Obstetric tracheal intubation guidelines and cricoid pressure – a reply
Bibliographic record
Abstract
We thank Dr Priebe for his interest in our Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics 1. One of our aims during writing the guidelines was to modernise the approach to obstetric general anaesthesia, in keeping with anaesthetic practice in the non-pregnant patient. In view of this, we have recommended many significant changes. Our literature search revealed a lack of robust evidence-based information, particularly in controversial areas, and therefore our group decided that it was necessary to produce guidelines based on expert consensus rather than high-level evidence. We decided that it was necessary to continue to recommend the use of cricoid pressure in the technique of rapid sequence induction, which is keeping with national or otherwise well-recognised non-obstetric and obstetric failed intubation guidelines in the UK, Canada, Italy and America 2-6. The use of cricoid pressure reflects UK practice, as shown in previous surveys 7, 8. On the other hand, we emphasise correct application of cricoid pressure, and early release of cricoid pressure during difficult laryngoscopy/tracheal intubation and for supraglottic airway device insertion. We have clarified that cricoid pressure may make airway management difficult, and that it is impossible to maintain cricoid pressure for prolonged periods of time. We wish to comment on Dr Priebe's point that cricoid pressure would not be introduced as a new technique were it to be assessed by the ADEPT process, as there is a lack of level 3b evidence for the use of cricoid pressure. The ADEPT process was described as a method of assessing and selecting new airway devices for introduction into hospitals 9. By definition, each use of a new device provides information, and hence such an assessment may be completed with a feasible number of patients 10. However, the incidence of pulmonary aspiration during obstetric general anaesthesia is sufficiently rare as to make a comparative assessment of the effect of cricoid pressure on this outcome virtually impossible (although there is suggestive evidence for its benefit in reducing regurgitation at induction in high-risk patients 11, 12). We are not introducing cricoid pressure into clinical practice, and therefore the burden of proof is on the safety of stopping its use rather than demonstrating its benefit. We would like to paraphrase Dr. Priebe's last sentence: ‘We need to prove that not using cricoid pressure in the obstetric population reduces difficulties and complications, compared to using optimised cricoid pressure, before we abandon it. We owe it to our patients.’
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".