A 32-year-old woman with a 6-month history of gastroesophageal reflux disease presents to the emergency department with acute appendicitis. She is scheduled for emergency appendectomy under general anesthesia. Her vitals are: BP 128/82 mmHg, HR 92 bpm, RR 18/min, SpO₂ 98% on room air. She last ate 2 hours ago. During rapid sequence induction, after pre-oxygenation and administration of induction agent and succinylcholine, the anesthesiologist applies cricoid pressure. What is the PRIMARY purpose of cricoid pressure during rapid sequence induction in this patient?

Explanation

## Cricoid Pressure in Rapid Sequence Induction **Key Point:** Cricoid pressure (Sellick maneuver) occludes the esophageal lumen by compressing it between the cricoid cartilage and the cervical vertebrae, preventing passive regurgitation and aspiration of gastric contents during the period of apnea and loss of protective airway reflexes. ### Mechanism of Action Cricoid pressure is applied with a force of 10 N during consciousness, increasing to 30 N after loss of consciousness. This compresses the esophagus posteriorly against the C5-C6 vertebrae, creating a physical barrier to gastric reflux. ### Clinical Context in This Patient This 32-year-old woman has: - Recent food intake (2 hours ago) — high aspiration risk - GERD history — increased gastric acid volume and reflux risk - Emergency surgery — cannot delay for fasting These factors make her a **high-risk aspiration candidate**, making cricoid pressure essential during RSI. ### Application Timing 1. **Pre-induction:** 10 N pressure with patient awake (to assess tolerance) 2. **Post-induction:** Increase to 30 N immediately after loss of consciousness 3. **Maintenance:** Continue until endotracheal tube cuff is inflated and position confirmed 4. **Release:** Only after confirmation of tube placement and cuff inflation **High-Yield:** Cricoid pressure should NOT be released until the endotracheal tube is confirmed to be in the trachea and the cuff is inflated — premature release defeats the purpose. **Clinical Pearl:** While cricoid pressure is standard in RSI, studies show it can impair visualization of the vocal cords in up to 60% of cases if applied too firmly. Gentle, progressive pressure is preferred. [cite:Miller's Anesthesia 8e Ch 28]