Life-saving or ineffective? An observational study of the use of cricoid pressure and maternal outcome in an African setting

Background: Cricoid pressure is a routine part of rapid-sequence induction of general anaesthesia in obstetrics, but its efficacy in saving life is difficult to ascertain. Methods: As part of a prospective observational study of caesarean sections performed between January 1998 and June 2000 in 27 hospitals in Malawi, the anaesthetist recorded whether cricoid pressure was applied, the method of anaesthesia, the use of endotracheal intubation, the occurrence and timing of regurgitation and any other pre- or intra-operative complications. Logistic regression was used to assess the effect of cricoid pressure, type of anaesthetic and pre-operative complications on vomiting/regurgitation and death. Results: Data were collected for 4891 general anaesthetics that involved intubation. Cricoid pressure was applied in 61%; 139 women vomited or regurgitated, but only 30 on induction of anaesthesia, in 24 of whom cricoid pressure was applied. There were 77 deaths, I I of which were associated with regurgitation, in 10 of which regurgitation contributed to the death. Nine of the I I mothers had cricoid pressure applied. Only one died on the table, the rest postoperatively. All those who died had preoperative complications. Conclusion: This study does not provide any evidence for a protective effect of cricoid pressure as used in this context, in preventing regurgitation or death. Preoperative gastric emptying may be a more effective measure to prevent aspiration of gastric contents. (C) 2008 Elsevier Ltd. All rights reserved.