Can’t Intubate, Can’t Oxygenate

This covers the CICO situation from the difficult airway drill.

• CICO should be verbally declared
• A CICO situation may occur when oxygen saturations are normal

A CICO situation occurs when there is a failure (or impending failure) to deliver oxygen due to supraglottic obstruction, and:

• This obstruction is unlikely to be relieved by persistent attempts at supraglottic rescue
• This obstruction may be bypassed with front of neck access
• Failure is defined as:
  • ETT
    Three optimal attempts.
  • SAD
    Two attempts with different sizes or devices.
  • Bag-Mask Ventilation with use of adjuncts
• Note that therefore the trigger for performing FONA is inability to establish airawy patency following optimal attempts at non-surgical techniques, not desaturation

Transitioning to CICO

Transition describes the phase of care leading up to, and including, a committed declaration of a CICO event. Key steps in transition:

• Prevent (where possible)
  • Adquate preparation
  • Preoxygenation
  • Airway assessment
    Consider:
    • Awake intubation
    • Awake tracheostomy
  • Use of adjunts and tools
    • Ensure attempts at:
      • Mask ventilation
        With adjuncts, and two-hands.
      • Supraglottic technique
      • Intubation
    • Continuous, apneic delivery of oxygen
      Mask, nasal prongs, or supraglottic airway.
  • Call for help early
    • Call for skilled help after failure of one technique
• Preparation
  Of CICO kit.
  • Prepare equipment after failure of two techniques
• Priming
  • Recognise the situation
    
    • Verbally declare when recognised, or after failure of three techniques
    • Many such situations may be recognition of impending CICO
      Focus shifts from supraglottic to infraglottic rescue.
  • Communicate
  • Demonstrate willingness to act
• Puncture
  Perform critothyrotomy.

Optimising Transition

Principles:

• Manage ambiguity
• Prevent and detect cognitive failure
  • Use of cognitive aids
  • Use pre-rehearsed responses
  • Be self-aware of vulnerability
• Optimise team support and coordination
• Monitor attention
• Minimise delays

Front of Neck Access

Cricothyrotomy techniques include:

• Scalpel cricothyrotomy
  • Faster than needle cricothyrotomy
  • More reliable than needle cricothyrotomy
  • Should be performed with neuromuscular blockade
  • Many techniques
    No evidence any one technique is superior.
• Needle cricothyrotomy
  • May be favoured by anaesthetists who are more comfortable with needles than scalpels
  • Use of a 14G cannula facilitates jet ventilation
  • Cannula can be converted to a definitive airway using Seldinger technique

Epidemiology of CICO

CICO is:

• A rare event
  ~1:10,000 to 1:50,000 of routine GAs.
  • ↑ risk in ICU and ED
• Influenced heavily by:
  • Organisational factors
    • Use of airway registries
    • Early warning and alert systems
    • Use of checklists
    • Safety culture
  • Cognitive errors
    • Use of cognitive aids
      Prompt team to adopt rehearsed practices.
    • Self-awareness
      Of vulnerability to error, and monitoring to detect and correct error.
    • Encourage
      Team members to speak up.
    • Real-time optimisation of the environment
      Enhance situational awareness.
  • Teamwork
    • Shared mental models
    • Role clarity
    • High coordination
    • Clear communication
    • Strong leadership
    • Rapid, robust decision making

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References

1. Frerk, C., Mitchell, V. S., McNarry, A. F., Mendonca, C., Bhagrath, R., Patel, A., … Ahmad, I. (2015, December 1). Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia. Oxford University Press. https://doi.org/10.1093/bja/aev371
2. ANZCA. PS 61: Guidelines for the Management of Evolving Airway Obstruction: Transition to the Can’t Intubate Can’t Oxygenate Airway Emergency. 2016.
3. Chrimes, N. The Vortex: A Universal ‘High-Acuity Implementation Tool’ for Emergency Airway Management. Br J Anaesth 117 Suppl 1, i20-i27. 2016 Jul 20.