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

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).

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.

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.

For CPD participants, this guideline provides information on what recognised CICO ER sessions involve and how to record this activity.