Sellick: Que disent les autres ?

La manoeuvre de Sellick

- Que disent les recommandations et RFE de nos sociétés savantes ?:

Cette manoeuvre est citée dans le document de la SFAR portant sur  la "Prise en charge des voies aériennes en anesthésie adulte, à l'exception de l'intubation difficile". Il y est dit qu'elle "peut gêner l’exposition glottique au cours d’une laryngoscopie directe". Elle l'est également dans le document portant sur l'intubation difficile ("Dans le cadre de l’urgence, l’ISR avec manoeuvre de Sellick est la technique de référence"). Dans la recommandation portant sur l'abord trachéal pour la ventilation mécanique des malades de réanimation il est indiqué qu'une "séquence d'induction anesthésique rapide (préoxygénation, administration IV d'un agent anesthésique et d'un curare d'action rapide, compression cricoïdienne) permet d'obtenir de bonnes conditions d'intubation et une protection des voies aériennes". Cette manoeuve est également recommandée dans le document portant sur la sédation et analgésie en structure d’urgence : "La pression cricoïdienne (hors contre-indication) débutée dès la perte de conscience et maintenu jusqu’à la vérification de la position de la sonde endotrachéale. Cette pression cricoïdienne doit être levée en cas de vomissement"

- L'intérêt de la manoeuvre de Sellick n'est cependant plus le même qu'il y a quelques années (1, 2, 3).

- Que lit on dans les recommandations étrangères ?

1. Chez les Sud Africains

Is cricoid pressure necessary ? [Rapid sequence intubation. Emergenc medicine society of South Africa EM015 EM015B]

" We don’t know – the evidence supporting the use of cricoid pressure is fairly limited and there is more and more evidence emerging about the damaging effects of this manoeuvre. It is acceptable to omit the use of cricoid pressure in RSI. It is also acceptable to use cricoid pressure, as long as it is released if it interferes with bag-mask ventilation or laryngoscopy. .

........ The use of cricoid pressure during RSI in the EC is controversial. The consensus of expert opinion at this point in time is that cricoid pressure should be applied after the patient has lost consciousness after the administration of the induction agent and continuously maintained until the cuff has been inflated and the position of the ETT has been confirmed to be correct. This guideline is subject to the following provisos:

• Cricoid pressure should not be used if the assistant is not trained and experienced with the procedure. EMSSA Practice Guidelines provide advice on recommended practice for emergency centres, emergency personnel and emergency care activities. The information within these papers statements is advice only. EMSSA will not be held liable for clinical outcomes related to these Guidelines

• Cricoid pressure should immediately be released and not reapplied if: o There is any difficulty in bag-mask ventilation. o A supraglottic airway device is inserted. o There is any difficulty with laryngoscopy, including if external laryngeal manipulation is required (which cannot be performed while maintaining effective cricoid pressure). o The patient vomits.

• The doctor may also elect not to make use of cricoid pressure at all during the RSI."

2. En Europe du nord

Pre-hospital airway management: Scandinavian Society for Anaesthesiology and Intensive Care Medicine 

Ils n'en parlent pas

3. Pour les suédois

Scandinavian clinical practice guidelines on general anaesthesia for emergency situations.

Jensenn AG et Al. Acta Anaesthesiol Scand 2010; 54: 922–950

"The use of cricoid pressure to reduce regurgitation is not based on scientific evidence. Therefore, its use cannot be recommended on the basis of scientific evidence. Anaesthesiologists can use the technique on individual judgement, but the anaesthesiologist must be ready to release the pressure if necessary. Cricoid pressure has been shown to limit the glottic view during laryngoscopy, and it should be releasedif such problems occur."

4. Pour les australiens 

Emergency Airway Management in the Trauma Patient

"In conscious patients the cricoid cartilage is palpated between the thumb and middle finger, with the index finger above. The cricoid cartilage is located just below the prominent thyroid cartilage (Adam’s apple). As anaesthesia is induced the pressure is increased in a vertical plane onto the vertebral body of C5. The amount of pressure needs to approximate to 30 Newtons, comparable to the pressure that would feel uncomfortable if applied to the bridge of the nose. Removal of cricoid pressure should only follow securing of the airway and the request of the person performing intubation."

5. Pour les anglais 

DAS RSI Intubation guidelines

"Cricoid force: 10N awake 30N anaesthetise. If poor view: Reduce cricoid force. If Failed intubation: Maintain 30N cricoid force. Consider reducing cricoid force if ventilation difficult. If failed oxygenation: Reduce cricoid force during insertion of the LMA"

6. Pour les canadiens

Prise en charge des voies aériennes – 2e partie – Recommandations lorsque des difficultés sont prévues

"As cricoid pressure is likely to have potential benefits, its continued use seems prudent during rapid sequence intubation in the patient at high risk of aspiration (Strong recommendation for, level of evidence C). However, if difficulty is encountered with face mask ventilation or tracheal intubation, or if SGD insertion is needed, progressive or complete release of cricoid pressure is justified."

7. Chez les US

Drug-Assisted Intubation in the Prehospital Setting (NAEMSP Position Statement)

"While we recommend the application of cricoid pressure, we note that there are presently no data to support the effectiveness of this technique during prehospital airway management."