Percutaneous Emergency Oxygenation Strategies in the “Can’t Intubate, Can’t Oxygenate” Scenario: PEOS in the CICO Scenario, #2

Percutaneous Emergency Oxygenation in the Can’t Intubate, Can’t Oxygenate scenario

The definitive guide for Anaesthetists

By Dr Andrew M.B. Heard

Copyright 2013 Andrew M.B. Heard

Smashwords Edition

Other Major Contributors:

Dr Gordon Chapman

Dr James Dinsmore

Dr David Dugdale

Dr Patrick Eakins

Dr Lip Yang Ng

Table of Contents

Preface

Background

CICV versus CICO

Management of the CICO scenario

CICO Timeline

CICO Equipment

Why should the cannula be the first choice oxygenation conduit?

CICO Algorithm for Anaesthetists

Cannula Cricothyroidotomy / Tracheotomy

Jet Oxygenation technique

Conversion to the Melker ™Airway

Scalpel Bougie technique

Scalpel Finger Cannula technique

Impalpable Anterior Neck Airway (IANA)

References

Video link

Preface

The support for airway training at Royal Perth Hospital has been instrumental in allowing us to put together this detailed document regarding the management of the CICO scenario. I would like to thank my department and colleagues for their continued support and patience. Since 2003 I have had the privilege of being a supervisor of airway training in our department and to run the airway fellowship that I set up at this time. We have now by late 2013 had 22 airway fellows complete their six month fellowship in our department. Their contribution to the development of this document over the years has to be acknowledged. Ultimately a true grasp of the important details and standardisation in the teaching of these techniques is essential for success. Our plan for the future is to establish a CICO Providers Course to give support to those who are involved in training in their own environment, and to instruct those who are interested in this topic.

Declaration of Interest: I do not receive, nor ever have received, personal funding from the healthcare industry.

Background

Following an airway related death in 2001 in the recovery room at Royal Perth Hospital (RPH), Western Australia, recommendations were made to develop equipment and training for the management of the ‘Can’t Intubate, Can’t Oxygenate’ (CICO) scenario. Training took the form of both manikin-based teaching (dry lab) and ethically approved emergency airway training using a live animal model (wet lab). Wet lab training is entirely voluntary. Additional dry lab training is provided for those individuals who do not wish to partake in wet lab training.

The animals are primarily used for emergency airway training. Animal blood taken for agar plate production preceded airway training by many years and continues to this day. The animals are also utilised to support many other studies and modes of medical training. This agrees with the National Health and Medical Research Council principle of reduction.

The wet lab resembles an operating theatre. There is an anaesthetic machine, piped gases, standard monitoring, an airway trolley and an ultrasound machine. The animals are anaesthetised by veterinary technicians as per veterinary anaesthesia guidance. Pulse oximetry, end-tidal carbon dioxide, electrocardiogram and intra-arterial blood pressure waveforms are displayed. Immediately prior to starting the training session, an upper airway obstruction is created to allow desaturation and hence simulate the CICO scenario.

Manikin and cadaveric training, although useful, is a poor substitute for the real life CICO situation. Cadaveric training is superior to manikin based training, but has the major drawback of a bloodless field.Replicating an operating theatre environment, using live anaesthetised animals and running the training as a genuine CICO situation has the benefit of allowing the trainee to practice taught skills in real time, use physiological tissue and understand some of the ‘human factors’ issues surrounding this critical incident. This model also enables extensive testing of the equipment recommended for managing the CICO situation. The animal model cannot completely reproduce the situation which would arise in a human subject, but is the closest model available.

CICV versus CICO - Oxygenation does NOT require ventilation

The term ‘Can’t Intubate, Can’t Ventilate’ (CICV) places emphasis on striving to achieve ventilation rather than life-saving oxygenation in the hypoxaemic patient. Keeping a patient alive with emergency oxygenation does NOT require normal minute ventilation and may, in fact, require no minute ventilation at all.

We believe the term ‘Can’t Intubate, Can’t Oxygenate’ (CICO) is preferable to CICV as oxygenation is of primary importance and carbon dioxide elimination is not immediately required. Jet ventilation in these circumstances should therefore be termed jet oxygenation. We use this terminology henceforth. The technique of ‘jet oxygenation’ and its rationale are discussed later.

Percutaneous Emergency Oxygenation (PEO) - a new term

Percutaneous Emergency Oxygenation (PEO) is a new term we have introduced to allow clearer description of procedures undertaken through the neck to achieve oxygenation in a critical event. In reviewing and reading many articles over the years it has been difficult to elucidate exactly what procedures had been undertaken e.g. ‘surgical airway’ is often used to describe insertion of a narrow-bore cannula and not a scalpel attempt. Infraglottic oxygenation is often used to describe percutaneous attempts, but is also used to describe jetting infraglottically by passage of a device via the oral route. Needle cricothyroidotomy is sometimes used incorrectly to describe cannula cricothyroidotomy and ‘cricothyroidotomy’ as a term in itself is used to describe airway access that may be via the cricothyroid membrane or through the trachea. Often there is no uniformity in descriptive terminology even within the same paper.

PEO is an umbrella term to cover CICO scenario attempts. It should be subsequently subdivided into cannula or scalpel techniques and then also indicate cricothyroid or tracheal routes of access. PEO as a term will allow easier technique descriptions and clearer interpretation of future research and