COURSE PROVIDER AND INSTRUCTOR MANUAL · Providers of the RHCE CICO course should have access to the following materials. An (*) denotes materials that are not included and should

‘CICO Course Instructors’ and Providers’ Manual August 2013

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‘CAN’T INTUBATE CAN’T OXYGENATE

(CICO)’ Management of the Critically Obstructed

Airway

COURSE PROVIDER AND INSTRUCTOR MANUAL

Rural Health Continuing Education (Stream One)

AUGUST 2013


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ACKNOWLEDGEMENTS

COURSE PROVIDER Sydney Clinical Skills and Simulation Centre (SCSSC), Royal North Shore Hospital, NSW.1 CONTRIBUTORS MANUAL EDITOR Leonie Watterson, Consultant anaesthetist, Royal North Shore Hospital (RNSH), Clinical Associate Professor Sydney Medical School, Director SCSSC COURSE CONCEPT AND MATERIALS Dr Tsung Chai, Consultant anaesthetist, Orange Base Hospital; Dr Roberta Edmeades, Consultant anaesthetist, Townsville Base Hospital; Dr Adam Rehak, Consultant anaesthetist, Royal North Shore Hospital (RNSH)/Senior instructor SCSSC; Dr Morgan Sherwood, Anaesthesia Fellow, St George Hospital, NSW; Anne Starr, Nurse Educator, SCSSC; Clinical Assoc Professor Leonie Watterson; Dr Helen Zois, Consultant anaesthetist, St George and Prince of Wales Hospitals, NSW. ORIGINAL MATERIAL Dr Nicholas Chrimes, Monash Medical Centre, Vic (Supraglottic Recue); Dr Andrew Heard, Consultant anaesthetist, Royal Perth Hospital (Infraglottic Rescue); Leonie Watterson and Adam Rehak (Transition). COURSE DEVELOPMENT FACULTY Course leads: Dr Tsung Chai; Dr Roberta Edmeades; Dr Adam Rehak. Instructors: Dr Philip Black, Consultant anaesthetist, Prince of Wales Hospital, NSW; Dr Nicholas Chrimes; Dr Micah Friend, Consultant anaesthetist, Royal North Shore Hospital; Dr Jagdeep Grewal, Fellow, SCSSC; Dr Oliver Hambidge, Registrar, Royal North Shore Hospital; Dr Andrew Heard; Clinical Assoc Professor Leonie Watterson; Dr Helen Zois. COURSE EXPERT WORKING GROUP Dr Tsung Chai, Dr Roberta Edmeades, Dr Micah Friend, Dr Andrew Heard, Dr Adam Rehak, Clinical Assoc Professor Leonie Watterson, Dr Helen Zois. EDUCATIONAL TEAM Dr Morgan Sherwood; Ms Stephanie O’Regan, Curriculum Development Officer, Senior Instructor, SCSSC; Dr Adam Rehak; Clinical Assoc Professor Leonie Watterson. COPYRIGHT © Sydney Clinical Skills and Simulation Centre 2013. The Vortex Approach is copyright Nicholas Chrimes and Peter Fritz. Vortex graphic provided by Designland. CONDITIONS OF USE The materials may be reproduced for study or non-commercial training purposes. Material should be used unmodified and attributed to the ‘CICO: Management of the Critically Obstructed Airway Course’, Royal Australasian College of Physicians. Reproduction of original work by authors or the expert working group which is referenced in the materials should be explicitly acknowledged.

DISCLAIMER Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editor and publisher are not responsible for perceived or actual inaccuracies, omissions or interpretation of the contents of the publication.

1 On behalf of the Royal College of Physicians (RACP) and collaborating colleges: ANZCA, ACEM, JFICM

This project was possible due to funding made available by RHCE (Stream One)


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CONTENTS Acknowledgements .............................................................................................................................. 2

Contents ................................................................................................................................................. 3

GENERAL INFORMATION .................................................................................................................... 4

1. Using this guide ............................................................................................................................. 4

2. Course description and program at a glance ............................................................................. 4

3. About the contributors .................................................................................................................. 5

PROVIDERS’ INFORMATION................................................................................................................ 6

1. Course materials ............................................................................................................................ 6

2. Resources required ....................................................................................................................... 7

3. Delivering the CICO course: Equipment ..................................................................................... 9

4. Delivering the CICO course: Providers’ tasks .......................................................................... 10

INSTRUCTORS’ GUIDE ....................................................................................................................... 11

1. Individual sessions ...................................................................................................................... 15

2. Bibliography ................................................................................................................................. 89

3. Video links .................................................................................................................................... 89


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GENERAL INFORMATION

1. USING THIS GUIDE This manual is a guide to providing and instructing on the ‘Can’t Intubate Can’t Oxygenate (CICO)’ - Management of the Critically Obstructed Airway Course.

2. COURSE DESCRIPTION AND PROGRAM AT A GLANCE Rationale Airway obstruction is a potential complication of many conditions and procedures in health. It is generally well managed, both in terms of prevention and rescue however a small and significant percentage of patients suffer serious morbidity and in some instances death as a result of a critically obstructed airway. Evidence derived from audit, case studies and coroners’ reports suggest that clinicians are inadequately prepared to recognize and manage a CICO situation; a situation that may be improved by technical and behavioural training and greater attention to systems improvement. Themes This course focuses on emergency responses aimed at four phases of care relevant to a Can’t Intubate Can’t Oxygenate (CICO) situation:

1. supraglottic airway management aimed to relieve airway obstruction and avert deterioration to CICO;

2. the transitional phase between supraglottic airway management and declaration of CICO;

3. management of CICO with infraglottic airway rescue and 4. management of a department or facility to ensure staff are prepared to manage

CICO.

While a variety of airway rescue techniques are described a key message of the program is that clinicians and their teams should be trained and familiar with the specific techniques and equipment that they will use. This program presents specific approaches to supraglottic (The Vortex Model) and infraglottic rescue (Dr Andrew Heard’s Western Australian model) and the equipment that these authors recommend as part of these approaches.

Target audience The course is intended for health professional teams from a range of settings who may be required to manage a CICO situation. Typical settings include: anaesthesia, surgery and perioperative care, Emergency, Intensive Care. Group size The maximum number of participants for this course depends on faculty numbers, rooms, equipment and other host site capabilities. We recommend 12-24 participants and a participant to instructor ratio of 4-6:1.

Structure and format The course is designed as a series of 60 - 90 minute modules over 7 hours which can be delivered separately or as a block. An example is shown in Table 1. The format includes interactive talks and hands-on practical workstations and simulations. Workstations and


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simulations employ scenario-based activities to provide an opportunity for team-based rehearsal of this event.

Table 1: Program

3. ABOUT THE CONTRIBUTORS

This project was developed and provided by the team from the Sydney Clinical Skills and Simulation Centre (SCSSC), a team of rural clinicians led by Dr Tsung Chai based at Orange Base Hospital and the course expert working group in partnership with the Royal Australasian College of Physicians (RACP) in conjunction with a RHCE (Stream 1) program grant.

The content uses specific original work developed by Nicholas Chrimes (Supraglottic rescue), Andy Heard (Infraglottic rescue) and Leonie Watterson (Being prepared - Human factors/ Equipment and systems) and material developed by consensus by the expert working group.

4. SPONSOR

This project has been funded by the Department of Health under the Rural Health Continuing Education Sub-Program (RHCE) Stream One (2011-2013) and is managed by the Committee of Presidents of Medical Colleges. RHCE (Stream One) is an initiative aimed at providing professional support for medical specialists and their teams in regional, rural and remote Australia.

0830 Registration

0900 (15min) Workshop overview

0915 (20min) Session 1: Why is CICO a problem?

0935 (25min) Session 2: Supraglottic airway rescue (Vortex Model) and Transition (

0955 (30min) Session 3: Supraglottic airway rescue workstation

1030 Morning tea

1050 (20min) Session 4: Managing a CICO situation – Infraglottic airway rescue (WA Model)

1110 (120min) Session 5: CICO Infraglottic airway rescue workstation

1310 Lunch

1340 (30min) Session 6: CICO – Managing Transition

1410 (90 min) Session 7: Integrated practice simulations

1540 Afternoon tea

1600 (15 min) Session 8: Being prepared: Equipment and system factors

1615 (15 min) Appraisals, final comments and close


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PROVIDERS’ INFORMATION

1. COURSE MATERIALS Providers of the RHCE CICO course should have access to the following materials. An (*) denotes materials that are not included and should be provided by individual providers. A hash (#) denotes templates that are included but will require customization. Templates are also available as standalone files in the course materials.

1. Marketing and communication material a. Flyer and booking form template (#) b. Pre-course correspondence (*)

2. Other course administration documents: a. Course sign-in sheet template (#) b. Confidentiality form (#) c. Course appraisal forms d. Certificate of attendance template (#)

3. Course delivery a. PowerPointTM presentation b. Trigger and demonstration videos

4. Instructors’ materials a. Instructors’ guide (this manual)(use to prepare for the course) b. The tabulated summary ‘Faculty guide’ (use during the course)


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2. RESOURCES REQUIRED The course will require the following resources summarised in Table 2:

Talks The course requires a seminar style room that has the capacity to seat 20 participants and up to five additional faculty.

Audio-visual requirements include projector and computer to utilise PowerPoint™ and play videos. Sound is required for the videos.

A white board with markers for interactive lectures is useful.

Workstations The workstations require three separate areas. These can either be in one large room or three smaller rooms. Each area will require a large table and an airway trolley. A laptop or PC will be required at each station and a monitor if available for videos and SimMan™ software.

An oxygen supply will be required for the workstations and simulations involving jet oxygenation techniques. This can be either wall mounted or cylinder gas.

Time Session Setting /Format

0830 Registration Meet and greet area/Sign in +/- coffee

0900 (15min) Workshop overview Seminar room/Talk

0915 (20min) Session 1: When is it a CICO situation? Seminar room/Talk

0935 (25min) Session 2: CICO – Preventing CICO - Supraglottic airway rescue (Vortex Model)

Seminar room/Talk

0955 (30min) Session 3: Supraglottic Rescue Workstation

Breakout workstations/Practical skills

1030 Morning tea

1050 (20min) Session 4: Managing a CICO situation – Infraglottic airway rescue (WA Model)

Seminar room/Talk

1110 (120min) Session 5: CICO Infraglottic airway rescue workstation

Breakout workstations/Practical skills

1310 Lunch

1340 (30min) Session 6: CICO – Being Prepared: Human Factors

Seminar room/Talk

1410 (90 min) Session 7: Integrated practice Breakout workstations/Simulations

1540 Afternoon tea

1600 (15 min) Session 8: Being prepared: Equipment and systems

Seminar room/Talk

1615 (15 min) Appraisals, final comments and close Seminar room/Talk


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The time turnover between the stations during the morning is very quick. If the stations are not set up in the same room then the rooms need to be in close proximity to ensure quick turn over between sessions. Ideally the area for the skill stations will also be in close proximity to the seminar area to avoid time delays.

