Cricoid pressure for oral board exam?

[FiO2@21]

I'm one of those people who opts not to employ cricoid pressure and unlike other colleagues whom I respect, I don't use "token" cricoid for the purposes of charting that it happened.

So now I'm in the position where it's definitely not in my "muscle memory" when answering board questions about RSI.

I'm thinking that most board examiners are academics who wouldn't automatically fail me if I didn't automatically include cricoid in my RSI description. If someone asked why I didn't apply cricoid pressure I'd say something like "while I recognize there is a possibility that cricoid pressure could reduce the incidence of regurgitation following induction, I would prioritize placing a secured airway as soon as possible".

I know I can rattle off some variation of the above without much thought. I can certainly pretend I'd do cricoid if it would save me from failing but it would really grind my gears.

What do you guys think?

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[repititionition]

I think simply saying that there is substantial evidence placing the practice in question, and, if pressed, being able to cite some of the most relevant points from that literature, would convince anyone that you had a reasoned position.

That, plus demonstrating flexibility if an examiner were to really press you on it, would certainly be enough for them to move on.

 

[UscGhost]

You could argue, legitimately that cricoid isn't necessary for the reasons mentioned above.

However, I wouldn't necessarily recommend it. Picking unnecessary battles in a time controlled oral boards where you have to spend extra time explaining why you didn't use cricoid may cost you in the end.

You also don't know how it will be received by the examiner. Will they perceive you as being cocky or argumentative? Even if you aren't, it's a risk that won't be likely to provide you any benefits and may end up hurting you a bit.

Oral boards isn't a great time to pick battles

 

[Simba1711]

I would not cite literature on oral boards. Haven’t done it personally but attendings told me in residency they can really grill you on the details of the literature. Just say you did rapid sequence and cricoid pressure for the sake of the exam. I don’t do cricoid pressure in real life.

 

[woopedazz]

Cricoid is potential free money in the exam for minimal time investment. The act of mentioning it is unlikely to garner any marks, and if it's not a focus for the scenario they're unlikely to call you out on it... but if the scenario turns "difficult airway" on you --> you immediately can say "release cricoid" and you've scored yourself an actual mark for nothing. If you hadn't applied it in the first place you miss out on that easy point.

The exam sometimes involves baiting the examiners down an easier path, even if it's not what you usually do.

Any examiner's feel free to correct me here. This is just my opinion that worked well for me.

 

[anaesthetic]

Cricoid is potential free money in the exam for minimal time investment. The act of mentioning it is unlikely to garner any marks, and if it's not a focus for the scenario they're unlikely to call you out on it... but if the scenario turns "difficult airway" on you --> you immediately can say "release cricoid" and you've scored yourself an actual mark for nothing. If you hadn't applied it in the first place you miss out on that easy point.

The exam sometimes involves baiting the examiners down an easier path, even if it's not what you usually do.

Any examiner's feel free to correct me here. This is just my opinion that worked well for me.

Release cricoid. “The patient aspirates. What do you do now?”

Anything you say can and probably will be used against you. Doesn’t mean it’s wrong to say these things per se, but be prepared to defend your answer and move on.

On high risk aspiration cases, I have the nurses do “cricoid pressure” which is almost universally done incorrectly, but the maneuver is institutionally ingrained in our practice and the moment something goes wrong, the first question will be “Why didn’t you hold cricoid?” Somehow, I doubt our hospital administrators would be receptive to “well, the literature says…”.

I do it, doesn’t seem to hurt, and provides reassurance to everybody else in the room.

 

[linkin06]

You could say, "due to possible inexperience of the assistant, I find that cricoid pressure can sometimes hinder my view. The best first view can be without cricoid, so I RSI patient with the best possible view." Of course, they'll probably say patient vomits, then you're holding cricoid anyways. it's not a right or wrong answer if you can give a reasonable explanation.

 

[deleted875186]

Agree with above, exam moves fast and will blow past cricoid so long as you say something resonable. Focus on other things to study for. If you don’t use cricoid, simply omit it from your RSI shpeil, and if asked why no cricoid give a brief one liner “I would consider cricoid to prevent passive aspiration but would release cricoid if laryngoscopy was difficult to facilitate rapid intubation”.

 

[Gasworks]

Tell them how you disagree with 50 year old dogma and by all means cite literature and throw in some anecdotal experiences. Walk out and brag to everyone else how you “schooled” the examiners. One your way out don’t forget to rebook your hotel for when you retake the exam next year.

