the CRNA’s requiring supervision. It is easy to foresee a potential future where should the adoption of CRNA’s be successful (against all odds) the newly minted CRNA’s are required to fill the backlog of vacancies in rural centres…

Aargh

As a nurse, my interest is in the patient as a person. Not in cost cutting for Government. That’s what the Grattan Institute is for.