Simulation sessions The simulations will require three separate areas. The areas set up for the skill stations can be utilised for the simulations if they have been set up in three separate rooms. The simulations are low to medium fidelity. A clinical area is not essential for the simulations, however a simulation suite can be utilised if available.

Each room will require a large table or bed, an adult size manikin, a laptop or PC and a patient monitor. The airway trolleys utilised for the skill stations will also be required.

Full size manikins are required for the simulations in the afternoon of the course. These need not be high fidelity. They do require a sufficiently realistic airway for oxygenation, airway adjuncts and intubation. Infraglottic rescue will be performed on neck models co-located with the manikins.

Ideally technical support will include three personnel to operate the SimMan™ software. The SimMan™ software (for vital signs monitoring) is free to download and available from Laerdal: http://www.laerdal.com/us/doc/86/SimMan?docid=1022609#/dl

The faculty should be familiar with the software. It is very user friendly and the scenarios only require adjustment of basic vital signs. The software can be utilised as monitoring for all the scenarios.

Technical support staff will need to be briefed prior to the scenarios on what is required throughout the simulation or workstation.


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3. DELIVERING THE CICO COURSE: EQUIPMENT The following checklist is based on the course for 12-18 people and three workstations.

Supraglottic Airway Rescue workstations (3 stations)

3 x Airway heads 3 x Airway trolleys (see list below) 3 x pillow or towels(1 for each station) Videolaryngoscope (if available) 2 x LMA Fast-track (if available) 2 x LMA Supreme (if available)

Infraglottic Airway Rescue workstations (3 stations)

12 Basic neck models 12 Bariatric neck models 4 x Melker packs 4 x Needle cricothyroidotomy packs 4 x Cricothyroidotomy packs 1 x Enk modulator set Manujet (if available) Oxygen supply (Cylinder with flow meter and pin, for Manujet™)

Integrated Workstations

As for Supraglottic Airway Rescue As for Infraglottic Airway Rescue 3 Adult sized manikins

All stations

Tables Laminates for use during skill stations PCs to show demonstration videos and resources Simulators to show changing SaO2 (one for each station)

Simulator options

Laerdal software on computer screen Handheld SaO2 simulator (available for purchase from Richard

Morris, St George Hospital, NSW) Integrated patient simulator Facilitator prompt (if none of the above are available)

Airway Trolley Contents

Hudson mask Non-rebreather mask Nasopharyngeal size 6, size 7 Guedel size 3, size 4, size 5 Manikin lubricant Cuff manometer LMA size 4, size 5 Scissors Tube tie

ET tube size 6, 7, 8 10ml syringe 20ml syringe Bougie Stylet Bag-valve-mask Laryngoscope Laryngoscope blade Size 3, Size 4


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4. DELIVERING THE CICO COURSE: PROVIDERS’ TASKS Here is a list of tasks that may help providers (Table 4): Table 4: Checklist of providers’ tasks Well before the course ( 4 weeks +) Completed

1) Facility rooms booked 2) Equipment and resources sourced 3) Course materials prepared 4) Marketing and recruiting completed. Participants’ bookings confirmed via

email

5) Course manual 6) Teaching faculty

a) Booked b) Roles allocated: course director and faculty roles c) Prepared: preparatory information provided and briefings completed

7) Technical and support personnel a) Rostered b) Roles allocated: team leader and roles c) Technical staff consulted and briefed about course schedule and

format

8) Administrative coordinator/contact person assigned 9) Catering ordered Shortly before the course (day before and morning of course)

Set up a) Rooms including chair configuration, whiteboard b) Course materials: PowerPoint (check embedded video); main seminar

room videos (confirm working with adequate audio); handouts; faculty guides; sign-on sheets, name badges, appraisal forms, certificates printed

c) Other course coordination materials: sign on sheets, handouts, writing paper, appraisals, certificates

d) Assignment of participants into groups of four to six e) Assignment of faculty to breakout rooms f) Rooms identified with signage to streamline movement of participants

During the course

1) Pre-course faculty preparation: meeting with course director 2) Interaction with participants: meet and greet; Sign on sheets completed;

Name badges allocated; Personal items secured; general support; Confidentiality forms signed.

3) ‘Housekeeping’ briefing (during introduction): Course privacy policy; confidentiality requirements; amenities; schedule; break opportunities; parking; security; Q&A.

4) Course coordination: Timekeeping, Catering 5) Technical support of IT After the course

Evaluation and certificate a) Appraisal forms distributed and collected at the end of the course b) Data entry of evaluations c) Certificates completed and distributed


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INSTRUCTORS’ GUIDE


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Time Session Format

0800 Faculty meeting

0830 Registration

0900

(15min)

Introduction and workshop overview

Aims and content: Welcome, introductions by participants, sponsors, aims of the workshop, overview of the program and housekeeping.

PowerPoint, discussion/introductions by participants

0915

(20min)

Session 1: Why is CICO a problem?

Aims:

1. Persuade audience that this is a problem worthy of addressing in a holistic way, i.e., techniques, human factors and systems

2. Ask the group to consider criteria for declaring CICO – introduce transition algorithm

3. Introduce concepts and algorithms to be used in course: ‘3 stages’ (Supraglottic Rescue – Transition decision – Infraglottic Rescue) and ‘3 components of each’ (Vortex and infraglottic rescue)

PowerPoint, discussion , Elaine Bromiley video (first 7 minutes), lessons from NAP4

0935

(25min)

Session 2: Supraglottic airway rescue and transition to CICO

Aims and content:

1. Presents Vortex model for supraglottic rescue and stresses importance of attempting all components before transitioning to infraglottic rescue

2. Explores clinical criteria for transitioning to infraglottic rescue using case examples

PowerPoint, talk and discussion

0955

(30min)

Session 3: Supraglottic rescue workstations

Aims and content: Practice content of previous talk

Concurrent practical workstations (all equivalent)

Group A Group B Group C


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Time Session Format

1030 Morning tea

1050

(20min)

Session 4: Managing a CICO situation – Infraglottic rescue

Aims and content: Explain three parts of Andrew Heard’s CICO algorithm (aligned with workshop stations 1-3) of Session 5

PowerPoint talk, video demonstration, demonstrate CICO kit

1110

(120min)

Session 5: Infraglottic rescue workstations

Aims: Practical Workstations

Workstation 2 can be run as doctors’ version (practice techniques) and nurses version (practice set-up)

Concurrent rotating workstations rounds 1-3

1: Cannula cricothyroidotomy/Jet oxygenation

2: MelkerTM conversion 3: Scalpel-bougie/Scalpel-Finger-Cannula techniques

3: Scalpel-bougie/Scalpel-Finger-Cannula techniques


2: MelkerTM conversion

2: MelkerTM conversion 3: Scalpel-bougie/Scalpel-Finger-Cannula techniques


4: Practice scenario 4: Practice scenario 4: Practice scenario All groups practice the same exercise which is an integrated rehearsal of the ‘3 Stages’.

1310 Lunch


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Time Session Format

1340

(30min)

Session 6: Managing transition – 7 failure factors and strategies Aims and content: 7 failure (human) factors and strategies including communication, assertiveness, team-work

1. How clinicians underperform in crises. Includes analysis and recommendations from Elaine Bromiley case and others.

2. Introduce 7 failure factors model 3. Refer also to Riley/Greenland/RHCE working party ANZCA Bulletin articles. 4. Practice assertiveness phrases

Discussion

1410

(90 min)

Session 7: Integrated practice scenarios

Aim: Integrates all lessons Technical and human factors) and recommendations including:

Practice guidelines/algorithms Equipment including ‘CICO Kit’ Coordinated team approach: team roles, record keepers and time prompts, good

communication with appropriate assertiveness

Concurrent mini team-based simulation scenarios x 4. Scenarios contain human factors challenges

Group A: Scenario 1-4 Group B: Scenario 1-4 Group C: Scenario 1-4

1540 Afternoon tea

1600

(15 min)

Session 8: Being prepared for CICO - Equipment and systems

Aims:

Assess an institution’s preparedness for this crisis- presents checklist that could be used as a quality assurance/risk management tool.

Encourage systems change including :Routine training/rehearsal including how departments can deliver training, adoption of uniform equipment and algorithms

Talk and Discussion Resource: Preparedness checklist

Based on article in ANZCA Bulletin by RHCE Working party

1615-1630 (15min)

Appraisals final comments and close


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1. INDIVIDUAL SESSIONS

Introduction and Course Overview

Format: PowerPoint (introductory session)

Aims: Welcome, ask participants to introduce themselves

Description: 1. Participants and faculty introduce themselves: name, profession, workplace and role and

anything they would like to gain from the course 2. Facilitator acknowledges contributors and sponsors, provides an overview of the

program, covers housekeeping

Duration: 30 minutes

Documents and resources: PowerPoint (Introduction)

Venue: Seminar room

Notes to accompany PowerPoint slides

Slide 1

No notes


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Slide 2

Facilitators should be familiar with Elaine Bromiley’s story and the campaign led by her husband Martin to improve management of CICO.

http://www.youtube.com/watch?v=JzlvgtPIof4

Slide 3

This program was originally run in 2011 at Orange Base Hospital as part of the RHCE (Stream One) program. Developed by the working group as a multi-professional, multi-disciplinary course aimed to improve preparation for the ‘Cannot Intubate, Cannot Ventilate (Oxygenate)’ (CICO) scenario. With emphasis on a team and systems- based approach, the course addressed a range of topics including defining the challenges of the CICO scenario, recognising a CICO scenario, preparedness to act, human factors, equipment and system design, along with hands-on practice of the trans-tracheal procedure.


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Slide 4

No notes

Slide 5

No notes

Slide 6

No notes


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Slide 7

No notes

Slide 8

No notes


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Session 1: Why is CICO a problem?

Format: PowerPoint discussion, Elaine Bromiley video (first 7 minutes), lessons from NAP4

Aims: 1. Persuade audience that this is a problem worthy of addressing in a holistic way – i.e.,

techniques, human factors and systems 2. Ask the group to consider criteria for declaring CICO – introduce the transition

algorithm 3. Introduce concepts and algorithms to be used in course: '3 stages' [Supraglottic Rescue –

Transition– Infraglottic Rescue] and '3 components of Supraglottic and Infraglottic rescue' (Vortex and Infraglottic rescue)


Documents and resources: PowerPoint (Session 1), Elaine Bromiley video (first 7 minutes)

Venue: Seminar room


Slide 1

No notes


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Slide 2

CICO is a rare event although possibly underreported. It is highly represented as a cause of anaesthesia related deaths.

