Success and Time to Oxygen Delivery for Scalpel-Finger-Cannula and Scalpel-Finger-Bougie Front-of-Neck Access: A Randomized Crossover Study With a Simulated "Can't Intubate, Can't Oxygenate" Scenario in a Manikin Model With Impalpable Neck Anatomy.

BACKGROUND: Emergency front-of-neck access (FONA) is particularly challenging with impalpable neck anatomy. We compared 2 techniques that are based on a vertical midline neck incision, followed by finger dissection and then either a cannula or scalpel puncture to the cricothyroid membrane. METHODS: A manikin simulation scenario of impalpable neck anatomy and bleeding was created. Sixty-five anesthesiologists undergoing cricothyrotomy training performed scalpel-finger-cannula (SFC) and scalpel-finger-bougie (SFB) cricothyrotomy in random order. Primary outcomes were time to oxygen delivery and first-attempt success; data were analyzed using multilevel mixed-effects models. RESULTS: SFC was associated with a shorter time to oxygen delivery on univariate (median time difference, -61.5 s; 95% confidence interval [CI], -84.7 to -38.3; P < .001) and multivariable (mean time difference, -62.1 s; 95% CI, -83.2 to -41.0; P < .001) analyses. Higher first-attempt success was reported with SFC than SFB (47 of 65 [72.3%] vs 18 of 65 [27.7%]). Participants also had higher odds at achieving first-attempt success with SFC than SFB (odds ratio [OR], 10.7; 95% CI, 3.3-35.0; P < .001). Successful delivery of oxygen after the "can't intubate, can't oxygenate" (CICO) declaration within 3 attempts and 180 seconds was higher (84.6% vs 63.1%) and more likely with SFC (OR, 5.59; 95% CI, 1.7-18.9; P = .006). Analyzing successful cases only, SFC achieved a shorter time to oxygen delivery (mean time difference, -24.9 s; 95% CI, -37.8 to -12.0; P < .001), but a longer time to cuffed tube insertion (mean time difference, +56.0 s; 95% CI, 39.0-73.0; P < .001). After simulation training, most participants preferred SFC in patients with impalpable neck anatomy (75.3% vs 24.6%). CONCLUSIONS: In a manikin simulation of impalpable neck anatomy and bleeding, the SFC approach demonstrated superior performance in oxygen delivery and was also the preferred technique of the majority of study participants. Our study findings support the use of a cannula-based FONA technique for achieving oxygenation in a CICO situation, with the prerequisite that appropriate training and equipment are available.

The Formulation of Cognitive Aids and a Systematic Approach to Emergency Front-of-Neck Access, Following a "Can't Intubate, Can't Oxygenate" Crisis in a Patient With Ankylosing Spondylitis.

A patient with ankylosing spondylitis in a "can't intubate, can't oxygenate" situation was rescued with cannula cricothyrotomy and transtracheal jet oxygenation. The case revealed clinical and systematic weaknesses, leading to standardization and reorganization of our equipment. Prepackaged cannula cricothyrotomy sets were placed in standardized locations in the operating rooms in line with our institution's "cannula first" policy. Cognitive aids specific to emergency front-of-neck access (eFONA) were created and placed strategically with the eFONA equipment to prompt and guide operators during airway emergencies. The aids have also been incorporated into our training curriculum to encourage their use.

A Prospective Audit of Airway Code Activations and Adverse Events in Two Tertiary Hospitals.

INTRODUCTION: Airway management outside the operating room can be challenging, with an increased risk of difficult intubation, failed intubation and complications. We aim to examine airway practices, incidence of difficult airway and complications associated with airway code (AC) activation. METHODS: We conducted a prospective audit of AC activations and adverse events in two tertiary hospitals in Singapore. We included all adult patients outside the operating room who underwent emergency intubation by the AC team after AC activation. Adult patients who underwent emergency intubation without AC activation or before the arrival of the AC team were excluded. Data were collected and documented by the attending anaesthetists in a standardised survey form shortly after their responsibilities were completed. RESULTS: The audit was conducted over a 20-month period from July 2016 to March 2018, during which a total of 224 airway activations occurred. Intubation was successful in 218 of 224 AC activations, giving a success rate of 97.3%. Overall, 48 patients (21.4%) suffered an adverse event. Thirteen patients (5.8%) had complications when intubation was carried out by the AC team compared with 35 (21.5%) by the non-AC team. CONCLUSION: Dedicated AC team offers better success rate for emergency tracheal intubation. Non-AC team attempted intubation in the majority of the cases before the arrival of the AC team. Increased intubation attempts are associated with increased incidence of adverse events. Equipment and patient factors also contributed to the adverse events. A multidisciplinary programme including the use of supraglottic devices may be helpful to improve the rate of success and minimise complications.

Intubation of the patient with a suspected or confirmed COVID-19 infection.

We propose a set of recommendations from our clinical practice for intubation of the patient with a suspected or confirmed COVID-19 infection, with a goal to safely securing the airway while optimizing infection prevention practices to reduce the risk to healthcare personnel.