Brull, Sorin J

Application of cricoid pressure (CP) during rapid sequence induction and intubation sequence has been a “standard” of care for many decades, despite limited scientific proof of its efficacy in preventing pulmonary aspiration of gastric contents. While some of the current rapid sequence induction and intubation guidelines recommend its use, other international guidelines do not, and many clinicians argue that there is insufficient evidence to either continue or abandon its use. Recently published articles and accompanying editorials have reignited the debate on the efficacy and safety of CP application and have generated multiple responses that pointed out the various (and significant) limitations of the available evidence. Thus, a critical discussion of available data must be undertaken before making a final clinical decision on such an important patient safety issue. In this review, the authors will take an objective look at the available scientific evidence about the effectiveness and safety of CP in patients at risk of pulmonary aspiration of gastric contents. We suggest that current data are inadequate to impose clinical guidelines on the use of CP because we acknowledge that currently there is not, and there may never be, a method to prevent aspiration in all patients. In addition, we reiterate that a universally accepted medical-legal standard for approaching the high-risk aspiration patient does not exist, discuss the differences in practice between the US and international practitioners regarding use of CP, and propose 5 recommendations on how future studies might be designed to obtain optimal scientific evidence about the effectiveness and safety of CP in patients at risk for pulmonary aspiration.

BACKGROUND: In patients who receive a nondepolarizing neuromuscular blocking drug (NMBD) during anesthesia, undetected postoperative residual neuromuscular block is a common occurrence that carries a risk of potentially serious adverse events, particularly postoperative pulmonary complications. There is abundant evidence that residual block can be prevented when real-time (quantitative) neuromuscular monitoring with measurement of the train-of-four ratio is used to guide NMBD administration and reversal. Nevertheless, a significant percentage of anesthesiologists fail to use quantitative devices or even conventional peripheral nerve stimulators routinely. Our hypothesis was that a contributing factor to the nonutilization of neuromuscular monitoring was anesthesiologists’ overconfidence in their knowledge and ability to manage the use of NMBDs without such guidance. METHODS: We conducted an Internet-based multilingual survey among anesthesiologists worldwide. We asked respondents to answer 9 true/false questions related to the use of neuromuscular blocking drugs. Participants were also asked to rate their confidence in the accuracy of each of their answers on a scale of 50% (pure guess) to 100% (certain of answer). RESULTS: Two thousand five hundred sixty persons accessed the website; of these, 1629 anesthesiologists from 80 countries completed the 9-question survey. The respondents correctly answered only 57% of the questions. In contrast, the mean confidence exhibited by the respondents was 84%, which was significantly greater than their accuracy. Of the 1629 respondents, 1496 (92%) were overconfident. CONCLUSIONS: The anesthesiologists surveyed expressed overconfidence in their knowledge and ability to manage the use of NMBDs. This overconfidence may be partially responsible for the failure to adopt routine perioperative neuromuscular monitoring. When clinicians are highly confident in their knowledge about a procedure, they are less likely to modify their clinical practice or seek further guidance on its use.