Slide 3

It is also highly represented as a cause of serious airway emergencies in critical care disciplines. The National Audit Project 4 was a prospective audit of serious airway complications defined as those resulting in death, brain damage, a surgical airway or unexpected ICU admission that occurred within the operating theatre, emergency department and intensive care units in the UK over a one year period.

Slide 4

It can be a technically difficult event to manage particularly when it occurs in conjunction with upper airway infection. Clinicians are not sufficiently exposed to CICO in the real world to remain well rehearsed.


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Slide 5

http://www.youtube.com/watch?v=JzlvgtPIof4

Slide 6

The NAP4 project found that practitioners were often underprepared to manage a range of airway problems in particular CICO situations. Uncertainty about the appropriate time to declare that supraglottic rescue had failed and to convert to infraglottic rescue was felt to be a large contributor. Practitioners also appeared unwilling to perform infraglottic rescue or were unfamiliar with aspects of it such as access and use of equipment or the procedure itself.

Slide 7

The significance of these factors is exemplified in the case of Elaine Bromiley who died as a consequence of a CICO situation that arose in the course of elective ‘low risk’ surgery. Her husband Martin, a pilot, speaks eloquently of human and system factors, particularly surrounding transition to CICO, that place patients like Elaine at risk of this event.

A number of other coroners’ reports also conclude CICO is suboptimally managed


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Slide 8

No notes


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Session 2: Supraglottic Rescue and Transition to Infraglottic Rescue

Format: Talk using case examples and discussion

Aims: 1. Presents Vortex model for supraglottic rescue and stresses importance of attempting

all components before transitioning to infraglottic rescue 2. Explores clinical criteria for transitioning to infraglottic rescue using case examples


Documents and resources: PowerPoint (Session 2)

Venue: Seminar room


Slide 1

No notes


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Slide 2

‘Can’t Intubate Can’t Oxygenate’ or CICO is a serious situation that is often sub-optimally managed. There are a variety of reasons for this. Sometimes infraglottic rescue is embarked upon prematurely before reasonable attempts at supraglottic rescue have been made. On other occasions it is delayed as clinicians persist for too long with supraglottic rescue despite evidence it has failed. This presentation focuses on supraglottic airway rescue techniques. It aims are twofold. Firstly to improve our technique so CICO situations are avoided and secondly to provide a framework for supraglottic rescue that assists us to recognise and declare CICO.

Slide 3

The Difficult Airway Society algorithms are well known and well considered emergency algorithms that encourage anaesthetists to have plans for specific scenarios related to difficult intubation and face mask ventilation.

They are considered somewhat limited in the respect that actions leading up to can’t ventilate via face mask are presented as sequential steps assuming the starting point has been attempted endotracheal intubation.

In practice the journey taken to arrive at failed face mask ventilation will vary on a case by case basis an emergency algorithm that allows for flexible journeys would be beneficial.


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Slide 4

No notes

Slide 5

No notes

Slide 6

The Vortex model of emergency airway management developed by Drs Nicholas Chrimes and Peter Fritz. We present it here as an example of an effective method for supraglottic airway rescue.


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Slide 7

The model conceptually organises supraglottic airway management into the three categories of airway support which we have termed ‘lifelines’. These are: face mask ventilation, endotracheal intubation and ventilation via supraglottic devices such as the laryngeal mask airway. The model recommends that a CICO should be declared only after appropriate rescue attempts have been made in each lifeline and these have failed to restore a clear airway. It predicts that if a best attempt has failed in all three categories of airway support then it is inevitable that desaturation will follow, if it hasn’t occurred already. In this situation a surgical airway – or infraglottic airway rescue - should be attempted.

Slide 8

Now let’s look in more detail at the sequence of lifelines. The spiral yellow arrow illustrates passage between the three lifelines. The thick end starts with the technique in use when difficulty is first recognised. The direction of the spiral indicates the order with which the other two lifelines are attempted. This order is determined by the clinical situation. In the diagram shown face-mask ventilation is being used as the initial mode of airway management. Optimal attempts at face mask ventilation fail to achieve a clear airway whereupon endotracheal intubation is attempted followed by insertion of a supraglottic device such as a laryngeal mask airway.


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Slide 9

The same approach applies in principle if the starting point is difficult endotracheal intubation or …

Slide 10

Unsuccessful insertion of a supraglottic device such as a laryngeal mask airway.

Slide 11

If any of these lifelines are successful restoring a clear airway then we move upwards and outwards toward the green rim of the funnel.

In contrast, as each lifeline fails we move deeper into the funnel and will continue to spiral down unless a clear airway can be restored. If a best attempt has failed in all three categories then it is inevitable that desaturation will follow, if it hasn’t occurred already. In this situation a surgical airway – or infraglottic airway rescue - should be attempted.


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Slide 12

These principles are demonstrated in the following video which depicts management of a difficult airway in an unconscious patient in the emergency department

http://vimeopro.com/johnmackenzie/cant-intubate-cant-oxygenate/page/1 Password: CICO

Slide 13

In this case several basic airway manoeuvres are employed to clear the airway as part of a best attempt in this lifeline.


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Slide 14

Several optimisation strategies are employed by the airway doctor over two separate attempts at intubation with face mask ventilation attempted in between.

Slide 15

As with the other lifelines there are a number of manoeuvres that can be performed to improve chances of success with the technique. We should consider the relative benefit of each of these and employ any that are feasible and appropriate to the circumstances.

Slide 16

There are no ideal number of attempts.

It’s reasonable to have more than one attempt at a lifeline as long as a different manoeuvre is used within the lifeline.

Using the example of endotracheal intubation we might have an initial attempt optimising our chances by performing a few manoeuvres before we stop and reoxygenate with bag mask ventilation. A second attempt at intubation may be reasonable if additionalmanoeuvres can be employed by suitably trained personnel.


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Slide 17

So how do we know whether we should persist with supraglottic rescue or declare a CICO situation?

Well firstly we should always persist with supraglottic airway rescue even after we have declared CICO and commenced infraglottic rescue

Secondly we declare a CICO situation when a best attempt at all 3 supraglottic lifelines have been attempted and have not unsuccessfully cleared the airway

Should we wait for oxygen saturations to fall?

The Vortex model recommends that we should not wait for saturations to fall before declaring CICO because it is inevitable if it hasn’t already occurred. In this sense declaring CICO early buys time and enables a surgical airway to be performed without prolonged desaturation.

In this presentation we recommend that a surgical airway or infraglottic rescue should only be performed if saturations are falling or are persistently low.

However to minimise the period of desaturation it’s important that we anticipate CICO and call for help during supraglottic rescue. To ensure we allow sufficient time to set up for infraglottic rescue we should verbalise the possibility of a CICO situation to the team and mobilise resources for infraglottic rescue once 2 of the 3 techniques have failed.


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Session 3: Supraglottic Airway Rescue - Practical Session

Format: Concurrent practical workstations (all equivalent)

Aims: 1. Practice content of Session 2. Specifically to rehearse supraglottic rescue and declaring a CICO event in a range of

situations.

Duration: 45 minutes (3 x 15 min stations)

Documents and resources: Laminates +/- Laptops with PowerPoint slides (from Session 2) at workstations

Venue: Breakout areas

Equipment: Refer to ‘Equipment for Workstations and Simulations’, specifically for Supraglottic Airway Rescue

Setup and preparation

Use either full manikins or airway-trainer-torsos depending on what is available Use SimMan™ software on a laptop to create the falling SaO2 tone to create

urgency Aim to have an assistant at each workstation to operate the software (if possible) You will need to brief your assistant on how you want the saturations to play out for

your scenario

Options for running the workstations

Three scenarios are run, each over 15 minutes. Participants can remain at the same physical location and be exposed to three different scenarios or alternatively can rotate around three different physical stations each repeating the scenarios.

Scenarios:

1. Supraglottic rescue in failed intubation in fasted patient/routine induction 2. Supraglottic rescue in RSI for C-Section 3. Supraglottic rescue in planned LMA case

Use the content from Session 2 (Airway Vortex model) as a teaching tool for these stations.

In each of the three scenarios the starting point of 'trouble' will be different, and thus the pathway to it becoming a 'CICO situation' will be different, but ultimately the goal of each station is the same – to cycle through all three lifelines of supraglottic rescue – i.e., best attempts at 1) face mask ventilation, 2) LMA ventilation, and 3) endotracheal intubation, but not necessarily in that order.

Each station will have a slightly different emphasis, in that while the participant will be expected to cycle through all three lifelines, the debrief and discussion will focus on one particular mode of supraglottic rescue.


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Workstation 1 – Failed intubation in fasted patient/routine induction

Background: Routine induction of 56 y/o female undergoing elective Anterior Cervical Decompression and Fusion. Risk factors for airway management include poor neck extension. Intubation is anticipated to be potentially but not likely to be difficult. Ventilation is not anticipated to be difficult. Direct laryngoscopy is planned as the primary approach with a video laryngoscope available in the room as backup.

Trigger: The difficulty will begin after the first attempt at intubation when the participant returns to mask ventilation which will be impossible.

Progress: All three supraglottic 'lifelines' will fail.

Discussion points: 'Best attempt at endotracheal intubation' - What will your best attempt look like?, Should you have the difficult airway trolley in the room? What is the role of the Videolaryngoscope in this scenario?

Workstation 2 – Failed intubation during RSI for Cat 1 LSCS (+ Foetal distress)

Background: 29 year old woman requiring RSI for Category 1 LSCS (foetal distress persistent FHR <100). BMI 30

Trigger: Difficulty begins during initial intubation attempt where a grade 3 view is obtained.

Progress: All supraglottic lifelines will fail and the patient desaturates

Discussion points: 'Best attempt at supraglottic airway device ventilation'; What will your best attempt look like?, What devices do you have at hand? Where are your ProsealsTM/SupremesTM/iGelsTM kept? Do you have these on-hand?

Workstation 3 - Carpal tunnel release (planned GA with LMA insertion)

Background: Moderately obese woman without GORD. Several indicators of difficult intubation: Mallampati view = 1; Thyromental Mental Distance = 6cm. Small mouth and overbite. Plan is to insert a LMA

Trigger: Difficulty begins when the LMA fails seat effectively, making ventilation impossible.

