To the Editor:—

Cricoid pressure (Sellick's maneuver) is a routinely used technique for the prevention of pulmonary aspiration of gastric contents during anesthesia in patients at high risk of aspiration. Its effectiveness in preventing regurgitation of esophageal contents has been demonstrated in several studies 1,2and in cadavers. 3–5However, its effectiveness in preventing aspiration in clinical practice is debated. 6The following case scenario clearly demonstrates its effectiveness during clinical anesthesia.

A 21-yr-old, 75-kg man presented for repositioning of an intraocular lens under general anesthesia. He had a history of esophageal reconstruction by gastric pull-through to treat childhood achalasia. General anesthesia about 2 yr earlier for eye surgery had resulted in pulmonary aspiration of gastric contents during induction of anesthesia. No further details were available. Preoperatively, he was apprehensive about recurrent aspiration. On the day of surgery, he was given metoclopramide 10 mg and ranitidine 20 mg intravenously; he had taken nothing by mouth for 15 h previously. In the operating room, he was positioned supine with extension of the neck. The cricoid cartilage was identified while the patient was awake. Following adequate preoxygenation, continuous cricoid pressure was applied immediately before the induction of anesthesia with propofol 200 mg and succinylcholine 120 mg in a rapid sequence manner. Laryngoscopy and tracheal intubation with a 7.5 endotracheal tube were easily accomplished, the endotracheal tube cuff was inflated with 10 ml of air, and cricoid pressure was released. This was followed immediately by the appearance of copious, greenish fluid in the mouth, which was suctioned. There were no further sequelae.

Although no prospective randomized controlled clinical studies can be done to prove its clinical efficacy, the above case illustrates that proper application of cricoid pressure is effective, at least in some patients, in the prevention of gastric aspiration from passive regurgitation.

Wraight WJ, Chamney AR, Howells TH: The determination of an effective cricoid pressure. Anaesthesia 1983; 38: 461–6
Vanner RG, O'Dwyer JP, Pryle BJ, Reynolds F: Upper oesophageal sphincter pressure and the effect of cricoid pressure. Anaesthesia 1992; 47: 95–100
Salem MR, Wong AY, Fizzoti GF: Efficacy of cricoid pressure in preventing aspiration of gastric contents in paediatric patients. Br J Anaesth 1972; 44: 401–4
Salem MR, Joseph NJ, Heyman HJ, Belani B, Paulissian R, Ferrara TP: Cricoid compression is effective in obliterating the esophageal lumen in the presence of a nasogastric tube. A nesthesiology 1985; 63: 443–6
Vanner RG, Pryle BJ: Regurgitation and oesophageal rupture with cricoid pressure: A cadaver study. Anaesthesia 1992; 47: 732–5
Brimacombe JR, Berry AM: Cricoid pressure. Can J Anaesth 1997; 44: 414–25