 

[Dr. Rude]

"Many consider it to be the standard of care, but the evidence for calling it so is not overwhelming, IMO".
But, It is unlikely to cause harm, it might help, so I would employ it making sure that the assistant was applying it correctly. Or some other BS

 

[dabears505]

How long have you been practicing that it's so engrained into your practice yet haven't taken oral boards?

 

[Urzuz]

How is this even a question? Why would you choose your oral boards as the time to go against dogma just for the sake of making a point? 🤦‍♂️

No wonder so many people fail this test.

 

[FiO2@21]

Tell them how you disagree with 50 year old dogma and by all means cite literature and throw in some anecdotal experiences. Walk out and brag to everyone else how you “schooled” the examiners. One your way out don’t forget to rebook your hotel for when you retake the exam next year.

How is this even a question? Why would you choose your oral boards as the time to go against dogma just for the sake of making a point? 🤦‍♂️

No wonder so many people fail this test.

To flesh my question out better, I was also a bit afraid that the oral board examiners would be academic types who might disagree with cricoid pressure and then ding me for wanting to do something that's controversial/counter-productive when I didn't even want to do it in the first place! I was clearly overthinking it.

I obviously have zero desire to make my personal preference a distraction during the exam. Sounds like most examiners would either prefer I apply cricoid or at the very least wouldn't punish me for using it as long as I acknowledge the possibility that it could theoretically worsen my glottic view.

Thanks everyone.

 

[FiO2@21]

How long have you been practicing that it's so engrained into your practice yet haven't taken oral boards?

You didn't have any habits by the time you finished residency? We didn't really have a "house style" so I developed and practiced preferences relatively early in residency.

 

[coffeebythelake]

To flesh my question out better, I was also a bit afraid that the oral board examiners would be academic types who might disagree with cricoid pressure and then ding me for wanting to do something that's controversial/counter-productive when I didn't even want to do it in the first place! I was clearly overthinking it.

I obviously have zero desire to make my personal preference a distraction during the exam. Sounds like most examiners would either prefer I apply cricoid or at the very least wouldn't punish me for using it as long as I acknowledge the possibility that it could theoretically worsen my glottic view.

Thanks everyone.

Agree with your points. Cricoid is dogma, with minimal benefit or even harm in some cases, and has been shown to worsen the glottic view (vs. Laryngeal / BURP manuever) I don't think an examiner will grill you on this unless they intended to make a big deal about cricoid vs no cricoid regardless of what you choose.

 

[Maz777]

I'm one of those people who opts not to employ cricoid pressure and unlike other colleagues whom I respect, I don't use "token" cricoid for the purposes of charting that it happened.

So now I'm in the position where it's definitely not in my "muscle memory" when answering board questions about RSI.

I'm thinking that most board examiners are academics who wouldn't automatically fail me if I didn't automatically include cricoid in my RSI description. If someone asked why I didn't apply cricoid pressure I'd say something like "while I recognize there is a possibility that cricoid pressure could reduce the incidence of regurgitation following induction, I would prioritize placing a secured airway as soon as possible".

I know I can rattle off some variation of the above without much thought. I can certainly pretend I'd do cricoid if it would save me from failing but it would really grind my gears.

What do you guys think?

I would definitely not do this for orals. Make it your muscle memory. True, cricoid pressure is academic dogma. Those administering the orals are usually of that variety though. If you try to cite newer data that cricoid pressure might not be indicated, prepare to be destroyed (and have memorized every one of those publications with every known study design/bias that could have impacted the results). For orals, err on the side of performing cricoid pressure for RSI. If an annoying examiner wants to press you on the efficacy of cricoid pressure, you could potentially say that newer data has called into question the efficacy of cricoid pressure but you would need to review the literature (although I wouldn't). Don't try to start citing papers or act like you know the literature. Every publication has inherent biases and (usually) major/minor study design flaws. Don't go down that route. Move on to the next question. I'd be a little worried about your ego coming through during orals based on your post. Would definitely recommend practicing with people you do not know very well and getting feedback on that issue. You'll need to swallow any sort of pride you have during orals.