Progress: All supraglottic lifelines will fail

Discussion points: 'Best attempt at mask ventilation', What will your best attempt look like? Will you use muscle relaxants?


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Slide 1

This practical workstation provides participants with an opportunity to rehearse aspects of supraglottic airway rescue presented in Session 2.

Slide 2

The facilitator explains the flow of the workstations for this practical session.


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Slide 3

Slide from Session 2 to be available during the workstations

Slide 4


Slide 5



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Slide 6



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Session 4: Infraglottic Airway Rescue

Format: PowerPoint (Session 4); videos for each technique: Cannula; Scalpel-Bougie; Scalpel-Finger-Bougie

Aims: 1. Explain three parts of Andrew Heard’s CICO algorithm (aligned with workstations 1-

3) of Session 5


Documents and resources: PowerPoint, videos

Venue: Seminar room


Slide 1

In this presentation we will focus on Infraglottic Airway Rescue.

Infraglottic Airway Rescue is commenced when a CICO situation is declared. We have covered the definitions and criteria for declaring CICO in the session on Supraglottic Airway Rescue.

Infraglottic Airway Rescue specifically refers to rescue techniques performed across the anterior surface of the neck via the cricothyroid membrane or the trachea - that is - below the larynx. Other terms you will be familiar with include cricothyroidotomy, surgical airway and transtracheal tracheal airway.


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Slide 2

This topic is also presented in Part 3 of the EdWISE E Learning module by the same name. This is available at www.edwise.edu.au

Slide 3

A key message of this session is that we must have an emergency plan for infraglottic rescue. That means being familiar with a workable algorithm, its associated procedures, the specific equipment required to undertake it and the roles of the team.

Slide 4

This session will focus on these aims focussing on an approach developed by Dr Andy Heard and his team from Western Australia.

Implementing this plan also means we must recognise and declare CICO appropriately. And that the team must be aware of its roles and be able to quickly mobilise resources for infraglottic rescue while supraglottic rescue is occurring. To address these aims we will also present two additional algorithms. Firstly a Transition algorithm to guide us with recognition and declaration of CICO and secondly a team-based algorithm which shows both supraglottic and infraglottic rescue. These algorithms were developed by members of the RHCE CICO Course


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Working Party.

Slide 5

Research conducted by this team suggests anaesthetists are generally, more comfortable with and successful at cannula based techniques. The Western Australian training model involves a structured, algorithmic approach to infraglottic rescue. Depending upon our ability - in any given situation - to palpate neck anatomy it may involve one or more of three primary procedures: cannula cricothyroidotomy, scalpel/bougie or scalpel/finger/cannula technique.

Procedure 1 - the Cannula Cricothyroidotomy or tracheotomy technique is suggested as the first line method IRRESPECTIVE OF whether neck anatomy is palpatable or not easily palpatable.

Procedure 2 - the Scalpel bougie technique - is suggested if the cannula technique fails AND the neck anatomy is easily palpatable. It uses a scalpel to perform a stab incision into the trachea to permit a bougie to be inserted via which ventilation can be delivered with a manual resuscitation bag.

Procedure 3 - the Scalpel - Finger - Cannula - technique - is suggested if cannula cricothyroidotomy has failed and either the neck anatomy is not palpatable or scalpel bougie attempts have failed. A scalpel is used to make an extended, superficial vertical incision, down to the strap muscles. The fingers are then used to blunt dissect down to the cricothyroid membrane or trachea at which point a cannula is inserted.

After a device is inserted into the trachea the goal is to oxygenate and stabilise. A Jet oxygenation technique is used if a cannula is in place. If a bougie is in place oxygenation will occur via a manual resuscitation bag or anaesthetic circuit.

Once the patient has been stabilised a secondary technique is used to insert a cuffed tube. A Melker conversion kit is recommended if a cannula is in place. If a bougie is in place an endotracheal tube can be railroaded over it.

Slide 6

We will present these techniques in the following order


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Slide 7

Cannula Cricothyroidotomy or tracheostomy is suggested as the first line technique when a CICO is declared. The aim of this procedure is to cannulate airway through the the cricothyroid membrane or trachea, choosing the most easily palpatable entry point. Let’s view a demonstration of the cannula cricothyroidotimy technique.

http://www.vimeopro.com/johnmackenzie/cant-intubate-cant-oxygenate/page/1

Password: CICO

Slide 8

Let’s walk through the equipment that you will need for cannula cricothyroidotomy. This comprises

A 14G luer lock non-safety cannula. We recommend the ‘Insyte’ brand.

A 5ml non- luer -lock syringe A source of sterile saline or water to be

drawn up into the syringe. This will allow better visualisation and provide tactile feedback of the aspiration of air - but if this is not immediately available then the technique should proceed without it!

A suitable oxygen delivery system. Three systems are commercially available: the Manujet™, ENK™ and RAPID-O2 Oxygen Insufflation Devive™ (formerly known as the Leroy system). We will discuss these shortly.

A high-pressure oxygen source. The Manujet™ is connected to a standard O2 pin system and the other devices are connected to an O2 flowmeter.


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Slide 9

Delivery of adequate oxygen flows through cannulas requires low compliance oxygen tubing connected to the appropriate high-pressure oxygen source. It also requires specific ‘jetting’ techniques to safely deliver adequate oxygen. These techniques may be critical to the survival of the patient in the interim before a definitive airway is secured. They are not difficult if you and the team are prepared.


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Slide 10

A variety of devices are available including the Manujet™ Jet Oxygenator (or Sanders injector); ENK™ device and Rapid O2 Oxygenation Insufflation Device (formerly known as the Leroy device)

Manujet: The Manujet is connected to a high-pressure oxygen source such as wall or cylinder oxygen via a pin connection. The pressure regulator on the Manujet™ device allows adjustment of pressure. This feature is not available on the Sanders™ Injector – which always delivers oxygen at 4 bar (or 4000 cm of water). If the device allows pressure adjustment, the pressure should be set to 1BAR (or 1000 cm of water). This reduction in pressure reduces flows to more manageable levels. 1 Bar delivers 250 mls/sec.

A lever when depressed by the operator delivers oxygen at the inspiratory pressure dialed on the regulator.

We should test this quickly by depressing the lever to ensure gas is delivered. We should hear a hiss sound and feel gas expelled from the end of the tubing. Before depressing the lever remember to hold the Manujet™ leur connector otherwise it can flick forcefully and causing an injury.

It is important to understand that i) oxygen flows from this device at the set pressure whenever the operator depresses the lever, and ii) this device does not have venting mechanism To allow excess intrathoracic pressure to escape. Thus, if the lever is depressed for long periods or without adequate pauses, and the patients upper airway is completely obstructed then pressures will increase very quickly. Gas trapping and barotrauma will likely ensue.

ENK and Rapid O2: The ENK™ and Rapid-O2™ devices are commercially available low-compliance oxygen tubing circuits that connect at one end to the oxygen nipple of a standard oxygen flowmeter, and at the other end to any luer-lock compatible connection such as a cannula. They have thumb/finger holes that allow some expiration of gas in between jetting. Once connected to the high-pressure oxygen source the flows should be turned to maximum, which is usually 15L/min. This will deliver 250 mls/sec during jet oxygenation, assuming all the holes are occluded during inspiratory flow.

Technique: We recommend the same oxygenation technique whether using a jet ventilator, the ENK device or a Leroy or Rapid-O2 configuration. This technique can fail if not performed correctly and has the potential to cause barotrauma; for example - pneumothorax, or pneumomediastinum. It is therefore important to use the safest effective jet oxygenation technique possible to avoid these complications. Here are some tips:

Check your settings

The ManujetTM should be set at 1.0 Bar (i.e., infant setting, in the Yellow Zone). The ENK™ and Rapid-O2™ devices should be connected to O2 at 15 litres per minute.


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Slide 11

Administer the first breath over 4 seconds

This approach will achieve two outcomes; it will deliver oxygen and may help prevent alveolar collapse or re-expand the lungs. This is important as at this point the lung volumes may be reduced and require re expansion to ensure a rapid response from the first jet. A 4 second jet at the pressures and flows recommended will deliver approximately 1000mls (i.e., 250 mls per sec). Observe chest movement to confirm that oxygen is being delivered to the lungs.

Slide 12

The rate-limiting step for the frequency of safe jet oxygenation is the patency of the expiratory pathway. Always keep in mind that oxygenation, rather than ventilation is important in the emergency scenario. We are not trying to control the CO2 initially; therefore, infrequent jets (breaths) of a known volume are preferable.

Subsequent jets (breaths) should only be given when needed. Observe the improvement in oxygen saturation and wait until the oxygen saturation has dropped by 5% from the maximum achieved with the initial jet. Using this objective trigger for subsequent jetting should avoid excessive jetting and decrease the risk of barotraumas

Subsequent jets (breaths) should be delivered over a 2 second duration. This approach should provide adequate oxygenation and gas exchange while minimising the risk of barotrauma. Wait again for a peak and subsequent 5% fall in saturation before delivering subsequent breaths. If there is no saturation reading for whatever reason, it is safe to insufflate 500 mls every 30 seconds if using a 14g cannula and Rapid-O2™ or ENK™ even in complete upper airway obstruction. If using a Manujet™ or Sanders™ injector, this will need to be disconnected from the cannula between jets (breaths) to allow expiration.


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Slide 13

Be suspicious of absent chest wall movement. Failure of initial chest rise may be due to either i) kinking or displacement of the cannula or, ii) equipment failure or disconnection.

Recheck the cannula position by saline aspiration and recheck of oxygen connections and oxygen delivery to the device.

Do not continue to jet until cannula position is confirmed, as jetting through a displaced cannula will create subcutaneous emphysema.

Desist immediately if surgical empysema appears.

Slide 14

If after 20 seconds there is no response or improvement in oxygen saturations despite chest movement, a second jet of 2.0 seconds duration should be administered.


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Slide 15

We should maximise expiratory flow though the patient’s airway. An obstructed upper airway can be improved with the usual manoeuvres to open it such as jaw thrust, chin lift or LMA insertion.

Only jet oxygenate whilst watching for chest wall rise and FALL to monitor inspiration, and more importantly, expiration. This gives a better indication of whether the expiratory pathway is obstructed. This situation could lead to ‘stacking’ of jetted breaths and, in turn, increased risk of barotrauma.

Slide 16

The scalpel-bougie technique


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Slide 17

The scalpel-bougie technique is suggested if the cannula cricothyroidotomy or tracheotomy fails and there is palpable neck anatomy. It involves the use of a scalpel to produce a small triangular hole in the cricothyroid membrane (or trachea), through which a bougie is inserted.

