Emergency Front Of Neck Access Research Articles

Impact of a departmental protocol and training on physician confidence in paediatric emergency front of neck access

Impact of a departmental protocol and training on physician confidence in paediatric emergency front of neck access

Simulating high-fidelity emergency front-of-neck access: Training in an obstetric setting.

In a cannot intubate, cannot oxygenate scenario (CICO), emergency front of neck access (eFONA) is the final lifesaving step in airway management to reverse hypoxia and prevent progression to brain injury, cardiac arrest and death. The Difficult Airway Society (DAS) guidelines advise the scalpel cricothyroidotomy method for eFONA. Anatomical and physiological changes in pregnancy exacerbate the already challenging obstetric airway. We aim to assess the impact made by introducing formal eFONA training to the perioperative medicine department of an obstetric hospital. Ethical approval and written informed consent were obtained. 17 anesthetists participated, (two consultants, one senior registrar, four registrars and eight senior house officers). Study design was as follows: Initial participant survey and performance of a timed scalpel cricothyroidotomy on Limbs & Things AirSim Advance X cricothyroidotomy training mannikin. Difficulty of the attempt was rated on a Visual Analogue Scale (VAS). Participants then watched the DAS eFONA training video. They then re-performed a scalpel cricothyroidotomy and completed a repeat survey. The primary endpoint was duration of cricothyroidotomy attempt, measured as time from CICO declaration to lung inflation confirmed visually. After a three-month period, participants were reassessed. Four anesthetists had previous eFONA training with simulation, only one underwent training in the previous year. The mean time-to-lung inflation pre-intervention was 123.6 seconds and post-intervention was 80.8 seconds. This was statistically significant (p = 0.0192). All participants found training beneficial. Mean improvement of VAS was 3. All participants' confidence levels in identifying when to perform eFONA and ability to correctly identify anatomy improved. On repeat assessment, 11/13 participants successfully performed a surgical cricothyroidotomy, mean improvement from first attempt was 12 seconds (p = 0.68) which was not statistically significant. This method of training is an easily reproducible way to teach a rarely performed skill in the obstetric population.

Emergency Front of Neck Access

The “Can't Intubate, Can't Oxygenate” (CICO) situation, while rare, is one of the most emergent and stressful scenarios ever faced by airway practitioners. Failure to provide adequate oxygenation can rapidly result in hypoxic brain injury and death. Emergency front of neck access provides a last resort, lifesaving route for the invasive oxygenation of patients. Adequate forward planning as well as recognition of at-risk patients is critical to avoidance of CICO situations. Multiple strategies exist for performing emergency front of neck access, and much debate exist as to which strategy is superior. All airway practitioners should be trained in at least one method of emergency front of neck access, as it may be required in unfamiliar environments at any time. A thorough understanding of the anatomy involved is important to avoid complications, and regular training has been shown to be vital to the maintenance of the skill. It is often the case that front of neck access is performed too late and a great emphasis has been placed on promoting a timely performance of the procedure.

Confidence in airway management proficiency: a mixed methods study of intensive care specialists in Australia and New Zealand

Objective: To explore self-confidence, and the respective facilitators and barriers, among intensive care specialists in Australia and New Zealand in relation to airway management. Design: A mixed methods study. Setting: 11 intensive care units across Australia and New Zealand. Participants: 48 intensive care specialists. Intervention: A structured online interview and the presentation of three discrete airway management clinical scenarios - routine endotracheal intubation, awake fibreoptic intubation (AFOI), and emergency front of neck access (FONA). Main outcome measures: Graded Likert scale responses regarding confidence in airway management were analysed, and perceptions of facilitators and barriers to confidence in each select scenario were obtained as free text. A deductive thematic analysis was done iteratively on free text entry and allowed for the development of a coding framework. NVivo software used the coding framework to run coding queries and cross-tabulations for comparison of relationships between themes and participant demographic characteristics. Results: Participants reported differing levels of confidence. Clinical experience, an anaesthetic qualification and training (including simulation) were the major facilitators to influencing confidence. Participants were more confident performing routine intubation than AFOI or FONA. Equipment, checklists or protocols, and availability of video-laryngoscopy were also identified as facilitators to confidence by most participants. Work relationships, teams and other staff availability were identified as further facilitators to confidence; lack of these factors were less commonly identified as barriers. Conclusions: Confidence in airway management among intensive care specialists in Australia and New Zealand varies, both between specialists and depending on clinical context. Multiple facilitators to improving this exist, including additional mandatory training.