 

[FiO2@21]

I would definitely not do this for orals. Make it your muscle memory. True, cricoid pressure is academic dogma. Those administering the orals are usually of that variety though. If you try to cite newer data that cricoid pressure might not be indicated, prepare to be destroyed (and have memorized every one of those publications with every known study design/bias that could have impacted the results). For orals, err on the side of performing cricoid pressure for RSI. If an annoying examiner wants to press you on the efficacy of cricoid pressure, you could potentially say that newer data has called into question the efficacy of cricoid pressure but you would need to review the literature (although I wouldn't). Don't try to start citing papers or act like you know the literature. Every publication has inherent biases and (usually) major/minor study design flaws. Don't go down that route. Move on to the next question. I'd be a little worried about your ego coming through during orals based on your post. Would definitely recommend practicing with people you do not know very well and getting feedback on that issue. You'll need to swallow any sort of pride you have during orals.

I have 0 plans to cite literature and definitely wouldn't get close to implying I know more than an examiner.

I posted this because I thought there might be a variability with examiners that might allow or even prefer I leave out cricoid pressure, since that would have been easier for me at this (super early) stage of preparation. Since that doesn't seem to be the case I'll just practice including cricoid during my RSI with a prepared caveat if I get pushed on that point by the examiner. No big deal.

 

[deleted875186]

I have 0 plans to cite literature and definitely wouldn't get close to implying I know more than an examiner.

I posted this because I thought there might be a variability with examiners that might allow or even prefer I leave out cricoid pressure, since that would have been easier for me at this (super early) stage of preparation. Since that doesn't seem to be the case I'll just practice including cricoid during my RSI with a prepared caveat if I get pushed on that point by the examiner. No big deal.

I never had an examiner mention or ask anything about literature or evidence for my answers during orals. I did not use any phrase like “there is evidence to support such and such” as well. In general they are not going to grill you on a topic like this especially if it is controversial. The test is more fast paced, and they tend to throw a few things from left field that might not be anticipated based on the stem to see how yoj react.

 

[dpmd]

This post caught my eye because we recently had an M and M discussion where the anesthesia presenter was practically in tears remorsefully describing how he didn't ask for cricoid pressure for an rsi that ended up aspirating and arresting. I was unaware there was any effort to overturn this as standard of care. Is it just a matter of wanting pressure in a different direction (as mentioned in a post above) or is there a push to not apply any pressure? And is that for any rsi or just ones where there isn't higher risk (like a bowel obstruction with liters in the stomach who hasn't decompressed which was the case for the death being discussed).

 

[cchoukal]

Your job isn’t to be “right,” whatever that is; your job is to string together the correct syllables in the correct order to pass the test. Whether it’s cricoid or anything else, goin so far against the grain and decades of culture simply because of an absence of data will create unnecessary risk.

 

[vector2]

This post caught my eye because we recently had an M and M discussion where the anesthesia presenter was practically in tears remorsefully describing how he didn't ask for cricoid pressure for an rsi that ended up aspirating and arresting. I was unaware there was any effort to overturn this as standard of care. Is it just a matter of wanting pressure in a different direction (as mentioned in a post above) or is there a push to not apply any pressure? And is that for any rsi or just ones where there isn't higher risk (like a bowel obstruction with liters in the stomach who hasn't decompressed which was the case for the death being discussed).

It's controversial cause there's some evidence that 1. Cricoid pressure typically isn't done with enough pressure to occlude the esophagus, 2. That even when there is enough pressure, there's enough variability in the relative position of the esophagus that cricoid pressure might not even be occluding the lumen, 3. The laryngoscopy view is so frequently made bad by cricoid that the person holding it releases it 50% of the time anyway

 

[FiO2@21]

This post caught my eye because we recently had an M and M discussion where the anesthesia presenter was practically in tears remorsefully describing how he didn't ask for cricoid pressure for an rsi that ended up aspirating and arresting. I was unaware there was any effort to overturn this as standard of care. Is it just a matter of wanting pressure in a different direction (as mentioned in a post above) or is there a push to not apply any pressure? And is that for any rsi or just ones where there isn't higher risk (like a bowel obstruction with liters in the stomach who hasn't decompressed which was the case for the death being discussed).

I'll be the first to say that there is no large study that convincingly tells us that cricoid pressure does not reduce aspiration.

There have been studies attempting to say this, but they're underpowered given how rare aspiration is in the first place. On the flip side, there aren't studies definitively telling us that it does reduce aspiration.