If the bougie has a hollow lumen (such as the Frova™ brand) it can be used to oxygenate the patient until a definitive airway is secured. This is achieved by connecting a Rapifit connector whereupon we can ventilate via a standard manual resuscitation bag.

Once the patient is re-oxygenated we proceed with a secondary technique then rail-road a size 6 endotracheal tube (ETT) over the bougie and oxygenate using a standard manual resuscitation bag. If the means of oxygenation via the bougie is not immediately available, we should proceed directly to rail-roading the ETT over the bougie.

Slide 18

This is the equipment that you will need to have ready to perform a Scalpel – Bougie technique.

A size 10 blade scalpel is recommended as it will be at least as wide as the Frova™ Bougie

Green gauze to remove blood

A hollow bougie

A ‘Rapifit™’ or equivalent connector to allow a standard circuit or self inflating bags to connect to the bougie .

A size 6mm internal diameter endotracheal tube

A 10 ml syringe to inflate the cuff

A manual ventilation bag for ventilation


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Slide 19

The scalpel-finger-cannula technique

Slide 20

The scalpel-finger-cannula technique is suggested when cannula cricothyroidotomy or tracheotomy has failed and there is no palpable neck anatomy. This technique can also be attempted if the scalpel-bougie technique has failed. It utilises the equipment used for the two other techniques, which we are labelled Kit 1 and Kit 3 in this presentation. It involves the use of a scalpel to make a midline, approximate 8cm vertical incision if possible, followed by blunt dissection with the fingers of both hands to identify the airway. A 14G cannula is then inserted into the airway and the patient re-oxygenated.


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Slide 21

Initial re-oxygenation of the patient via one of the cannula-based infraglottic rescue techniques may be life saving, but it is likely that the patient will subsequently require a definitive cuffed airway for both airway protection and ventilation.

We recommend the use of the Melker™ conversion kit as it utilises the existing 14G cannula for a wire-guided seldinger technique to insert a size 5 cuffed tube.

The Melker™ kits come pre-packaged and will contain – a guidewire to pass down the cannula; a dilator that sits within the tracheal tube; a cuffed size 5.0 tracheal tube; a scalpel to enlarge cuts in the skin and tissues as needed and a syringe for inflating the cuff of the tube. We recommend using a size 10 scalpel blade rather than the blade presented in the kit as this limits the depth of insertion of the blade required protecting against posterior wall damage.

Slide 22

Let’s now place these techniques within the broader context of the infraglottic airway rescue algorithm.

Firstly let’s look at the decision to declare and commence CICO, or Transition. The NAP4 audit found that attempts at infraglottic rescue were often suboptimal and there was a high incidence of failure. Contributing to this were technical factors, poor decision-making and disorganisation. We have created this list to remind us of factors placing us at risk of failure if we have not prepared for them.


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Slide 23

This Transition Algorithm assists with recognition and declaration of CICO.

The key points are:

1. The cue for infraglottic rescue is a CICO situation. This is declared when a ‘best’ attempt at each of the three supraglottic rescue lifelines has failed and saturations continue to fall.

2. We should mobilise resources for infraglottic rescue when 2 of the 3 supraglottic rescue lifelines have been tried and failed.


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Slide 24

This CICO Team Emergency Protocol guides team members roles and resource allocation. These are shown in blue to the right of the WA algorithm.

Team roles: Team members should be clear on their roles. We suggest:

If enough senior people are available it is worthwhile allocating teamleader to direct the intervention using the algorithm as a guide

A proceduralist to attempt the cannula cricothyroidotomy. The person attempting the infraglottic airway technique should be the most skilled at this procedure available. They should also be the person who is in the best frame of mind to attempt the task. By this we mean that the primary airway doctor, who has initially encountered difficulty and then failed to oxygenate the patient via supraglottic rescue techniques, will likely be highly stressed. In this state they may be less capable of successfully performing infraglottic rescue, even if they are the most experienced or skilled person present. In this case they may be better suited to one of the other roles.

A second proceduralist must persist with attempts to oxygenate the patient via the three supraglottic lifelines: bag mask ventilation, laryngeal mask airway or endotracheal intubation. This may deliver some oxygen to the patient and buy them some time. Ideally this person would also have an assistant.

A team member to assist with supraglottic airway rescue A team member to assist the infraglottic airway rescue by preparing the equipment for the cannula

technique and handing it to the proceduralist A second assistant should prepare the equipment for jet oxygenation. The cannula cricothyroidotomy

may not be successful. Having equipment ready to attempt the next technique will save time and reduce stress. The second assistant should then prepare the equipment for the scalpel -based techniques as well as ensuring that the cardiac arrest trolley is present.

Someone should record the events. If a spare person is available he or she should scribe as the event unfolds. This person could also cross check activity against the algorithm, keep track of time and report back to the team.

All team members should feel empowered to voice concerns and verbalise ideas in a productive and useful manner. This will be difficult but especially important in such a stressful situation.


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Session 5: Infraglottic Airway Rescue - Practical Session

Format: Practical sessions

Aims: Practice content of Session 4

Description:

In rounds 1-3 participants rotate through three different workstations that run concurrently. In round 4 groups remain at the last station they completed. The setup is changed such that all stations run an identical station simultaneously, the aim of which is to practice an integrated scenario involving all three stages covered in stations 1-3.

1. Cannula cricothyroidotomy and jet oxygenation 2. Conversion of cannula to definitive airway – Melker™ device 3. Scalpel-bougie technique 4. Integrated practice

The purpose of this workstation is to: become familiar with the steps and decisions of the CICO algorithm and work

through each of these steps in order think about how the team should be managed/lead during this crisis. practice the scalpel-finger-cannula technique

Duration: 120 minutes (4 x 30 minute stations)

Documents and resources: See equipment list infraglottic rescue; lap-tops with videos and PowerPoint slides for review; laminates of algorithms.

Venue: Breakout areas

Equipment: See Infraglottic Airway Rescue

Structure:

Workstation 2 can be run as doctors’ (practice techniques) and nurses (practice setup) version.

1:Cannula cricothyroidotomy / Jet oxygenation

2: MelkerTM conversion 3: Scalpel-bougie /Scalpel-Finger-Cannula techniques

3: Scalpel-bougie /Scalpel-Finger-Cannula techniques

1: Cannula cricothyroidotomy/ Jet oxygenation

2: MelkerTM conversion

2: MelkerTM conversion 3: Scalpel-bougie /Scalpel-Finger-Cannula techniques

1: Cannula cricothyroidotomy / Jet oxygenation

4: Practice scenario 4: Practice scenario 4: Practice scenario


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Slide 1

This practical workstation provides participants with an opportunity to rehearse aspects of supraglottic airway rescue presented in Session 2.

Slide 2

The facilitator explains the flow of the workstations for this practical session


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Slide 3

Slide from Session 4 to be available during the workstations.


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Workstation 1: Cannula Cricothyroidotomy/Jet oxygenation

Steps

1. Revise the CICO algorithm highlighting the ‘success’ pathway: cannula cricothyroidotomy – jet oxygenation –conversion to ETT using the Melker™ Kit (if waking patient is not feasible).

2. Demonstrate the cannula cricothyroidotomy technique. 3. Demonstrate how to jet oxygenate. 4. Have participants to practice this in pairs with one person as proceduralist

and the other as assistant.


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Workstation 2: Conversion to endotracheal tube with Melker™ Kit

Steps

1. Revise the CICO algorithm highlighting the “success’ pathway: cannula cricothyroidotomy – jet oxygenation –conversion to ETT using the Melker™ Kit (if waking patient is not feasible).

2. Demonstrate how to use Melker kit to convert to a definitive airway. 3. Oxygenate with Manual Resuscitation bag. 4. Have participants to practice this in pairs with one person as proceduralist and the

other as assistant.


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Workstation 3: Scalpel-Bougie and Scapel-Finger-Cannula Techniques

Steps

1. Revise the CICO algorithm highlighting the ‘failure’ pathway. For example: Context: The CICO has already been declared. Cannula cricothyroidotomy has

been performed. First decision: Has it enabled successful jet oxygenation? If ‘no’ then prepare for

a Scalpel-based technique Second decision: Feel the neck for palpable anatomy. Is the anatomy palpable? If

‘yes’ then perform the scalpel-bougie technique, if ‘no’ then perform the scalpel-finger-cannula technique.

Third decision: If scalpel-bougie has been performed has it enabled oxygenation? If ‘no’ then perform the scalpel-finger-cannula technique.

2. Demonstrate the scalpel-bougie technique. 3. Have participants practice this. 4. Demonstrate the scalpel-finger-cannula technique. 5. Have participants practice this.


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Workstation 4: Practice In the fourth round all groups undertake an identical workstation.

Aims

The purpose of this workstation is to:

1. Rehearse each of the steps and decisions in the CICO algorithm in order 2. Consider how the team should manage this crisis including roles and when to

mobilise specific pieces of equipment. 3. Rehearse as a team

Overview

Each participant takes a turn demonstrating the emergency algorithm in sequence with other members of the group playing another team role. They should run this like a game. The participants should start by declaring a CICO and follow the next step shown in the algorithm (cannula cric). They then assume that their initial step has failed and refer to the algorithm for guidance on their next step (e.g. scalpel-bougie if neck anatomy is palpable). Each procedure should be assumed to fail until they finally reach the scalpel-finger-cannula procedure which succeeds.

Steps

1. Start with a short introduction

The facilitator places the procedures in the context of the CICO team algorithm. He/she walks through the algorithm steps whilst demonstrating the algorithm on a neck trainer asking participants to take on assisting roles (show them the CICO protocol).

2. Brief the participants on how to run the scenarios

“You have just declared a CICO emergency. I’d like you to work in teams through the steps of the CICO algorithm, so (then pointing to the algorithm):

Begin at the start of the algorithm by performing a needle cricothyroidotomy. Then I want you to assume that the cannula cricothyroidotomy fails (e.g., there

was blood or vomit in the airway) so you need to move to the surgical arm of the algorithm.

Start by feeing the neck. If you think that the neck anatomy is palpable then attempt a scalpel bougie

technique. If you don’t think the neck anatomy is palpable OR if for some reason you have

been unsuccessful in intubation with a scalpel-bougie technique (e.g., you did not correctly identify the neck structures) then move on to the scalpel-finger-cannula technique and jet ventilate.

Finally, use the Melker set to convert a cannula technique to a definitive airway.


