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September 1999
Volume 63 |
Number 9
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| Brian A. Sellick,
M.B.: Father of Cricoid Pressure Maneuver (1918-1996) |
David J. Wilkinson,
M.B., Ch.B.
Brian Arthur Sellick, a consultant anaesthetist at the Middlesex
Hospital in London, died on July 13, 1996, at the age of 78. Although
contributing widely in many branches of anaesthesia, his name
is internationally known because of his description of cricoid
pressure to prevent regurgitation of gastric contents during intubation
of the trachea. Sellick's maneuver, as it became known, spread
rapidly across the world and has been taught and practiced ever
since. There are those who have suggested that the use of this
type of approach to obstruct the esophagus is not new, however,
and it is interesting to read the early descriptions of this sort
of technique by those who practiced resuscitation in the 18th
century.
The inception of "an institution for affording immediate
relief to persons apparently dead from drowning" on April 18,
1774, by Thomas Cogan, M.D., and William Hawes, M.D., in London,
was a paradigm shift in medical management and social behavior.
Although occasional reports of successful resuscitation attempts
had appeared in the medical press for several decades, there was
no systematic attempt to introduce such practice on a regular
basis. Cogan and Hawes gained support from a large number of doctors
who lived near the River Thames and who were willing to be called
out to assist in attempted resuscitations. The impetus for lay
people to join in was purely financial initially: the Society
resolved to pay the sum of two guineas to anyone who attempted
to revive a drowned person, provided that those endeavors lasted
for at least two hours!
Very sophisticated equipment was designed to facilitate
this practice. The three mainstays of treatment were to restore
respiration by expired air or bellows ventilation, the drying
and warming of patients and the use of tobacco smoke enemas. To
facilitate ventilation, there was the initial development of oral
and nasal airways; from these came the development of curved metal
tubes that could be placed blindly by palpation into the trachea.
The initial "institution" evolved over the next decade gaining
Royal patronage from George III in the process to become The Royal
Humane Society. The Society* is still in existence
today and is still pursuing the ideals of its ancestors in rewarding
bravery and skill by the general public through a series of medals
and scrolls.
Every year since its inception, the Society has awarded
a series of silver and gold medals to special research projects
presented in the form of essays. One of the winners of a Silver
Medal in 1788 was Charles Kite of Gravesend. He wrote in his essay
titled "An Essay on the Recovery of the Apparently Drowned," that
"the restoring of the action of the lungs to be of the very
first importance in all our attempts to recover the apparently
dead." In addition, he described the use of pressure on the
front of the neck as follows to "prevent the air passing into
the stomach instead of entering the lungs." This does not
appear to be a new concept of Kite's. His reporting is more in
the tone of accepted technique. James Curry of Northampton went
into greater detail in his "Observations on Apparent Death..."
published in 1796. He wrote, "Not merely blowing into the nostril
or mouth will do Air will pass into and distend the stomach.
Therefore the second assistant with his right hand to press backwards
and draw gently downwards towards the chest the upper part of
the wind-pipe, that part which lies a little below the chin which
from its prominence in men is vulgarly called Adam's Apple; by
doing this the Gullet will be completely stopped up whilst the
windpipe will be rendered more open to let air pass freely into
the lungs." He suggested that those trying to resuscitate
should continue for at least six hours!
In this we see a very different purpose between those
early pioneers of resuscitation and Sellick. One group was trying
to prevent forced ventilation of the stomach while Sellick was
trying to prevent gastric contents causing soiling of the lungs.
Sellick introduced most effectively a reverse Kite or Curry.
Sellick started his anesthesia training at Middlesex Hospital
and was a junior resident there during the London Blitz. At the
end of the war, he was appointed to the staff of Middlesex and
started to specialize in thoracic anesthesia. His work on early
ventilators and hypothermia were pivotal in those pioneering days.
He had visited Swan's Clinic in Denver, Colorado, and brought
back to London the practices used there. The team that developed
the surface cooling technique for the treatment of atrial septal
defects relied heavily on Sellick's undoubted skills. But strangely,
it was not this work or his later work with screen oxygenators
that were to be his lasting memory, though he taught several generations
of anaesthetists the finer points of cardiac and thoracic anesthesia.
His paper on cricoid pressure appeared in the Lancet
in 1961. It is an excellent short communication and bears re-reading
now. He wrote, "When the contents of the stomach or esophagus
gain access to the air-passages during anaesthesia, the consequences
are disastrous. In spite of modern anaesthetic techniques or sometimes
regrettably because of them, regurgitation is still a considerable
hazard during induction of anaesthesia, particularly for operative
obstetrics and emergency general surgery." This was a time
in which the literature was full of reports of disasters of this
nature, and a crucial investigation had been undertaken by the
Association of Anaesthetists of Great Britain and Ireland into
43 cases of regurgitation or vomiting that proved fatal during
anaesthesia. The results of this investigation and suggestions
for the management of these cases was published in Anaesthesia
in 1951 and was the forerunner of all subsequent anesthesia audit
and critical incident reporting. The greatest concern was in operative
obstetrics, and a variety of techniques were described to minimize
problems, but they still arose.
