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Cannula cricothyroidotomy in the impalpable neck: An observational study of simulated ‘can’t intubate, can’t oxygenate’ scenarios by teams following a cannula-first algorithm in live anaesthetised pigs

Wycherley, A.S., Debenham, E.M., O’Loughlin, E., Anderson, J.R., Syed, F.R. and Raisis, A.L. (2022) Cannula cricothyroidotomy in the impalpable neck: An observational study of simulated ‘can’t intubate, can’t oxygenate’ scenarios by teams following a cannula-first algorithm in live anaesthetised pigs. Anaesthesia and Intensive Care .

Link to Published Version: https://doi.org/10.1177/0310057X211066927
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Abstract

Live animal models can be used to train anaesthetists to perform emergency front-of-neck-access. Cannula cricothyroidotomy success reported in previous wet lab studies contradicts human clinical data. This prospective, observational study reports success of a cannula-first ‘can't intubate, can't oxygenate’ algorithm for impalpable anatomy during high fidelity team simulations using live, anaesthetised pigs.

Forty-two trained anaesthesia teams were instructed to follow the Royal Perth Hospital can't intubate, can't oxygenate algorithm to re-oxygenate a desaturating pig with impalpable neck anatomy (mean (standard deviation, SD) 16.2 (3.5) kg); mean (SD) tracheal internal diameter 11 (1.4) mm. Teams were informed that failure would prompt veterinary-led euthanasia.

All teams performed percutaneous cannula cricothyroidotomy as the initial technique, with a median (interquartile range, IQR (range)) start time of 42 (35–50 (24–93)) s. First-pass percutaneous cannula success was 29% to both insufflate tracheal oxygen and re-oxygenate. Insufflation success improved with repeated percutaneous attempts (up to three), but prolonged hypoxia time increasingly necessitated euthanasia (insufflation 57%; re-oxygenation 48%). First, second and third percutaneous attempts achieved insufflation at median (IQR (range)) 74 (64–91 (46–110)) s, 111 (95–136 (79–150)) s and 141 (127–159 (122–179)) s, respectively. Eighteen teams failed with percutaneous cannulae and performed scalpel techniques, predominantly dissection cannulation (n = 17) which achieved insufflation in all cases (insufflation 100%; re-oxygenation 47%). Scalpel attempts were started at median (IQR (range)) 142 (133–218 (97–293)) s and achieved insufflation at 232 (205–303 (152–344)) s.

While percutaneous cannula cricothyroidotomy could rapidly re-oxygenate, the success rate was low and teams repeated attempts beyond the recommended 60 s time frame, delaying transition to the more successful dissection cannula technique. We recommend this ‘cannula-first’ can't intubate, can't oxygenate algorithm adopts a ‘single best effort’ strategy for percutaneous cannula, with failure prompting a scalpel technique.

Item Type: Journal Article
Murdoch Affiliation(s): School of Veterinary and Life Sciences
Publisher: Australian Society of Anaesthetists
Copyright: © 2022 by Australian Society of Anaesthetists
URI: http://researchrepository.murdoch.edu.au/id/eprint/64940
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