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3. Run the scenarios

The participants should start by declaring a CICO and follow the next step shown in the algorithm (cannula cric). They then assume that their initial step has failed and refer to the algorithm for guidance on their next step. Each procedure should be assumed to fail until they finally reach the scalpel-finger-cannula procedure which succeeds. For example:

Declare CICO, allocate roles (as per CICO protocol), refer to algorithm. Follow the next step laid out in the algorithm (cannula cricothyroidotomy). Perform

cannula cricothyroidotomy. They then assume that their initial step has failed and return to the algorithm (e.g.,

failure due to blood or vomit present in the airway or there may be no obvious reason).

They palpate the neck and imagine they can feel the trachea or cricothyroid membrane (they should be able to on these models).

Perform scalpel-bougie cricothyroidotomy. Assume it fails (e.g., unable to advance bougie due to incorrect anatomy

identified/incorrect technique). Return to the algorithm and proceed to next step: scalpel-finger-cannula. Jet oxygenate through the cannula. Convert to Melker™ airway.


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Session 6: Managing Transition - 7 failure factors and strategies

Format: Discussion

Aims: How clinicians underperform in crises. Includes analysis and recommendations from

Elaine Bromiley case and others. Refer also to Riley/Greenland/RHCE working party ANZCA Bulletin articles

Introduce 7 Failure (human) factors and strategies including communication, assertiveness, team-work

Practice assertiveness phrases


Documents and resources: PowerPoint (Session 6)

Venue: Seminar room


Slide 1

This presentation looks specifically at human and systems factors that can impede a team’s ability to successfully make the transition from supraglottic to infraglottic rescue.


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Slide 2

We know from the findings of coroners’ reports and the NAP4 that CICO is often sub-optimally managed: frequently it is embarked upon either prematurely or too late, or is executed unsuccessfully. The reasons for this are multifactorial.

Slide 3

We have reviewed key articles and coroners’ reports looking at reasons why management of CICO fails. We present these as seven ‘failure factors’ along with suggested strategies for avoiding and mitigating them.

WE will go through these in turn.


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Slide 4

Effective management of crises requires good decision making and decisive action but a review of the case reports involving CICO situations suggests that indecision often plays a contributory role in sub-optimal management.

In particular uncertainty about when to declare that supraglottic rescue has failed and to move to infraglottic rescue appears to be a large contributor. This may be because there are no clear guidelines on what constitutes a CICO event.

Slide 5

Q: So how do we arrive at this decision? General decision-making theory advises us that our decisions will be improved if we follow the points listed here. Q: Look at the list – do you feel these may help you make a decision to declare a CICO?

Discussion points: It’s about using information well, using best evidence, maximising other people’s understanding of the

situation and incorporating their judgment in the decision. Evidence-based guidelines are extremely useful if these are available and we will discuss this in the next

slide. Encouraging people to speak up and inviting input are also important. For example it was reported in the

enquiry into Elaine Bromiley’s death that the nursing staff felt a CICO situation existed and expected to perform a surgical airway but did not communicate this to the medical staff. People may also feel more confident to speak up if they can refer to a best practice management guideline that is displayed in the room.

Consulting experts is also helpful if time permits. We just need to remember that time is critical in a CICO situation and we need to arrive at the decision quickly.


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Slide 6

Just before we look in detail at using algorithms and guidelines to declare CICO it’s also useful to consider some of the key decisions that help avoid CICO situations from arising.

Q: As an example, how many decisions do you estimate you would make looking after a patient with a dental abscess from the time he or she presented to the ED to the post-op period?

In the case of airway infection, which is a well know high risk group there are a number of management decisions that might avert CICO developing in the first place. Here are just a few.

Slide 7

Now we look specifically at a guideline for CICO. We present our ‘Transition’ algorithm, which we used in Sessions 2 and 3 on supraglottic airway rescue. We recommend this is readily available. A reduced version is incorporated into top part of the CICO team algorithm. Q: Does anyone want to walk us through it?

Discussion points: The key to transition is to keep supraglottic rescue simple and timely and have regular stop and review points.

We recommend the vortex cognitive aid as it provides clear criteria against which we can appraise the adequacy of supraglottic airway rescue based on the success or otherwise of a best attempt at rescue using a face mask, endotracheal tube and supraglottic device such as a laryngeal mask airway.

If we follow the techniques suggested under all three lifelines and these fail to restore oxygenation (for example an oxygen saturation of greater than 90%) then supraglottic rescue has failed and we have a CICO situation.

But we don’t want to embark on infraglottic rescue prematurely so if you don’t feel you have a CICO then continue supraglottic rescue and review and ask the question frequently. Start mobilising resources for CICO and be prepared to upgrade the situation to a CICO at the next review point.


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Slide 8

Despite meeting criteria for CICO we still need to commit to our decision and make others aware of this. Sometimes this doesn’t happen.

Sometimes we think we are communicating but the message is unclear to others. Unclear communication compounds indecisiveness by reducing the situation awareness of other team members who could potentially assist decision-making by pointing things out or supporting us.

Finally being too consultative can hamper decision-making. It is important to consult and cross check to ensure that the team agrees it’s a CICO but consultation should be not be allowed to degenerate to vacillation or disagreement which may lead to delayed or inappropriate action. There needs to be a leader who makes it clear whether it is a CICO or whether the situation is still at the level of supraglottic airway rescue. This needs to be verbally updated.

Slide 9

Q: Can we do it?

Let’s look again at our algorithm (Slide 7).

It starts with the question ‘Is this a CICO?’ We recommend you have an algorithm such as this that displays this question for all members of the team to view during supraglottic rescue. If you feel the situation meets the criteria of a CICO then verbalise this clearly to the team ‘We have a CICO situation’. If not then return supraglottic airway rescue and review in one minute or earlier. Then update again

Q: Can anyone see any difficulty declaring CICO this way?


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Slide 10

No notes

Slide 11

We know that during uncommon and stressful events such as CICO it is easy for ‘human factors’, such as impulsiveness, denial, freezing, indecisiveness and simply losing track of time, to negatively impact performance. Stress also degrades our performance and that other others by forcing other errors, delays and reducing troubleshooting. This is quite evident in the Coroners’ reports of deaths from CICO several of which are available on-line.

There are many factors that underlie these behaviors. Here is a list of factors we have extracted from various publications addressing reasons that lead clinicians to perform sub-optimally in the lead-up to an adverse event. Q: Have you experienced any of these and can you see any playing a part in a CICO?


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Slide 12

Strategy 3 – Manage your stress

Many of the strategies listed with the other ‘key factors’ in this presentation will go a long way to optimising our own performance.

Probably the most effective thing we can do in addition to these is to manage our stress and be mindful – or deliberately focused.

Slide 13

Q: What are some effective ways of managing stress?

Discussion points: Stop and review points work extremely well in helping people to be methodical, creating a sense of order and reducing stress levels.

We can manage our stress by monitoring and managing our own responses and behaviors. For example, if we are aware we have stress (high heart rate, fast breathing, tight chest and head, high pitched or pressured voice) we can slow our breathing and speak slowly. These steps are a form of biofeedback, and may improve our ability to function cognitively, and at the very least will create the impression that we are calm and in control. If we appear calm it will likely help other team-members to remain calm and perform better.


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Slide 14

Lack of assertiveness appeared to play a part in the now well-known case of fatal CICO suffered by Elaine Bromiley. When team-members are unwilling or unable to contribute in a supportive way the team is at greater risk of committing errors and making poor decisions. Similarly, conflict within a team may negatively impact communication and decision making. In a crisis the intelligence of the team is potentially greater than any individual because of improved situation awareness and decision-making and dispersal of stress.

Slide 15

It’s surprising how reluctant other team members can be to share an observation or express a concern. Some may feel the situation is in hand because they have a lot of confidence in the senior clinicians leading the situation. Others may not want to interfere. People need to know explicitly that it is OK to speak up


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Slide 16

This is well known in aviation where assertiveness training is well established.

It’s not uncommon for us to downplay or soften a query when we feel assertiveness is required however there are many examples of this contributing to aviation accidents and possibly in health.

Q: Look at the least assertive query (no 6) and the most (no 1). Which one are you most likely to use?

Slide 17

‘Graded assertiveness’ is a technique all pilots learn and are expected to use if they have a concern about safety. The concerned person has four ways of expressing his or her concern starting with a mildly assertive expression. If this does not result in anyone responding adequately to the concern then the concern is restated at a higher level of assertiveness (Grade 2). If needed this continues to level 4 which demands a response.


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Slide 18

Strategy 4 - Invite input from team members

There are other strategies we can employ to improve team assertiveness. This is what we recommend:

It is important to encourage people to contribute but they need to understand the situation so it helps to think aloud, summarizing the situation and clarifying the goals. Say ‘Please speak up if you are concerned or have suggestions’.

Adding to this we should keep the atmosphere calm.

Effective team leadership will be required. The team-leader should be someone other than the airway proceduralist if possible. Ensure communication is relayed through the team-leader.

Noise levels and crowd control may need managing but do it calmly as an agitated leader will create stress among the team.

And thank people for their input. It may help in future crisis situations.

Slide 19

No notes


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Slide 20

Failure factor 5 – Unpreparedness

Even after we recognise and agree we have a CICO situation we might still be reluctant to commit to infraglottic rescue for a variety of reasons. We might lack confidence in our ability, the right equipment may not be immediately available or the team on whom we rely upon may be unfamiliar with the equipment or the procedure. This is understandable as there are numerous techniques described along with a variety of equipment.

Strategy 5 - Be physically prepared to perform infraglottic rescue

Preparation occurs at a number of levels: individual, team, department and system. Having a systematic approach in our workplace will be useful to ensure everyone is on the same page with preparation including equipment officers, trainers and people involved in quality assurance.

We will cover this in Session 8.

Slide 21

No notes


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Slide 22

Failure factor 6 - Time

Once a best attempt has been made at each of the three supraglottic rescue techniques, it is important to clearly declare that this is a CICO situation to the team. Unfortunately, even if we do this we may fail if we don’t anticipate the amount of time required to set up for and perform infraglottic rescue.

Slide 23

Strategy 6 – Mobilise resources for infraglottic during supraglottic rescue

In order to be prepared for infraglottic rescue in the event of a CICO situation we should mobilise resources for infraglottic rescue in parallel with supraglottic rescue. This should definitely commence by the time we have failed at two of the three supraglottic pathways in the Vortex model.

Before attempting the third supraglottic rescue technique the team leader should call for help if this hasn’t occurred already.

He or she should also mention to the team that this may be a CICO situation and gather appropriate equipment and personnel. Team roles should be allocated as part of this mobilisation of resources.


