Procedures

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)

http://tomselleck.tv-website.com/

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

A Soldier’s 5 is good for Clinicians, too

I spent some 6 years as an Army reservist in the Australian Army. Several aspects of my time (and training) have helped me in my career in both Anaesthetic and Intensive Care nursing. I’ll address some of these in future posts.

Perhaps the most relevant of these is the concept of the “Soldier’s 5”. It is a choice of 5 seconds, 5 minutes or 5 points that a soldier needs to know NOW.

An example might be using a new weapon:

the pointy end (towards the bad guy)
the safety (how not to hurt yourself)
the trigger (how to actually fire the thing)
The aiming reticle (how to aim it)
Where the ammunition goes and how to re-attach magazines (how to keep the thing going)

Of course in the real world, a soldier would ideally have lessons on new equipment before heading into battle.

Much like healthcare.

The benefit of the “Soldier’s 5” is that the method can be used from simple points with new practitioners through to more complex tasks with experienced practitioners.

A clinical example might be:

Synchronous Intermittent Mandatory Ventilation (SIMV) is a form of positive pressure ventilation
SIMV requires the patient breathe through an ETT
It can be volume or pressure controlled (set volume OR pressure)
SIMV allows a set number of breaths/minute but will “Synchronise” with spontaneous breaths
SIMV generally allows PEEP and Pressure Support adjustment

It works with auditory and kinetic learners, and the short points can be recorded by visual learners.

The “Soldiers 5” is generally highly repeatable: once used, the learner can rapidly become the teacher.

Of course, there is no scope for in depth understanding or for learner questioning, so a thorough follow up session relating theory to practice with an educator is recommended.

The team leader isn’t always the senior registrar (or the Director of ICU)

About four years ago I took some leave from my position and worked in another department for 6 months or so. I didn’t do this because I wanted to, I did it because I had to. That will be a much later post, and is a much different story from this one. I mention it here because the story from this post happened in the midst of the worst week of my career that forced me away for 6 months and nearly out of nursing…

The team leader isn’t always the senior registrar (or the Director of the ICU)…

At the start of our night shift we had an admission. She was a pillion passenger on a motorbike and had gone from the motorbike into a window, which had been thoughtfully opened by the rider of the bike who had been jettisoned though the glass head first, milliseconds earlier. He had died at the scene.

She had a head injury and severe liver damage and multiple long bone fractures and that night would require two operations in theatre and two trips to CT, as well as activated factor VII and the Massive Tranfusion Protocol. We couldn’t bring her ICP below 50mmHg, and she quite frankly had us all concerned.

All that was to come.

Right now she had just arrived in our ICU and had been too unstable for the emergency department to do a head scan, so our job was to stabilise her and get her to radiology on another floor and then back to our floor to OT.

A large team of nurses and junior doctors gathered at the bedside, ready to do what was required. The Director of ICU was the consultant and was standing back, arms casually folded, making decisions and guiding the team. Sometime over the next half hour the night shift doctors started drifting in, taking over from their day shift counterparts so they could prepare for the medical handover round.

Eventually, the consultant decided that if she was going to get to radiology now was the time. I was the ACCESS (or Bay nurse, or float nurse) in the area. He nodded towards me and I started delegating nurses to collect equipment, medications, transfer monitors and test transport ventilators, which is the kind of thing an ICU consultant might not know about. Keeping an eye on our activity and the patient the consultant started filling in the details for the night shift senior registrar.

I work with a truly wonderful team. Most of the senior nurses are interchangeable within roles, although we all have unique approaches to problems and situations. Right now, senior nurses and spare staff were completing delegated tasks, reporting to me and awaiting the next objective. I had people undertaking several steps of the process at the same time. Admittedly, this was before tabards clearly stating “Team Leader” or “Airway Nurse”…

Having been nominated to transfer the patient to CT, the oncoming senior registrar quickly looked around and asked the team at the bedspace if he could have some medications, (he seemed to ask everyone, or no-one, but not any one person) and proceded to list propofol (running already), noradrenaline (also running), vecuronium (infusing due to ICP), morphine (check) and midazolam (you guessed it, also being given) and then added mertaminol (something new).

Not only did he request those medications, he yelled those requests, with strengths and concentrations, and he yelled them over the quiet that had characterised our efforts so far.

Naturally, no-one much paid him attention. Certainly no one dropped what they were doing and ran to the medication room.

