sellick maneuver, BURP , OELM

sellick maneuver, BURP , OELM

1. SELLICK MANEUVER BURP,OELM DR . ZIKRULLAH

2. SELLICK’S MANEUVER CRICOID PRESSURE (CP) Introduction Brian Arthur Sellick was a consultant anesthesiologist at Middlesex hospital, London. His description of CP to prevent regurgitation of gastric contents during induction and intubation of trachea made him famous world over Cricoid pressure during induction of anesthesia was first described in his paper in Lancet in 1961

3. He demonstrated, C P must be exerted by an assistant. Before induction the cricoid is palpated and lightly held between the thumb and second finger. As induction begins pressure is exerted on cricoid cartilage mainly by the index finger. It should be maintained until the ETT is secured.

4. Cricoid Pressure CP presses cricoid cartilage against the cervical vertebrae(C6)and so compresses lumen of pharynx. It counteracts a reduction in OESP during induction and prevents regurgitation. The pressure applied should be backward and in mid line. The CP is a force and is therefore measured in newtons (1Kg=9.8N).

5. The cricoid cartilage (CC) is signet ring shaped and is a complete ring. It is attached superiorly to the thyroid cartilage by the cricothyroid ligament and inferiorly to the first tracheal ring. The esophagus begins at the lower border of the CC, and the cricopharyngeus muscle guards the esophageal opening. The CC differs in size and location in adults and children.

6. Indications During RSI, CP is used to protect the paralyzed patient from passive regurgitation. These are : 1) Non fasted patients 2) Esophageal pathology 3) Hiatus hernia 4) Bowel pathology 5) Vomiting prior procedure

7. Sellick Maneuver  

8. Technique of cricoid pressure Single-Handed Cricoid Pressure Double-Handed Cricoid Pressure

9. Single-Handed Cricoid Pressure For single-handed CP, the thumb and middle finger are placed on either side of the CC, and the index finger is placed above to prevent lateral movement of the cricoid . [ The laryngoscopic view is better with the head in the Magill position and with single-handed CP as compared with double-handed CP. It is recommended that the application of CP should be performed with the left hand from the left side of the patient, thus preventing interference with laryngoscopy , specifically when the laryngoscope blade is inserted from the right corner of the mouth.

10. Double-Handed Cricoid Pressure The bimanual or two-handed CP technique uses the single-handed technique, as previously described, in addition to using the assistant's right hand to provide counterpressure beneath the cervical vertebra for neck support. The purpose of this maneuver is to provide support to the hyperextended arch of the vertebral column to maintain the efficacy of CP and optimize the laryngoscopic view. Variations of this technique include placing the left hand behind the head and holding the extended head to maintain the Magill intubating position.

11. Timing of C P It should be explained to the patient. CP should be applied by assistant before the induction. Pressure should be increased to 30N as patient loses consciousness. And maintained until airway is secured.

12. How much cricoid force prevent regurgitation It has been assessed by cricoid yoke. 30N cricoid force prevent regurgitation in all cases with eosophageal pressure of 42mm Hg due to saline in cadavers. Therefore 30N CF will prevent regurgitation of eosophageal contents and replaces the function of UOS, when it relaxes from its mean awake value about 40 mm Hg. 30N force provide a pressure of 200 mm Hg below the 10 cm square area of lamina of cricoid.

13. CRICOID YOKE Is a mechanical device that is known to provide optimal cricoid pressure consistently . It is designed to deliver 44 Newtons of pressure to the cricoid cartilage. Device is held by grasping ends of the stainless steel wings with thumb and forefinger of each hand and pressing down with molded foam cushion againts cricoid cartilage.

14. Nasogastric tube and C P Sallick originally suggested that eosophageal tube can  the risk of regurgitation by breaching both upper and lower sphincters and interfere the application of CP . However there has been little evidence to support this So if nasogastric tube is inserted it need not to be removed before a RSI. Further more NGT is not occluded by CP, they should be left open to atmosphere to vent liquid and gases to limit the  in gastric pressure during induction.

15. LMA and C P LMA does not prevent regurgitation. Despite this, LMA is recommended as an airway in failed intubation drill for paralyzed patient who can not be intubated or even ventilated by face mask, but the CP should be maintained. LMA does not reduce the efficacy of CP .

16. Complications Some conscious patient feel difficulty in breathing mainly during inspiration when applied pressure is more than 20N. But most patient tolerate 20N force without being uncomfortable. It should be in range of 10 – 20N not more than that when the patient is awake.

17. Difficulty in intubation CP causes 1) Compression of airway 2) Displacing the larynx 3) Collapsing the thyroid cartilage and distorting the larynx 4) If force > 40N can prevent even mask ventilation. In such conditions applied force is reduced until airway is secured with ETT.

18. Eosophageal rupture CP maintained during retching would allow eosophageal pressure to rise, which may result in eosophageal rupture. Sellick originally advised that CP should be released if retching occurs during induction. But it is recommended now that CP should be continued as this complication has not been reported till date.

19. Guidelines for C P After preoxygenation CP with a force of 10N should be applied to awake patient in ideal head and neck position for intubation . If retching occurs pressure should be maintained. With loss of consciousness the force should be increased to 30N and continued until airway is secured. CP should only be applied by trained assistant with correct level of force.

20. Cricoid Pressure in Clinical Practice In clinical practice, the application of a predetermined CP can be sustained for only a short period of time. The application of CP with a flexed arm could be sustained only for a mean time of 3.7 minutes at 40 N, with considerable onset of pain at 2.3 minutes.

21. In view of the fact that sustained CP cannot be maintained for more than a few minutes, it has important clinical implications in the situation of failed endotracheal intubation in the presence of a full stomach.

22. . Further, an important clinical limitation to the application of CP in clinical practice is that it may interfere with airway management ( endotracheal intubation, face mask ventilation, and LMA placement), and failure to manage the airway appropriately is a more frequent cause of morbidity and mortality compared with the risk of pulmonary aspiration

23. BURP “BURP”-backwards, upwards, right, pressure May help with difficult intubation

24. “BURP” – also known as “External Laryngeal Manipulation” B ackward, U pward, R ightward P ressure: manipulation of the trachea 90% of the time the best view will be obtained by pressing over the thyroid cartilage Differs from the Sellick Maneuver

25. Thyroid versus Cricothyroid Cartilage Thyroid cartilage used in “BURP” maneuver. Does not form a complete ring around the trachea. Cricothyroid Cartilage used in CricoidPressure, does form a full ring around the trachea allowing for the compression of the esophagus.

26. 90% of the time the best view will be obtained by pressing over the thyroid cartilage – because, anatomically, the vocal cords are connected here. This maneuver is known to improve Cormack & Lehane laynngoscopic grade by 1

27. DIFFERENCE B/W SELLICK MANEUVER 1.Pressure over CRICOID cartilage. 2.Deteriorate laryngoscope view. BURP 1. Pressure over THYROID cartilage. 2. Improve Cormack & Lehane’s laryngoscopic grade by 1 y 1

28. OELM OPTIMAL EXTERNAL LARYNGEAL MANEUVER DONE TO IMPROVE LARYNGOSCOPIC VIEM

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