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Slide 24

Failure Factor 7 – Neglect of supraglottic rescue

It’s easy to become fixated on particular steps in the management during an event like this and some important activities might be neglected. This includes continuation of supraglottic rescue even after the CICO is declared and infraglottic rescue commenced. Obviously, this is dependent upon there being adequate human resources but it just might provide lifesaving amounts of oxygen.

Slide 25

Strategy 7 – Continue supraglottic rescue in parallel with infraglottic rescue

Ensure you allocate a team-member to continue supraglottal rescue. This may also optimise venting of gas, and prevent barotrauma, during jet insufflation in infraglottic rescue.


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Slide 26

Let’s summarise these failure factors and strategies.


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Session 7 – Integrated practice scenarios

Format: Simulations

Aims: Integrates all lessons (technical and human factors) and recommendations including:

Rehearsal of ‘3’ and ‘3’ stages of rescue

o ‘3’ supra-glottic rescue lifeline

o decision to transition to infra-glottic rescue and infraglottic rescue

o ‘3’ primary paths of infraglottic rescue

Application of the algorithms

Practice with the equipment including the ‘CICO Kit’

Rehearsal of a coordinated team approach: team roles, record keepers and time prompts, good communication with appropriate assertiveness

Description:

In this session participants will manage four mini-scenarios in groups of three. Each group stays at the same workstation with one facilitator. The facilitator (1) introduces the session (assumes groups may be in different break out rooms and (2) runs four scenarios, internally managing change over time between scenarios.

Duration: 90 minutes - Intro (5); Scenarios (4 x 20); Wrap-up (5)

Documents and resources: See equipment list simulations; lap-tops with videos and PowerPoint slides for review; laminates of algorithms.

Equipment List – See list

Set-up

Each table has one set equipment and all tables are identical (i.e. will perform same activities)

Use either full manikins or airway-trainer-torsos depending on what is available for the supraglottic rescue component

Use neck models (situated nearby) for the infraglottic airway rescue component Use SimMan™ software on a laptop to create the falling SaO2 tone to create

urgency Aim to have an assistant at each workstation to operate the software (if possible) You will need to brief your assistant on how you want the saturations to play out for

your scenario

Venue: Breakout rooms


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Guide to introducing the session

The introduction comprises (1) a statement of the workstation aims (2) a briefing and (3) a short familiarisation before the scenarios commence.

(1) Aims – see above

(2) Briefing

We will do four short scenarios to rehearse ‘3’ and ‘3’ stages of supraglottic and infraglottic rescue and transition.

Each scenario will require you to manage a difficult airway involving some degree of airway obstruction. These will vary in respect to the stages of airway rescue that will be appropriate for resolution – i.e., supraglottic only or supraglottic transitioning to infraglottic. Each scenario will require a justification of the choice to desist or proceed with transition to infraglottic rescue and, in the event of the latter, the stage of the CICO algorithm used.

You should pre-allocate roles and prepare for the scenario in advance using the preparedness checklist and change roles before each scenario.

Each scenario will commence with the facilitator (me) setting the scene. I will provide patient vital signs and info to enable you to make a judgment about next steps.

We acknowledge that the manikin lacks important life like features that are important in assessing airway obstruction. The facilitator will try to provide cues and will not trick you. The faculty nurse (if present) will be acting as a nurse and his / her comments will need to be considered as in real life, rather than interpreted as a cue from big brother.

Remember, this is a really low fidelity scenario so please ask anaesthetist to talk about the things you look for from the end of the bed etc the things that make you the airway expert for example: Patient’s state of agitation, posture, paradoxical resps, accessory muscles etc.

The scenario may have challenges built in for the purposes of rehearsing topics addressed earlier in the workshop, including possibly the need to consider criteria for CICO; negotiate and be assertive and work under time pressure. The facilitator may play a role in the scenario to enable these situations to be practiced.


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Guide to running scenarios Scenario 1/4 Overview

Intended outcomes - Not a CICO (Supraglottic rescue resolves situation) i.e. “1-2-1” stage Structural elements for discussion

Following the obstructed airway algorithm with stabilisation before declaring CICO What criteria to declare CICO Responding to pressure to perform CICO when not indicated

Set-up

Patient (Resus Annie™) in Recovery with O2 mask around neck, trolley slightly head up, but flat on his back.

Simulator Settings: Simman RR 8 , HR 95-120 BP 150/90 - 165/95 over 2 mins Sa O2 90

Briefing

Briefing from facilitator Recovery ward. A 35 year old man BMI 35 had a tonsillectomy for obstructive sleep

apnoea, Handed over to recover nurse by confederate(facilitator) increasingly drowsy, laboured breathing and snoring.

O/E you find him unrousable, RR 8, snoring and SAO2 85%. O2 mask has fallen off although the nurse is at liberty to replace this before she calls for other team members. BP 160/95 HR 110

Patient background info on the anaesthetic sheet

OSA no CPAP machine , day time drowsiness denied but partner says snores a lot and wakes himself up; IDDM, hypertensive and high cholesterol. Preop notes show he had Insulin this am Actrapid 4 units with a half piece of dry toast; Normal Insulin last night 24 units long acting BSL preop 4.5

Intra-op: 200 fentanyl , 10 mg morphine; roc; ETT Grade 2 +BURP Start Scenario

Confederate hand-over to recovery nurse “Thanks for helping this guy really isn’t great but I’ve got to go to the bathroom really urgently sorry to leave him to you to sort out there’s others around to help you out”


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Progress: Sa O2 90 –falls to 84 over 20 secs unless O2 mask put on, drops to 88% if Hudson

mask put on Initial intervention will reveal him to be difficult to oxygenate with bag and mask with

Sao2 remaining < 90%. 2 handed bag and mask ventilation will be difficult although some chest rise esp if

coordinated with his resp attempt i.e., Sat O2 never really improves greatly but not terrible 84-88

At this stage if suggestion of CICO hasn’t come from group, the facilitator could pause and ask is this a CICO? Try to get the nurses to prompt the anaesthetists to refer to the Transition section of the algorithm and use graded assertiveness. Then ask what equipment should we be getting ready but don’t over prompt by suggesting LMA unless it is not coming from the group. An LMA will succeed in achieving an airway. Narcan will result in reawakening, but depending on dose and progress of scenario you could make laryngospasm return and possibly deteriorate again.

SaO2 will rise slowly when Nasopharyngeal airway x 2 inserted or LMA BSL will be 1.9 and he will respond somewhat to glucose although will remain

drowsy. Discussion

1. Tell us about this case? What happened and why did we manage it the way we did? 2. Why was this not a CICO? What criteria were present/not present? 3. What could the scenario have evolved differently to convert it a CICO?


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Scenario 2/4 Overview

Intended outcomes: Aim is to push them into CICO algorithm (i.e. 1 2 3 stage) and then run with which ever method they choose (i.e. 1, 1-2 or 1-3). Needle will work in this situation, but scalpel bougie / scalpel finger bougie Ok.

Structural elements for discussion Referral to the preparedness for CICO checklist Team-based decisions – opportunities to plan with surgeons, ICU, ED, anaesthetists

+ nurses Team preparation – event leader, proceduralist, airway assistant, set-up people x 2,

timekeeper, scribe Set-up

Patient (Resus Annie) in recovery with O2 mask around neck, trolley slightly head up, but flat on his back.

HR 60 reg, BP 160/110, RR 16, SpO2 96% 6 l Hudson mask Briefing

Briefing by facilitator Recovery. 70 year old patient after carotidendarterectomy GA awaiting transfer to ICU. Surgeon now standing beside bed 300ml in Redivac, neck is distended a little and possibly ongoing. Surgeon somewhat concerned about neck swelling. Keen to explore early preferably in OT under controlled conditions of GA. Patient background info from anaesthetic sheet

70 years ex-smoker gave up 2 weeks ago, hypertensive and high cholesterol on medication, has stable angina, last ECHO showed no valve lesions and reasonable ejection fraction

Previous R Fempop Bypass Anaesthetic sheet show 150 MCG fentanyl, 120 Propofol , Vecuronium 7mg, Grade 3 larynx by registrar Clonidine 75 mcg intra op Morhpine 3 mg in OT 2 lots of 2mg in recovery

Pre scenario Discussion

1. What are you looking for on examination?( no respiratory distress, normal voice, trachea difficult to feel but not obviously deviated, minimal use of accessory muscles, able to lie reasonably flat if you try it but surgeon wants him sitting)

2. How are you going to put him to sleep?


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Start Scenario

Induce anaesthesia (pretend and talk through quickly) Progress:

Patient will desaturate after induction by what-ever method Loss of pharyngeal muscle tone even without relaxants Early NP airways will slow but not prevent desaturation LMA difficult to get a good seal because of swelling but may slightly improve Sats but

only to high 80s Aim is to push them into CICO algorithm. Will succeed with needle but OK for any

method they choose. Final Discussion

Refer to CICO checklist – what level of preparedness have group members achieved? Re they familiar with equipment in their units; would nurses know what equipment to use etc.

Team preparation – event leader, primary proceduralist, airway assistant, set-up people x 2, timekeeper, scribe.


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Intended outcomes: CICO need to perform all ‘3’ and ‘3’ stages of rescue Structural elements for discussion

Two potential proceduralists – anaesthetists + surgical registrar Dilemma about optimal location – controlled conditions of OT or elsewhere

Set-up

Patient (resus Annie) in OT with O2 mask around neck, trolley slightly head up, but flat on his back. 6 l Hudson mask

No monitoring until team place it. Then initial vitals will be: RR 24 HR 130-160 BP 150/90 - 170/100 Sa O2 with O2 99%

Briefing

Briefing from facilitator Patient admitted for drainage of abscess after dental extractions several days ago;

preop CT scan ordered and but brought back from X-ray without scan as they are unhappy without anaesthetic assistance

Induction bay of OT. Surgeon (registrar) has brought him into induction bay as he thinks we need to proceed quickly

Large man in obvious distress (Megacode with ice packs wrapped around head and neck). Sitting up on trolley from faculty voice is hoarse, drooling, barely coping with saliva. Able to lie down for short periods if given a sucker self-suctioning mouth

Has IV in situ has had antibiotics ( if asked no response to Neb AD)

Patient background info from anaesthetic sheet – NA (no old notes) Start Scenario

Let team get monitoring on BP SaO2, team time out, preop checks, etc. Progress: Supraglottic rescue attempts

Deteriorates: develops soft inspiratory stridor, becoming sweaty

Cough and Speak, Spasms so SaO2 falling to 90% Further fall in Sao2 will depend on management Impossible to get view with laryngoscopy can’t get laryngoscope into mouth properly May get a little improvement if attempts LMA but not good seal CPAP helps a bit Able to assist with bag/ mask +/- nasopharyngeal airway + CPAP will hold at 83%


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Progress: Transition: SaO2 83% sweaty, HR rising, BP going up, seesaw resps mainly using accessory

muscles despite supraglottic rescue Progress: Infraglottic rescue attempts

Progress through 3 steps to scalpel finger bougie If surgeon does it fails (Surgical route needle unsuccessful landmarks not palpable)

Discussion Points

Team-based decisions – how would you decide who the proceduralist and what method?

