Quantifying the Effective Cricoid Force to Occlude the Esophageal Entrance in Anesthetized and Muscle-Relaxed Children: A Videolaryngoscopy-Based Assessment.

BACKGROUND

When cricoid pressure was introduced in pediatric anesthesia, the cricoid force was not defined, leading pediatric anesthesiologists to question its necessity, effectiveness, and safety. We hypothesized that airway complications encountered in clinical practice may have resulted from the exertion of excessive cricoid force.

METHODS

Using a novel instrument, we measured cricoid force during Glidescope® videolaryngoscopy in three groups of 40 anesthetized children: Group 1 (3-5 years), Group 2 (6-8 years), and Group 3 (9-14 years). A biased-coin up-and-down design was employed to estimate the median force required to prevent the insertion of a suction catheter into the esophagus.

RESULTS

There were no instances of difficult endotracheal intubation. The median cricoid force required to prevent suction catheter insertion into the esophagus in 90% of patients was 4.85 Newton (N) (95% CI 4.12-7.34) in Group 1, 8.74 N (95% CI 8.30-9.73) in Group 2, and 13.0 N (95% CI 11.2-16.9) in Group 3.

CONCLUSIONS

Age-appropriate cricoid force applied under videolaryngoscopic guidance effectively occludes the esophageal entrance without compromising endotracheal intubation. These forces are substantially lower than the thresholds known to cause airway distortion or obstruction in children and are lower than the force recommended for adults. These findings may have implications for the use of cricoid pressure as a component of the rapid sequence intubation (RSI) technique in children at risk of pulmonary aspiration.

TRIAL REGISTRATION: ClinicalTrials.gov (NCT05290844).