In the relative quiet after the senior registrar had stopped yelling, the Director of ICU quietly turned to the senior registrar and said “I don’t think you’re in charge just at the minute, do you?” And pointed in my direction.

A look of understanding crossed the registrar’s face, (the force was strong with this one) and he asked me for his preferred medications. I quickly ran him through what he currently had, and asked two nurses to ensure adequate supplies had been made up for the trip.

The patient was out the door and on the way in less than 10 minutes from the time the decision to go had been communicated.

At the recent smaccGOLD 2014 conference on the Gold Coast, several presenters addressed issues surrounding “tribes”: nursing, medical, ICU, Emergency, Anaesthetics, Pre-Hospital and specialities. (Big shout out to @Socratic_EM, @cliffreid et al.) All presenters promoted a blurring of the “tribes” for the betterment of patient care.

Similarly, recent practice changes and coronial investigations have promoted readily identifiable clothing, tabards of stickers identifying roles in resuscitation or intervention situations, especially when teams are ad hoc and staff capabilities are unclear.

All of these ideas and practice changes are valuable. But that isn’t what this post is about.

When we do know our staff, and we do know our own capabilities, we shouldn’t be afraid to cede responsibility to another with more knowledge of a process or procedure. We don’t lose power or respect, rather we empower others and ourselves.

The Director of ICU wasn’t any less in charge of the situation, and wasn’t any less of a decision maker. He knew what his role was and so did everyone else there. But it had been a long time since he had actually prepped a patient for a trip to radiology.

Even without identifying markers, everyone else knew their roles as well. And amongst the senior staff, any one of us could have coordinated the transfer. It was just via allocation that it was me.

Similarly, if the senior registrar had taken a moment to assess the situation, breathe in, and look – he wouldn’t have been at a disadvantage when it came his turn to lead the team to and from the radiology department, either. We learn these lessons in first aid, in PHTLS, ALS, ATLS and all the other courses we do. Sometimes it is a matter of safety, and sometimes just to ease the wheels of communication and teamwork.

Midazolam Does Not Work Until it is Given

Midazolam Does Not Work Until It Is Given

Most of us have seen patients on midazolam. Some of us might’ve had some for minimally invasive procedures. The patient doesn’t remember anything and it’s possible they have the same conversation over. The patient doesn’t remember anything and they have the same

oh.

Right.

Anyhow, we had a gentleman who went into VF. He kept his output (he was monitored with both arterial line and ECG) but it was fading. He DID keep his alertness, however. We were very fast with the defibrillator. A senior registrar (who was on scene) proceeded to do what you do…charged, apologised “I’m very sorry sir…!”

And Zapped.

Followed by a cry of “SOMEBODY GET HIM MIDAZOLAM!!!”

And Zapped again.

He reverted, we got him the midazolam, can’t actually remember whether he needed to be intubated…but he remembered everything…and the first thing he did say was “CAN YOU PLEASE NEVER DO THAT AGAIN?”

In anaesthetics, we had a patient who had had his induction dose of proposal, suxemethonium, and fentanyl. We intubated him reasonably promptly, and as the anaesthetic nurse I set out to help the scout nurse with positioning the patient. The anaesthetist answered his telephone. The patient didn’t like us moving him. Pressure alarms went off on the ventilator…the whole thing. The anaesthetist gave more propofol, we positioned the patient, the surgeon started the procedure…the patient jumped, the anaesthetist rapidly sedated the patient with more propofol and told the surgeon “it was OK, they’ve had some midazolam”.

Except the patient hadn’t yet been given any.

Hence the tip: MIdazolam does not work until it has been given.

Midazolam is wonderful drug in for use in critical care. In small doses, it is relatively short acting. It is painlessly administered intranasally (equivalent dosage for I.V. – good for kiddies) and usable IV or via deep I.M. (obviously not as painlessly). It has a small number of incompatibilities in solutions and is good for procedural sedation, long term ICU sedation and as a second line treatment for status epilepticus.

It’s not perfect – it can cause respiratory depression or arrest and should be used with caution with intoxicated patients – it is metabolised in the liver via CYP3A4 (of the CYP450 family of oxidising enzymes) so drunk patients may have a prolonged duration of action.

This is NOT an administration guide for a medication. Clinicians should use their own judgement and adhere to relevant policies.