So we have to rely on studies examining the anatomy/physiology of the maneuver.

They've done cadaver studies demonstrating that cricoid could prevent saline from refluxing and there was one small series demonstrating that cricoid prevents OG tubes from being passed. I think there are case reports of aspiration seen once cricoid was released.

There have been conflicting imaging studies showing that the esophagus doesn't actually get occluded with cricoid but that the portion of the pharynx prior to the esophagus does get occluded. There was small study suggesting that LES tone actually goes down with cricoid pressure but those were in awake patients.

There's a meta-analysis that did not show reduced first pass success or intubation time but an RCT that showed slower intubation time.

So overall pretty unconvincing data either way. I personally have not been using cricoid pressure because of the insane variability in technique. It could be helping or it could be making it worse. To be completely honest since we're relatively anonymous here, I'm not even sure I could do it "properly". Maybe if everyone in the OR had to knock out reps with a trainer like this I'd feel differently. Those of use who don't use cricoid aren't completely unsupported. AHA removed routine use of cricoid during CPR from their recommendations, I think a couple critical care societies did also did the same.

Going back to your case, what if he did ask for cricoid and then others suggested that the patient aspirated because the intubation took too long?

I think it's definitely less controversial (though not completely devoid of controversy) to place an NGT and decompress prior to induction. I have one or two attendings say an awake flexible scope intubation should be done in cases of SBO with a large volume of gastric contents if you can't place an NGT. I doubt this is a realistic expectation, the overlap between patients who can't tolerate an NGT placement but somehow could tolerate an awake fiberoptic seems super tiny. Unless it was just unsuccessful passing of the NGT rather than lack of cooperation? Who knows.

 

[dpmd]

I'll be the first to say that there is no large study that convincingly tells us that cricoid pressure does not reduce aspiration.

There have been studies attempting to say this, but they're underpowered given how rare aspiration is in the first place. On the flip side, there aren't studies definitively telling us that it does reduce aspiration.

So we have to rely on studies examining the anatomy/physiology of the maneuver.

They've done cadaver studies demonstrating that cricoid could prevent saline from refluxing and there was one small series demonstrating that cricoid prevents OG tubes from being passed. I think there are case reports of aspiration seen once cricoid was released.

There have been conflicting imaging studies showing that the esophagus doesn't actually get occluded with cricoid but that the portion of the pharynx prior to the esophagus does get occluded. There was small study suggesting that LES tone actually goes down with cricoid pressure but those were in awake patients.

There's a meta-analysis that did not show reduced first pass success or intubation time but an RCT that showed slower intubation time.

So overall pretty unconvincing data either way. I personally have not been using cricoid pressure because of the insane variability in technique. It could be helping or it could be making it worse. To be completely honest since we're relatively anonymous here, I'm not even sure I could do it "properly". Maybe if everyone in the OR had to knock out reps with a trainer like this I'd feel differently. Those of use who don't use cricoid aren't completely unsupported. AHA removed routine use of cricoid during CPR from their recommendations, I think a couple critical care societies did also did the same.

Going back to your case, what if he did ask for cricoid and then others suggested that the patient aspirated because the intubation took too long?

I think it's definitely less controversial (though not completely devoid of controversy) to place an NGT and decompress prior to induction. I have one or two attendings say an awake flexible scope intubation should be done in cases of SBO with a large volume of gastric contents if you can't place an NGT. I doubt this is a realistic expectation, the overlap between patients who can't tolerate an NGT placement but somehow could tolerate an awake fiberoptic seems super tiny. Unless it was just unsuccessful passing of the NGT rather than lack of cooperation? Who knows.

I was in the why the hell didn't you decompress and fluid resuscitate the patient before getting to the OR camp but as a surgeon I wouldn't feel right commenting on how long an intubation took anyway. Dude was supine with his full stomach on the or table before they figured out the one small iv they had was dislodged so the cricoid pressure was the last thing on my mind but was being harped on so much that the thread title piqued my curiosity. In a similar type patient who couldn't tolerate ng placement I worked with anesthesia to basically do a seated position sedation for placing the ngt which resulted in violent decompression of the stomach outside of the patient and unfortunately onto the anesthesiologist. Followed by an uneventful rsi after he changed his clothes. I don't think any amount of cricoid would have kept him from aspirating if he had gone directly to supine rsi. The distance achieved of gastric contents around the tube was impressive.

