Cricoid pressure… time to change?

Revised 22 April 2014

Cliff Reid recently wrote a post on cricoid pressure in response to a long online discussion (since deleted) featuring the usual logical fallacies, circular arguments and dogmatic claims of negligence against enlightened practitioners who have discarded this unproven technique.

He originally invited the ‘tongue-in-cheek’ renaming of the procedure to highlight its drawbacks.  However, due to the unnecessary offence caused, Cliff has wisely decided to withdraw the parody with its misfiring acronym. His perspective on why he thinks cricoid pressure lacks value, and on the storm that raged following his original post, is worth reading.

I think these comments left on the original post remain valid. The first by Cliff himself, explaining his original post and where he was coming from:

Please note I have had some feedback that this post has caused offence to person(s) I have the utmost respect for, for which I sincerely and publicly apologise. I am grateful for their honest feedback which has resulted in some subtle rewording to avoid the impression of ad hominem attack. [Editor note: the original parody of cricoid pressure and its acronym have since been removed]

I consider cricoid pressure to be potentially harmful to patients, and feel duty bound to challenge it most assertively. Through social media we have immense influence and here I have attempted to offset its continued promotion by other influential figures who add credence to those who wield the power to punish a provider legally or professionally for not following a non-evidence based guideline.

I respect these colleagues immensely, and I respect ABSOLUTELY their right to hold and express different views to myself, but I do NOT respect all of their views, and I do not believe any view held by a ‘public figure’ (including me) should be protected from critique, criticism or even ridicule if the latter promotes detailed consideration and skepticism of the topic in question. I promise it is NEVER personal.

Please read the post in the spirit it is intended – as a cheeky poke in the ribs to those who actively put themselves in a position of influence, forfeiting any entitlement to protection from criticism. If you think this is ‘anti-anaesthetist’, read the paragraph beginning ‘An unsurprising but at the same time very reassuring observation…‘. I am continually in awe of the anaesthetists I work with who are so much smarter than me and who have taught me so much.

Finally to the individual practitioner torn over this issue. Please follow your institutional policy, and always do what you think is best for the patient in the moment. If the guideline doesn’t fit with what you think is right, work on changing the guideline.

Keep lysing the dogma

Cliff

… and this was my reaction to Cliff’s post:

It is clear that (this) is:

“..an example of an intervention introduced with little evidence, handed down from teacher to student over the years as a pseudoaxiom. Pseudoaxioms need to be criticised, studied and discarded where appropriate.”

To me it is clear that:
(1) there is little to no evidence for it’s benefit
(2) there is low level evidence that it can cause harm
(3) the weight of evidence is for harm over benefit, especially in the critically ill due to distraction, unnecessary added complexity, and delay to first pass intubation.

It is obscene to think that there are health professionals who would claim that those who do not perform this unproven procedure are negligent. We need to eradicate this procedure being deemed mandatory from any guideline or recommendations (such as NAP4) on RSI. We also need to name and shame the logical fallacies used by proponents of this technique to justify its use.

I have amended the LITFL CCC entry on cricoid pressure appropriately:
http://lifeinthefastlane.com/education/ccc/cricoid-pressure/

Cheers and thanks
Chris

Look out for John Hinds’ destruction of cricoid pressure in the ‘Cricoid… to press, or not to press?’ debate from smaccGOLD  (likely packed with logical fallacies on both sides for edutainment purposes) when released on the SMACC podcast…

Ultimately, I agree with Cliff — it is up to the individual to make up his or her own mind, and importantly to follow local policy. But I am adamant that no claims can be made about cricoid pressure, or not performing cricoid pressure, being a standard of care. Any guidelines or protocols that suggest otherwise should be challenged. No one should be allowed to call a doctor negligent for performing or not performing cricoid pressure given the (lack of) evidence. Logical fallacies and wrong-headed thinking should always be challenged when deployed in a sincere debate  — indeed, I expect others to do the same when I am the perpetrator.

Like Cliff, I apologise for any unnecessary offence caused by promoting the original parody-gone-wrong. We are humans and we make mistakes. In future we will try to remain hard on the issues, but softer on the people that matter as we try to defend what we think is right.

Down with dogma!

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Comments

  1. says

    Thanks Chris. It is indeed the thought that colleagues would testify that we are negligent (or have deviated from the standard of care) for not applying it that disturbs me the most, when they cannot substantiate their recommendation with any science. It is unethical and against reason.

    • says

      Definitely Cliff -- that is what has stirred me up too. I actually don’t mind if someone else performs cricoid pressure if they have their reasons, even though I don’t agree with them. The evidence base is so poor it is not worth being dogmatic about it.
      The guidelines and so-called experts making recommendations need to recognise that clinical practice can vary within the limits defined by the current evidence base.
      Chris

  2. Mark Fisher says

    “That which can be asserted without evidence, can be dismissed without evidence.” – Christopher Hitchens

  3. Upul Hewa says

    I’ve been waiting for the last 13 years for this to happen and it still continues to persist despite the lack of any supportive good quality evidence. Tried many a times to stop people distracting the process of RSI with no avail. Good luck to all of us in the near future to change this practice as there are enough people out there who regard this procedure as “Gold standard for prevention of passive aspiration”.

  4. says

    If I may be permitted to add some quotes from my SMACC talk on ‘What to believe, when to change’ as it seems that we are indeed at a point when we must consider a change in practice.

    First from Thomas Aldous Huxley
    ‘History warns us, however, that it is the customary fate of new truths to begin as heresies and to end as superstitions’

    and secondly (also from TAH)
    ‘…irrationaly held truths may be more harmful than reasoned errors..’

    and lastly from the rather remarkable Maya Angelou
    ‘Do the best you can until you know better. Then when you know better do better.’

    I think we now know better, don’t we?

    S

  5. Victoria says

    Like Chris, I was disturbed by the words “standard of care” being used again and again. It felt subversive. I remember when steroids for blunt spinal cord injury were the standard of care- now shown to be harmful. Standard of care shouldn’t be stated when the evidence for it or against it doesn’t exist.

    Keep an open mind….

    Victoria

  6. says

    So -- is it not time for an international consensus statement on RSI of the critically unwell, acknowledging the controversy and the fact that “RSI” as an entity is practiced in many different forms (Morris & Cook 2008 paper) with uncertainty over the value of certain components, a sin this paper

    http://pdfs.journals.lww.com/anesthesia-analgesia/2010/05000/Rapid_Sequence_Induction_and_Intubation__Current.14.pdf

    We’ve come a long way from the head down, head tilt, pre-curarisation form of Safar’s original RSI and Sellicks description of CP…

    A contemporary consensus statement might serve useful for expert testimony in the future, rather than the current state of play.

    How about it?

    • says

      Agree Tim -- for it to be worth anything I expect it would need to involve relevant professional bodies.
      Policy statements from ACEP and ACEM would be a useful beginning, I think.
      Who knows the Twitter discussion caused by this might lead to a new trial :-) -- big brain researchers like Young, Delaney and Finfer have started discussing it at least as a result!
      Chris

  7. says

    …maybe. Leads from those with significant involvement in EM/CC/PHEC would seem obvious

    Weingart & Reid would seem sensible places to start…FOAMed users shaping policy, not the usual turgid top-down approach via committee

    Just my tuppence worth.

Comments