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


… 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:

Cheers and thanks

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!

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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