How do you decide if you have time to perform this in OT under controlled conditions?


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Intended outcomes: CICO need to perform all ‘3’ and ‘3’ stages of rescue plus ALS for hypoxic cardiac arrest Structural elements/learning objectives

ED – early admission demise Disagreement with colleague about transfer of patient to OT Cardiac arrest

Set-up

Scenario takes place in the ED Simulator: stridor, saturations of 80%, RR 25, HR 130, BP 190/110

Briefing

Briefing from facilitator Patient presents with breathing difficulty. Patient provides a history (with difficulty) of

previous airway cancer treated 2 years ago with surgery and radiotherapy. He has recently been diagnosed with a recurrence of this airway tumour and is booked to have a microlaryngoscopy next week. He has smoking related airways disease and is on regular bronchodilator treatment.

OE: he appears to have evidence of existing COAD with chest hyperexpansion and use of accessory muscles of respiration. In addition he has stridor, saturations of 80%, RR 25, can’t phonate easily and evidence of a previous radical neck dissection and possible mandibulectomy and tethering suggestive of radiotherapy. Mouth opening is limited to two cm.

Patient background info from old notes: Medical records not available. Start Scenario

Progress: Early treatment Treatment by the team may include: Nebulised adrenaline, Heliox and

dexamethasone There will be a mild but inadequate response to this with SaO2 rising to 86%

Progress: Decision-making/assertiveness

The facilitator advises the team that the surgeon wants to perform a tracheostomy under LA in the OT but the team leader is not confident the patient can be transferred safely to theatre. He/she needs to negotiate this as a mock telephone call with the surgeon. Objective is to rehearse Assertiveness


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Initial Discussion

1. What is your plan? Are you going in a lift with this patient? What is the best location to secure the airway and what would be the preferred anaesthesia?

Scenario Part 2

Irrespective of the final decision, the patient deteriorates and becomes unconscious Progress: Supraglottic rescue attempts fail Progress: Transition: Meets criteria for CICO Progress: Infraglottic rescue attempts

Progress through 3 steps to scalpel finger bougie. The needle cannula will work temporarily before kinking (faculty may need to pause and kink cannula with audience aware of this) prompting a modification in response (scalpel bougie or scalpel finger).

Meanwhile heart rate rapidly slows to 30bpm and femoral pulses become thready. SaO2 stops reading suggesting imminent hypoxic cardiac arrest requiring cardiac compressions and ALS for bradycardia/asystole while the airway is secured. This will be successful (faculty need to be ready to prompt if team are slow)

If ED/surgeon does procedure it fails (Surgical route needle unsuccessful landmarks not palpable)

Discussion Points

Team-based decisions – how would you decide who the proceduralist and what method?

How do you decide if you have time to perform this in OT under controlled conditions?


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Session 8: Being prepared – A systems plan

Format: Discussion

Aims: Encourage systems change including: Routine training/rehearsal including how

departments can deliver training, adoption of uniform equipment and algorithms Assess an institution’s preparedness for this crisis. Presents checklist that could be

used as a quality assurance/risk management tool.

Description:


Documents and resources: PowerPoint (Session 8); CICO Preparedness Checklist/Audit tool

Venue: Seminar room


Slide 1

This session aims to help you preparing your department or facility to be prepared for CICO situations.

While critical care clinicians should be trained and mentally prepared as individuals to manage CICO, the onus also falls on hospital facilities and departments to ensure their system is prepared to deal with the event.


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Slide 2

This is a list of the actions we feel are important. Every department or facility has different needs so it’s important that a customised approach is used.

We will go through a few slides to explain what we mean by these points. As we do this we would like you to take notes appraising how useful each point would be if applied to our department.

At the end of the presentation we will ask you:

Q:How do you feel your department should be set up?

Raising awareness of CICO - Make ‘CICO’ a brand name within your department

Firstly let’s start with the first point ‘Create a CICO ‘brand’ in your department’. Using the example of cardiac arrest where we have a cardiac arrest trolley, cardiac arrest algorithm and audit tools we could develop the equivalent for CICO: e.g., A CICO equipment kit; CICO algorithm and a ‘CICO Preparedness Checklist’. Such as those used in this program. These would assume that the department or hospital uses a uniform approach to managing CICO.

Slide 3

We have already discussed decision-making in the section on Transition. Key points from that session include the value of cognitive aids in declaring CICO such as the Transition algorithm (shown here) and the Vortex cognitive aid which gives us a framework for deciding when supraglottic airway rescue has failed.

It’s also very important that we communicate with the team: we want to encourage people to speak up if they are concerned we are not declaring CICO (or alternatively being too impulsive and declaring it without a reasonable trial of supraglottic rescue). We also want to declare CICO clearly and unambiguously so everyone knows that the goals have changed to include infraglottic rescue.


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Slide 4

Irrespective of what algorithms you choose to use everyone needs to be familiar with them including the nursing staff.

In this program we use four cognitive aids or algorithms:

the Vortex cognitive aid gives us a flexible schema for supraglottic rescue recognizing that the order in which we attempt manouvres such as face mask ventilation, insertion of LMA and endotracheal intubation will vary.

The Transition algorithm (shown at the top of the algorithm on the slide) guides us as supraglottic rescue to ensure we neither neglect basic airway techniques nor persevere with futile manouvres that have already failed. It reminds us to start mobilising resources for infraglottic airway rescue before we actually declare CICO.

Andy Heard’s algorithm gives us a sequential framework for infraglottic rescue.

The Emergency Team algorithm incorporates all of these to guide the whole event including team members roles and mobilization of resources.

It’s not imperative that you adopt these algorithms.

Q: What algorithms will work best in your practice?

Slide 5 It is imperative that you stock equipment that works with your chosen algorithm and that everyone is familiar with it. In this program we recommend particular brands that the authors of the algorithms recommend. Q What equipment does your department stock? Do you know where it is kept and how to use it? Is it contained within a dedicated CICO pack?


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Slide 6

Here are examples of how a few different centres stock their CICO packs

Slide 7

This is the Leroy O2 Insufflator prior to it being commercialised as the Papid-O2 Oxygen insufflation device


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Slide 8

This photo demonstrates the level of detail we need to apply to our knowledge of this equipment and its storage and maintenance.

The photo shows Rapifit connectors. These have subtle differences that affect whether they fit a Frova bougie or a Cook Airway Excahnege catheter and whether they have a universal airway connector or connect to a jet oxygenator.

Slide 9

No notes

Slide 10

No notes


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Slide 11

Assistance – Calling for help is an important part of the CICO algorithm. CICO rosters The system should ensure that assistance is reliably available either via a roster or form of agreement about support from other senior medical officers (e.g. Ear Nose and Throat surgeons and Intensive Care Physicians). They should be available at short notice and a reliable communication system to contact these people should be in place. Q: How does this work in your facility? Q: Is it reliable? Would it be improved with a roster or an explicit escalation plan? When help arrives it helps if everyone is following the same plan Q: What is the likelihood that the ED, ICU anaesthesia and surgical specialists in your facility would follow a similar approach?

Q: Is it feasible to have all departments agree on a uniform approach and participate in interdisciplinary training?


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Slide 12

Everyone who has a role in CICO should receive some training.

There are a range of training options:

1. Self-directed learning: Individuals can prepare outside of the department through personal reading, E learning and workshops but the content should match what they will do in the workplace.

2. Departmental meetings can be used to gain agreement on activation criteria, algorithms and equipment; They can also be a forum for demonstrations of technique and raising awareness within the department of equipment and algorithms. Case –based discussion of scenarios are easily achieved within the structure of departmental meetings.

3. Hands-on departmental training: Training is likely to be most effective when the challenges of real-world situations are reproduced. Ideally hands-on workshops are run that enable step-by-step practice of the specific techniques and equipment the anaesthetist plans to use along with rehearsal of the algorithm within the context of time-critical scenarios.

4. Interprofessional training: Better still critical care disciplines could undertake interdisciplinary training thereby enabling team-based competencies to be rehearsed such as role allocation, leadership, decision-making, assertiveness and ergonomic practice. Attributes of staff amenable to training are shown in the “CICO Preparedness Checklist”. Clearly this type of training is more difficult to implement due to scheduling challenges and the resources involved in running scenario-based team training however it is worth attempting if possible. This program was designed to provide the resources to do this.

Slide 13

Quality assurance (QA)

As we can see preparation occurs on a number of levels. From a systems perspective it is useful to have a “CICO Preparedness Checklist”. This can be used to induct new staff, periodically audit preparedness and undertake a review of critical airway events to identify system faults which can be corrected. Let’s refer to the checklist now along with your notes Q: Which aspects of preparation does your department currently undertake?

Q What opportunities exist to improve system preparedness in your department?


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2. BIBLIOGRAPHY

Heard AMB, Green RJ, Eakins P. The formulation and introduction of A ‘Can’t Intubate, Can’t Ventilate’ algorithm into clinical practice. Anaesthesia, 2009; 64:601-608.

The Vortex Approach [Internet]. Melbourne: Clinical Crisis Education; c2013 [cited 2013 Apr 3]. Available from: http://www.vortexapproach.com/Vortex_Approach/Vortex.html

NAP4 Audit – reference as previously.

The Difficult Airway Society [Internet]. London: Home of the Difficult Airway Society; [cited 2013 Apr 3]. Available from: http://www.das.uk.com/

EdWISE eLearning site [Internet]. Sydney: EdWISE; c2012 [cited 2013 Apr 03]. Available from: http://edwise.moodle.com.au/

3. VIDEO LINKS

1. Cannula cricothyroidotomy video:

http://vimeopro.com/johnmackenzie/cant-intubate-cant-oxygenate/page/1

www.youtube.com/watch?v=Pzf29LT6VJQ

2. Melker conversion of cannula cricothyroidotomy video:

www.youtube.com/watch?v=J1pUJYOWfog

Melker conversion: http://vimeopro.com/johnmackenzie/cant-intubate-cant-oxygenate/page/2

3. Scalpel-bogie cricothyroidotomy:

www.youtube.com/watch?v=TveIsbjmakU


4. Scalpel-finger-cannula cricothyroidotomy:

www.youtube.com/watch?v=waGiiEyzqX8
