Library resource guides: ANZCA & FPM CPD Program resources: Can’t intubate, can’t oxygenate (CICO)

Guide index

Can’t intubate, can’t oxygenate (CICO)

Simulation activity which aims to ensure anaesthetists have recognised training to prevent (where possible) and manage a CICO situation.

Participate in a CICO-related activity - find recognised courses and workshops on the college website
Additional CICO-related resources can be found on the CICO tab of the Airway library guide.

CPD Value: CPD participants may claim this under Emergency response Can’t intubate, can’t oxygenate (CICO) activity.

Recognised emergency algorithms

At this stage, ANZCA does not exclusively endorse any one emergency algorithm for CICO situations but recognises the need for clinicians to be familiar with at least one.

The following background resources and accompanying algorithms are suitable for use in infraglottic airway access/ front-of neck access:

Transition from supraglottic to infraglottic rescue in the “can’t intubate can’t oxygenate” (CICO) scenario.
Report from the ANZCA Airway Management Working Group - November 2014.
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This report was written as part of the development process by the Australian and New Zealand College of Anaesthetists (ANZCA) for difficult airway management. The content of this review relates to the prevention, identification and management of decision to proceed to emergency surgical airway in the critical event of being unable to ventilate or oxygenate a patient having induced general anaesthesia. This is referred to as the “can’t intubate, can’t oxygenate” (CICO) scenario. This report forms the basis for ANZCA professional document PS61 and its accompanying background paper (PS61-BP).
PG61(A) Guideline for the management of evolving airway obstruction: transition to the Can’t Intubate Can’t Oxygenate airway emergency 2017
This document summarises the available information and evidence relating to airway obstruction evolving to a 'Can't Intubate, Can't Oxygenate (CICO)' situation. It includes strategies to prevent and identify the event and then manage the decision to transition to infraglottic rescue.
PG61(A) Guideline for the management of evolving airway obstruction: transition to the Can’t Intubate Can’t Oxygenate airway emergency Background Paper 2017

Recommended readings

Chrimes N, Fritz P. The vortex approach: management of the unanticipated difficult airway [Internet]. 2013.
Sabato SC, Long E. An institutional approach to the management of the 'Can't Intubate, Can't Oxygenate' emergency in children. Paediatr Anaesth. 2016;26(8):784-793. Keywords: airway; airway devices; airway obstruction; cricothyroidotomy; difficult airway; pediatric; tracheotomy; transtracheal.
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Abstract
The 'Can't Intubate Can't Oxygenate' emergency is rare in children. Nevertheless, airway clinicians involved in pediatric airway management must be able to rescue the airway percutaneously through the front of the neck should this situation be encountered. Little evidence exists in children to guide rescue techniques, and extrapolation of adult evidence may be problematic due to anatomical differences. This document reviews the currently available evidence, and presents a practical approach to standardizing equipment, techniques, and training for managing the 'Can't Intubate Can't Oxygenate' emergency in children.
Heard A. Percutaneous Emergency Oxygenation Strategies in the ‘Can’t Intubate, Can’t Oxygenate’ Scenario. Smashworks Editions, 2013. [Ebook]
REQUEST A CHAPTER VIA THE LIBRARY.
Greenland KB, Acott C, Segal R, Goulding G, Riley RH, Merry AF. Emergency surgical airway in life-threatening acute airway emergencies--why are we so reluctant to do it?. Anaesth Intensive Care. 2011;39(4):578-584.
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Abstract
'Can't intubate, can't oxygenate' scenarios are rare but are often poorly managed, with potentially disastrous consequences. In our opinion, all doctors should be able to create a surgical airway if necessary. More practically, at least all anaesthetists should have this ability. There should be a change in culture to one that encourages and facilitates the performance of a life-saving emergency surgical airway when required. In this regard, an understanding of the human factors that influence the decision to perform an emergency surgical airway is as important as technical skill. Standardisation of difficult airway equipment in areas where anaesthesia is performed is a step toward ensuring that an emergency surgical airway will be performed appropriately Information on the incidence and clinical management of 'can't intubate, can't oxygenate' scenarios should be compiled through various sources, including national coronial inquest databases and anaesthetic critical incident reporting systems. A systematic approach to teaching and maintaining human factors in airway crisis management and emergency surgical airway skills to anaesthetic trainees and specialists should be developed: in our opinion participation should be mandatory. Importantly, the view that performing an emergency surgical airway is an admission of anaesthetist failure should be strongly countered.

ANZCA & FPM resources

CPD Activity Guide
This guide contains a list of all the activities associated with the ANZCA and FPM CPD Program, as well as links to associated individual activity guides and forms.
ANZCA and FPM CPD Program: Can’t Intubate, Can’t Oxygenate ER Session Guideline
This guideline assists hospitals, private practice groups and other course providers to develop and conduct Can’t intubate can’t oxygenate (CICO) Emergency Response (ER) sessions. It defines the learning objectives and other requirements for education providers to become recognised CICO ER providers for the purposes of the ANZCA and FPM CPD program.
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For CPD participants, this guideline provides information on what recognised CICO ER sessions involve and how to record this activity.
PG61(A) Guideline for the management of evolving airway obstruction: transition to the Can’t Intubate Can’t Oxygenate airway emergency 2017
This document summarises the available information and evidence relating to airway obstruction evolving to a 'Can't Intubate, Can't Oxygenate (CICO)' situation. It includes strategies to prevent and identify the event and then manage the decision to transition to infraglottic rescue.
PG61(A) Guideline for the management of evolving airway obstruction: transition to the Can’t Intubate Can’t Oxygenate airway emergency Background Paper 2017

Airway Assessment by Pierre Bradley, Gordon Chapman, Ben Crooke, Keith Greenland, Australian and New Zealand College of Anaesthetists This airway assessment resource has been produced for use by ANZCA Fellows and trainees to improve understanding and guide management of airway assessment and difficult airways. It is the first of an airway resource series and complements the Transition to CICO resource document (and ANZCA professional document PS61).
Publication Date: August 2016
Transition from Supraglottic to Infraglottic Rescue in the “Can’t Intubate Can’t Oxygenate” (CICO) Scenario: Report from the ANZCA Airway Management Working Group by ANZCA Airway Management Working Group This report was written as part of the development process by the Australian and New Zealand College of Anaesthetists (ANZCA) for difficult airway management. The content of this review relates to the prevention, identification and management of decision to proceed to emergency surgical airway in the critical event of being unable to ventilate or oxygenate a patient having induced general anaesthesia. This is referred to as the “can’t intubate, can’t oxygenate” (CICO) scenario. This report forms the basis for ANZCA professional document PS61 and its accompanying background paper (PS61-BP).
Publication Date: November 2014
The Vortex Approach by Nicholas Chrimes; Peter Fritz This text outlines a simple, team-based approach to managing the unanticipated difficult airway. The approach is designed to address many of the issues identified as contributing to morbidity & mortality in difficult airway management. It consists of a comprehensive education program based around a simple framework for decision making and supported by a straightforward cognitive tool.
Call Number: Free eBook
ISBN: 9781301795505
Publication Date: Jan. 22, 2013

ANZCA: Airway Library Guide
This guide has been designed for anaesthetists interested in the locating resources relevant to airway/CICO management, including those resources available through the ANZCA library.