 

[coffeebythelake]

This post caught my eye because we recently had an M and M discussion where the anesthesia presenter was practically in tears remorsefully describing how he didn't ask for cricoid pressure for an rsi that ended up aspirating and arresting. I was unaware there was any effort to overturn this as standard of care. Is it just a matter of wanting pressure in a different direction (as mentioned in a post above) or is there a push to not apply any pressure? And is that for any rsi or just ones where there isn't higher risk (like a bowel obstruction with liters in the stomach who hasn't decompressed which was the case for the death being discussed).

My bigger question in this case is... Did thr patient have some mechanical bowel obstruction and if so was an NG tube placed beforehand. That matters more than cricoid pressure

 

[dpmd]

My bigger question in this case is... Did thr patient have some mechanical bowel obstruction and if so was an NG tube placed beforehand. That matters more than cricoid pressure

Obstruction from an incarcerated hernia. I missed past of the presentation so I wasn't sure why there was no ngt. I agree with you that its placement (and placing the damn thing to suction which apparently the new hospital policy is saying you have to wait for an X ray to confirm placement in order to do this which is the stupidest policy I have heard in a while since an ng not on suction is an aspiration risk in any patient and more so for an obstructed one)

 

[Ezekiel2517]

You're fine, don't overthink this. If they ask you why you did or didn't give cricoid, just tell them why. As an oral board examiner I know once told me long ago, more than anything else, they want to know your thought process. They want to know what you're thinking. So tell them

 

[vector2]

Obstruction from an incarcerated hernia. I missed past of the presentation so I wasn't sure why there was no ngt. I agree with you that its placement (and placing the damn thing to suction which apparently the new hospital policy is saying you have to wait for an X ray to confirm placement in order to do this which is the stupidest policy I have heard in a while since an ng not on suction is an aspiration risk in any patient and more so for an obstructed one)

It is imperative for you as a surgeon to make sure the pt with a bonafide obstruction has an NGT by the time you're putting in the case request. It shouldn't be one of those things where the anesthesiologist in pre-op has to be the one telling the patient he needs one. Or even worse, discovering it's a difficult placement at the last minute thus delaying the case, or god forbid rolling the dice and doing an RSI without one in place.

Also, most anesthesiologists would be glad to do the right thing for the patient and help topicalize the nares and proximal nasopharynx if it means having a working NGT in place before induction of anesthesia

 

[dpmd]

It is imperative for you as a surgeon to make sure the pt with a bonafide obstruction has an NGT by the time you're putting in the case request. It shouldn't be one of those things where the anesthesiologist in pre-op has to be the one telling the patient he needs one. Or even worse, discovering it's a difficult placement at the last minute thus delaying the case, or god forbid rolling the dice and doing an RSI without one in place.

Also, most anesthesiologists would be glad to do the right thing for the patient and help topicalize the nares and proximal nasopharynx if it means having a working NGT in place before induction of anesthesia

Yeah, that was why I was surprised this patient made it all the way to the OR without one.

 

[coffeebythelake]

I dont know how strong the evidence is but this was what I was taught when I was a resident. Start at 10N of force when awake and gradually increase to 30N when induction drugs are being given. Use thumb and middle finger to feel for both sides of the cricoid cartilage and use the index finger to push down.

How many people know how to apply that much force? Or what that even means?

 

[vector2]

Yeah, that was why I was surprised this patient made it all the way to the OR without one.

This happens to me like once a quarter. The resident and/or the floor nurse who has an active "insert NGT" order either don't do one or they give up immediately when the pt refuses without telling the pt how dangerous it is to induce anesthesia without one.

 

[Arch Guillotti]

Start at 10N of force when awake

I don't do any when they are awake.

 

[dpmd]

The nurses will even give up without an attempt if the patient says no without going over the risks of refusal or at least letting me know so i can do so. Super frustrating.

 

[coffeebythelake]

The nurses will even give up without an attempt if the patient says no without going over the risks of refusal or at least letting me know so i can do so. Super frustrating.

That seems to be the theme with nursing nowadays. New nurses are horrible at procedures once deemed nursing tasks. Even IVs. Tried once, or pt refusal, punted and charted as MD notified.

 

[DocVapor]

This reminds me of one of my nightmare cases that will be sticking with me throughout my career.

