Cricoid Pressure Application Guidelines

Training and Essential Knowledge

The person performing cricoid pressure must understand that the recommended force is 10 N initially in the awake patient, increasing to 30 N after loss of consciousness, as recommended by the British Journal of Anaesthesia 2
Training should include hands-on practice with force measurement devices, as knowledge around how much force to apply is consistently inconsistent among practitioners, according to the British Journal of Anaesthesia 2
The assistant must recognize that excessive force (>30 N) causes patient discomfort, retching, and can trigger the very aspiration event the maneuver aims to prevent, as stated in the British Journal of Anaesthesia 2

The person applying cricoid pressure must be empowered and trained to release pressure immediately if the laryngoscopist reports difficult visualization of the larynx, as recommended by the World Journal of Emergency Surgery and Anaesthesia 1, 3, 5
They must understand that if active vomiting occurs, cricoid pressure should be removed immediately to prevent oesophageal rupture, according to the British Journal of Anaesthesia 2
The assistant should recognize that cricoid pressure can worsen airway obstruction, impede facemask ventilation, distort laryngeal structures, and make intubation nearly eight times more difficult during rapid sequence induction, as stated in the British Journal of Anaesthesia 2

In the operating room for emergency laparotomy, anesthesiologists should be suitably experienced and familiar with managing emergency general surgery patients, as recommended by the World Journal of Emergency Surgery 1, 5
The anesthesia team should follow their country's current standard practice regarding cricoid pressure use, recognizing international variation exists, according to the World Journal of Emergency Surgery 1, 5
Pre-hospital organizations must have written and well-rehearsed protocols for cricoid pressure application and release, as stated in Anaesthesia 3
The practitioner with the most anesthetic experience should usually perform the first intubation attempt, while a trained assistant applies cricoid pressure, as recommended by Anaesthesia 3
Every effort should be made to ensure successful first-pass intubation, as the number of attempts is limited to three, according to Anaesthesia 3

The oesophagus sits posterolateral to the cricoid ring (mainly on the left side) in 50-91% of patients, not directly posterior as originally assumed, as stated in the British Journal of Anaesthesia 2, 6
Traditional midline cricoid pressure may not achieve oesophageal compression; paralaryngeal pressure may be more effective, though this is not standard practice, according to the British Journal of Anaesthesia 6

Most problems occur when too much force is applied (>30 N), causing airway distortion and making intubation more difficult, as stated in the British Journal of Anaesthesia 2
Cricoid pressure is uncomfortable in awake patients, particularly when force exceeds 20 N, and can cause retching and aspiration, according to the British Journal of Anaesthesia 2
The force can be reduced to 20 N if the patient is positioned head-up, as recommended by the British Journal of Anaesthesia 2
The assistant must maintain clear communication with the laryngoscopist throughout the procedure, as stated in Anaesthesia 3
There should be no hesitation to release cricoid pressure if requested by the intubating clinician, as recommended by the World Journal of Emergency Surgery, British Journal of Anaesthesia, and Anaesthesia 1, 2, 3

Despite lack of evidence, cricoid pressure remains standard practice in many countries because aspiration, though rare, carries extremely high mortality and morbidity risk when it occurs, as stated in the World Journal of Emergency Surgery, British Journal of Anaesthesia, and British Journal of Anaesthesia 1, 2, 5, 7
The 4th National Audit Project (NAP4) identified cases where omission of cricoid pressure led to patient harm or death from aspiration, but also found no cases where cricoid pressure itself caused major complications, according to the British Journal of Anaesthesia 2