Cricoid pressure

What it is (and what it’s for)

• Cricoid pressure (Sellick manoeuvre) = backward pressure on the cricoid cartilage to try to reduce regurgitation of stomach contents during induction of anaesthesia.
• It is mainly used during rapid sequence induction (RSI) when aspiration risk is high (e.g., emergency surgery, full stomach).
• Aim: compress the oesophagus against the cervical vertebrae (note: anatomy can vary, so it is not always reliably effective).
• It is not a substitute for good RSI technique: pre-oxygenation, timely intubation, cuff inflation, and suction readiness remain essential.

When you might use it (common first-week scenarios)

• Emergency laparotomy / bowel obstruction, trauma, or any patient with a presumed full stomach.
• Obstetrics (e.g., category 1–2 Caesarean) depending on local policy and senior preference.
• Severe reflux/hiatus hernia or delayed gastric emptying (e.g., opioids, diabetes gastroparesis) where aspiration risk is judged high.
• If uncertain: ask the supervising anaesthetist early and agree a plan (including when to release it).

When to be cautious or avoid

• If it makes ventilation or intubation difficult: cricoid pressure should be modified or released promptly on instruction.
• Known or suspected laryngeal trauma, unstable neck injury, or anterior neck mass: discuss with senior; avoid causing harm.
• Active vomiting/retching: cricoid pressure may worsen oesophageal injury risk—prioritise turning head to side, suction, and airway protection.
• If awake or lightly anaesthetised: it can be painful and may provoke coughing/retching—apply only when the patient is unconscious (unless specifically instructed).

How to do it (step-by-step practical)

• Position: patient supine, head in sniffing position if appropriate; ensure you can access the front of the neck.
• Identify landmarks: thyroid cartilage (Adam’s apple) above; cricoid cartilage is the firm ring just below it.
• Hand position: use thumb and index/middle finger to stabilise the cricoid cartilage in the midline; press straight backwards (posteriorly), not upwards.
• Timing: apply after loss of consciousness and before positive pressure ventilation (unless instructed otherwise). Maintain until the tracheal tube cuff is inflated and correct placement is confirmed.
• Force (rule-of-thumb): gentle while awake (if ever required), then increase once unconscious; avoid excessive force that distorts the airway.
• Communication: the airway operator should clearly say “apply cricoid”, “increase”, “decrease”, “release”, and “reapply”. Repeat back to confirm.

If it causes problems (what to do immediately)

• If you cannot ventilate: ask for permission to reduce or release cricoid pressure; improving oxygenation comes first.
• If laryngoscopy view is worse: adjust (slightly reduce, reposition to midline) or release on instruction; consider external laryngeal manipulation separately (BURP/ELM) if requested.
• If the patient regurgitates: keep cricoid pressure only if it is helping and not worsening vomiting; suction aggressively, head down/side if feasible, and proceed with airway protection as directed.
• If intubation is delayed: maintain oxygenation; cricoid pressure should not prevent rescue ventilation or supraglottic airway placement if needed (release if required).

Team roles and set-up

• Assign a trained assistant specifically to cricoid pressure; they should not be multitasking.
• Agree the plan before induction: who applies, when to apply, what to do if ventilation/intubation is difficult, and when to release.
• Have suction on and within reach before induction; ensure a working Yankauer sucker.
• Document if used (and any issues): helpful for handover and learning.