New attending, medical direction. On call. One of the most experienced CRNA's. Surgeon calls exploratory laparotomy for dead bowel, guy has had a working NG tube that has been to suction. For some reason surgeon sends pt to CT for one last quick scan before coming to OR. Apparently NG tube comes out during CT. They call me to ask if I want it back in. I say no because it was my understanding he was coming straight to OR and I felt low risk he had large volume and I didn't want an NG opening up the vomit highway.

Somehow some random Nursing Educator uses this guy as a teaching opportunity for nursing students and puts an NG down before getting to OR. Complete surprise to me as I walk in the room for induction (I was also covering a C/S). Tube looks completely clean and pristine.

I don't use cricoid. We induce and as soon as CRNA starts laryngoscopy the guy aspirates a large volume. Apply lots of suction and get the tube in, then I get the bronch and washout as best I can. Surgery proceeds and patient slowly starts dying despite everything I could do. We get him off the table and dropped off in ICU, and the surgeon says to me that he ended up having to resect so much dead bowel that there's no chance the guy will survive.

Patient dies 30 minutes later with the trusty CRNA that started the case sleeping soundly in bed because he'd been relieved.

So many failures, and I probably blame myself for more than I should.

I still don't do cricoid pressure.

 

[nimbus]

This reminds me of one of my nightmare cases that will be sticking with me throughout my career.

New attending, medical direction. On call. One of the most experienced CRNA's. Surgeon calls exploratory laparotomy for dead bowel, guy has had a working NG tube that has been to suction. For some reason surgeon sends pt to CT for one last quick scan before coming to OR. Apparently NG tube comes out during CT. They call me to ask if I want it back in. I say no because it was my understanding he was coming straight to OR and I felt low risk he had large volume and I didn't want an NG opening up the vomit highway.

Somehow some random Nursing Educator uses this guy as a teaching opportunity for nursing students and puts an NG down before getting to OR. Complete surprise to me as I walk in the room for induction (I was also covering a C/S). Tube looks completely clean and pristine.

I don't use cricoid. We induce and as soon as CRNA starts laryngoscopy the guy aspirates a large volume. Apply lots of suction and get the tube in, then I get the bronch and washout as best I can. Surgery proceeds and patient slowly starts dying despite everything I could do. We get him off the table and dropped off in ICU, and the surgeon says to me that he ended up having to resect so much dead bowel that there's no chance the guy will survive.

Patient dies 30 minutes later with the trusty CRNA that started the case sleeping soundly in bed because he'd been relieved.

So many failures, and I probably blame myself for more than I should.

I still don't do cricoid pressure.

Would have been interesting to see how big the stomach was on the CT scan.

 

[DocVapor]

Would have been interesting to see how big the stomach was on the CT scan.

I was so upset/mad/exhausted I never even thought to look.

Needless to say, the number of people I trust to do the right thing shrank tremendously that day.

 

[dabears505]

Did you hook up the NG to suction?

 

[Simba1711]

I had a bowel obstruction case come up. Of course patient doesn’t have an ng tube. Told surgeon to place one. 400cc just on placement.

 

[dpmd]

Did you hook up the NG to suction?

Was probably barely larger than a dobhoff and even on suction doesn't pull stuff out quickly. This is the current problem I deal with despite specifically ordering a large bore NG. The nurses want to use a more comfortable tube I guess. Never mind the consequences to the patient

 

[chessknt]

This reminds me of one of my nightmare cases that will be sticking with me throughout my career.

New attending, medical direction. On call. One of the most experienced CRNA's. Surgeon calls exploratory laparotomy for dead bowel, guy has had a working NG tube that has been to suction. For some reason surgeon sends pt to CT for one last quick scan before coming to OR. Apparently NG tube comes out during CT. They call me to ask if I want it back in. I say no because it was my understanding he was coming straight to OR and I felt low risk he had large volume and I didn't want an NG opening up the vomit highway.

Somehow some random Nursing Educator uses this guy as a teaching opportunity for nursing students and puts an NG down before getting to OR. Complete surprise to me as I walk in the room for induction (I was also covering a C/S). Tube looks completely clean and pristine.

I don't use cricoid. We induce and as soon as CRNA starts laryngoscopy the guy aspirates a large volume. Apply lots of suction and get the tube in, then I get the bronch and washout as best I can. Surgery proceeds and patient slowly starts dying despite everything I could do. We get him off the table and dropped off in ICU, and the surgeon says to me that he ended up having to resect so much dead bowel that there's no chance the guy will survive.