Sellick's seminal paper shows lateral X-rays of the neck
with the esophagus containing a latex tube full of contrast medium,
and the effect of cricoid pressure is wonderfully demonstrated.
"Cricoid pressure must be exerted by an assistant. Before induction,
the cricoid is palpated and lightly held between the thumb and
second finger; as anaesthesia begins, pressure is exerted on the
cricoid cartilage mainly by the index finger. Even a conscious
patient can tolerate moderate pressure without discomfort but
as soon as consciousness is lost, firm pressure can be applied
without obstruction of the patient's airway. Pressure is maintained
until intubation and inflation of the cuff of the endotracheal
tube is complete." The diagrams and photographs of this application
of pressure are excellent. He goes on to echo the thoughts of
Kite and Curry saying, "During cricoid pressure the lungs may
be ventilated by intermittent positive pressure without risk of
gastric distension."
He was aware that this technique should not be relied
on totally and that there were drawbacks in its use. He advocates
the use of all possible methods to try to empty the patient's
stomach using a Ryle's tube or esophageal tube and adds that these
should be removed before induction to prevent their presence from
hampering the natural esophageal sphincters. He describes preoxygenation,
an open vein and the importance of ready suction and a tipping
trolley much as we would today. In the discussion, he writes,
"The 'old-fashioned' inhalational induction in the supine or
lateral position with head down tilt has something to commend
it. If vomiting occurs, it usually does so at lighter levels of
anaesthesia when protective reflexes are still present." He
goes on to say about cricoid pressure that "it should never
be used to control active vomiting because the esophagus might
be damaged by vomit under high pressure." His paper then highlights
the management of 26 high-risk cases in which his technique was
used without any problems at all. He mentions that in three of
these cases, when the cricoid pressure was removed after the airway
had been secured, the pharynx was filled with gastric contents,
thus illustrating the effectiveness of the technique for at least
those three cases.
Sellick's elegant paper changed the face of anesthesia
across the world. Every anesthesiologist is now familiar with
a rapid sequence induction with cricoid pressure, although some
do not realize the association with Brian Sellick. What did he
think of this? We do not know; his contemporaries describe him
as "that sort of a chap who was full of good ideas." He was not
particularly interested in history, and there is no evidence that
he ever read the words of Kite or Curry. He was just another lateral
thinker.
All anesthesiologists and most patients should remember
the name of Brian Sellick with much gratitude. He changed what
was a frightening, dangerous induction of anaesthesia to a more
controlled and safer procedure. But we should not forget the other
contributions he made to our specialty, and his record with hypothermia
in cardiac surgery had no equal in his time in Europe. He received
many accolades during his life, including the Henry Hill Hickman
medal of the Royal Society of Medicine and the Gold Medal of the
Royal College of Anaesthetists. A happy man with a wonderful sense
of humour and a ready smile, he left the world a better place
and his specialty a safer one.
David J. Wilkinson, M.B., Ch.B., is Consultant
Anaesthetist, St. Bartholo-mew's Hospital, and Honorary Archivist,
Association of Anaesthetists of Great Britain and Ireland, London,
United Kingdom.
References:
- Kite C. An essay on the recovery of the apparently dead. London:
C Dilly; 1788.
- Curry J. Popular observations on apparent death from drowning,
suffocation etc. with an account of the means to be employed
for recovery. Northampton: T Dicey and Co; 1792.
- Pallister WK. Obituary Brian Arthur Sellick. Anaesthesia.
1996; 51:1194-1195.
- Sellick BA. Cricoid pressure to control regurgitation of
stomach contents during induction of anaesthesia: preliminary
communication. Lancet. 1961; 2:404-406.
- Morton HJV, Wylie WD. Anaesthetic deaths due to regurgitation
or vomiting. Anaesthesia. 1951; 6:190-201 and 205.
- Coleman DJ, Day BL. Anaesthesia for operative obstetrics;
value of cuffed endotracheal tube. Lancet. 1956; 1:708-709.
- Cope DHP and Pallister WK Personal communications.
* This purely charitable organization is
dependent totally on voluntary donations. Anyone wishing to support
this further should contact the Honorary Secretary, Major General
C. Tyler, Royal Humane Society, Brettenham House, Lancaster Place,
London WC2E 7EP, United Kingdom.
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