Accuracy of Cricothyroid Membrane Identification Using Ultrasound and Palpation Techniques in Obese Obstetric Patients: An Observational Study

(Int J Obstet Anesth. 2021;48:103205) Emergency front of neck access (e-FONA) is a potentially life-saving intervention but requires the accurate identification of the cricothyroid membrane (CTM). CTM identification failure is most common in obese females, who also have an increased risk of emergency and elective cesarean delivery. This study aimed to compare accuracy of CTM identification using ultrasound (US) compared with palpation in obese obstetric patients.

Major complications of airway management: a prospective multicentre observational study.

We conducted an observational study of serious airway complications, using similar methods to the fourth UK National Audit Project (NAP4) over a period of 1 year across four hospitals in one region in the UK. We also conducted an activity survey over a week, using NAP4 methods to yield an estimate for relevant denominators to help interpret the primary data. There were 17 serious airway complications, defined as: failed airway management leading to cancellation of surgery (eight); airway management in recovery (five); unplanned intensive care admission (three); and unplanned emergency front of neck access (one). There were no reports of death or brain damage. This was an estimate of 0.028% (1 in 3600) complications using the denominator of 61,000 general anaesthetics per year in the region. Complications in patients with 'predicted easy' airways were rare (approximately 1 in 14,200), but 45 times more common in those with 'predicted difficult' airways (approximately 1 in 315). Airway management in both groups was similar (induction of anaesthesia followed by supraglottic airway or tracheal tube). Use of awake/sedation intubation, videolaryngoscopy and high-flow nasal oxygenation were uncommon even in the predicted difficult airway patients (in 2.7%, 32.4% and 9.5% of patients, respectively). We conclude that the incidence of serious airway complications is at least as high as it was during NAP4. Despite airway prediction being used, this is not informing subsequent management.

Dexmedetomidine and emergency front of neck access for acute stridor in advanced laryngeal carcinoma: Anesthetic challenges

Supraglottic airway obstruction due to airway malignancy resulting in respiratory distress is a medical emergency requiring urgent re-establishment of airway patency, with tracheostomy to alleviate the stridor and threat to life. We report a 61-year-old male patient who presented with acute stridor, dyspnea, and a left-sided metastatic neck mass to the emergency room. The patient was rushed to the operation theater for emergency tracheostomy under monitored anesthesia care. We hereby discuss a successful surgical cricothyroidotomy, post failed emergency tracheostomy under dexmedetomidine infusion.

Comparing the Cric-Guide® emergency front of neck access device to a scalpel-bougie-tube technique in a porcine model that simulates bleeding

Comparing the Cric-Guide® emergency front of neck access device to a scalpel-bougie-tube technique in a porcine model that simulates bleeding