Patient dies 30 minutes later with the trusty CRNA that started the case sleeping soundly in bed because he'd been relieved.

So many failures, and I probably blame myself for more than I should.

I still don't do cricoid pressure.

I mean cause if death there is not going to be ards or hypoxia so it really didn't matter at all.

 

[pocafx]

I had a case recently. SBO. NGT put out 3L in OR literally over 4 minutes. Inuduced rsi no cricoid another liter came out when placing ETT.

 

[DocVapor]

Did you hook up the NG to suction?

No, I assumed the CRNA had since I was fresh out of residency and that's the first thing I would have done upon getting in the room. Well I learned the hard way what happens when you make assumptions.

I mean cause if death there is not going to be ards or hypoxia so it really didn't matter at all.

True. Still didn't help me feel better about it at the time.

 

[repititionition]

while bowel obstructions are slam dunk for pre-induction NGT, what other abdominopelvic pathologies do others empirically place them for?

 

[pocafx]

I have not done awake ngt as an anesthesiologist. How many are you guys doing or have done?

 

[kb1900]

I have not done awake ngt as an anesthesiologist. How many are you guys doing or have done?

Surely you did during intern year though? I mean I probably did 50-100 between surgery and ICUs


This is tangential but in our ORs we are treating ozempic patients as full stomachs/RSI. The other day I was relieving a co-resident from a otherwise healthy mid 30s BMI 42 RnY and noted almoost 300cc in the suction container. Apparently all from immediately post-induction OGT.

 

[pocafx]

None during intern year. I had a cush year. I thought nurses place most of them?

 

[DocVapor]

None during intern year. I had a cush year. I thought nurses place most of them?

Depends on if you're at a Veteran's Affairs facility or a NY facility.

 

[Katheudontas parateroumen]

This question from OP applies to any answer you give on the oral boards. As mentioned by a few here, it’s all about thought process. You don’t have to go into great detail about what you are going to do. The examiners have a set of questions they want/have to go through. Follow up questions are usually kept to a minimum and move on.

This is why answering the UBP way is not advised from the book. You will certainly be cut off by your first sentence to get on with it to the point. If they ask how would you induce this patient you just say I’m concerned about SBO so I’d make sure to have NGT decompression prior to induction and then RSI. If they want to follow up with cricoid they will, but you’ll be surprised that they will just skip right over it. If for some reason they wanna ask you for cricoid, you can totally say your thoughts there. Anything is game as long as you can explain things. The only true fatal errors are things like screwing up ACLS or Difficult airway algorithm and truly poor decision making even after multiple prompting. The examiners really try to help you and lead you.

 

[coffeebythelake]

This question from OP applies to any answer you give on the oral boards. As mentioned by a few here, it’s all about thought process. You don’t have to go into great detail about what you are going to do. The examiners have a set of questions they want/have to go through. Follow up questions are usually kept to a minimum and move on.

This is why answering the UBP way is not advised from the book. You will certainly be cut off by your first sentence to get on with it to the point. If they ask how would you induce this patient you just say I’m concerned about SBO so I’d make sure to have NGT decompression prior to induction and then RSI. If they want to follow up with cricoid they will, but you’ll be surprised that they will just skip right over it. If for some reason they wanna ask you for cricoid, you can totally say your thoughts there. Anything is game as long as you can explain things. The only true fatal errors are things like screwing up ACLS or Difficult airway algorithm and truly poor decision making even after multiple prompting. The examiners really try to help you and lead you.

Agree with this. The oral boards is stressful but not meant to be tricky or "gotcha" style questioning. Reasonable plan and rationale is enough.

 

[Radetzky]

The cricoid discussion is interesting because it always clear, no matter what setting, that nobody has actually read the original paper from which the practice originated. It refers to a common practice in that day being head down inhalational induction, even for sick patients. In fact the concept of RSI appears to be only several years old at that point.

He then goes on to describe that he gave cricoid to 26 patients. And 3 of them had massive regurgitation after cricoid was released. The results are summarized in 12 lines.

This is the evidence upon which the practice is built. The paper would have been rejected by any journal it was submitted to by todays standards.

Oh, and it was mentioned that with cricoid, you can now ventilate without worry about gastric insufflation