203 Ultrasound Identification of the Cricothyroid Membrane for Emergency Front of Neck Access

The difficult airway society states that emergency front of neck access skills should be recapped every 6 months amongst those practitioners expected to perform the skill. Furthermore, the national audit states that, of the 25 emergency cricothyroidotomy cases, 9 failed. These were largely due to incorrect identification of the midline and tube misplacement. There is a convincing argument for training practitioners in ultrasound identification of the cricothyroid membrane, mitigating the risks of incorrect midline identification and blood vessel damage Our aim was two-fold: introduce and embed the skill of ultrasound identification of the cricothyroid membrane for use in emergency front of neck access and encourage regular recap of these skills through a training package of blended learning, consisting of videos, ‘tea trolley’ style theatre training and a more formal simulation-based course that focuses on the ultrasound and front of neck access skill and human factors as we know this is a key factor in the success or failure of this scenario.A pilot course was rolled out amongst anaesthetic trainees to assess relative comfort with performing emergency front of neck access. The course consisted of a short lecture on the background and anatomy, teaching of the ultrasound skill using live subjects, practising of ultrasound-guided front of neck access on animal necks and finally a simulation with debrief surrounding implementation of the skill itself and human factors. This course is now being rolled out regionally and aims to teach all trainees in the region. We encourage trainees to generate their own informal logbook of ultrasound cases, whereby they consent patients to undergo a short ultrasound scan in the anaesthetic room prior to intubation, have their neck marked and then are rescanned after intubation to confirm correct identification. This should be done with ‘normal’ airways, not just those expected to be difficult, as this practice embeds the skill. Our ‘tea trolley’ style teaching is yet to be commenced but will involve ad hoc teaching within the theatre suite including the multi-disciplinary team who would be involved in such an event – the anaesthetist, operating department practitioner and theatre team. Finally, we are generating a video bank, which can be accessed in users’ own time to recap and review the process and troubleshooting of ultrasound identification of the cricothyroid membrane and ensuing cricothyroidotomy.An improvement was reported in trainees’ comfort levels to perform ultrasound-guided cricothyroidotomy and all trainees felt that this was a worthwhile skill to embed into their practice. These improvements were tested via a pre- and post-course questionnaire. The same we hope will be true for the tea trolley training and we aim to address the human factors involved during these sessions too.The aspiration is that ultimately ultrasound identification of the cricothyroid membrane for emergency front of neck access will at the very least become a skill that all trainees are formally taught and encouraged to practice and at the most will become the new standard for plan D airway access in the difficult airway society guidelines.

VIETNAMESE ANESTHESIOLOGISTS TRAINING ABOUT EMERGENCY FRONT OF NECK ACCESS IN THE CANNOT INTUBATE - CANNOT OXYGENATE CRISIS

Background: Emergency front of neck access (eFONA) is the last resort in the Cannot Intubate - Cannot Oxygenate (CICO) crisis. The presence of an algorithm and a well-trained team have been recognized as being essential in reducing errors to achieve a positive outcome. The objective of this study was to evaluate the current situation regarding training, experience and availability of the various means of managing CICO and eFONA in Vietnamese hospitals. Methods: We sent out a link for a 10-question electronic survey to lead anaesthesiologists who subsequently distributed the link to their staff. This was followed by a paper questionnaire at the anaesthesia conference in Hue City. Results: 49.3% of anesthetists are aware of local guidelines in their hospital compared to 69.5% being aware of international guidelines. Only 90 (29.8%) respondents felt they could manage the CICO/eFONA crisis with confidence. Some form of training in managing a CICO crisis has been received by two thirds of respondents (203, 67.2%). Only 88 (29.1%) respondents had received any hands-on simulation training. The majority of participants agreed that some form of compulsory training for CICO/eFONA would be appropriate (98.7%, 298/302). Conclusion: There was a shortage in training, the experience of anesthetists and availability of the various means of managing CICO and eFONA in Vietnamese hospitals. Simulation training should play a vital part in this situation Key words: CICO, eFONA, training and equipment

Current practice of German anesthesiologists in airway management : Results of anational online survey.

There is aworldwide consensus among experts that guidelines and algorithms on airway management contribute to improved patient safety in anesthesia. The present study aimed to determine the current practice of airway management of German anesthesiologists and assess the safety gap, defined as the difference between observed and recommended practice, amongst these practitioners. To determine the effect of implementing the guidelines on airway management practice in Germany amongst anesthesiologists and identify potential safety gaps. Asurvey was conducted in September 2019 by contacting all registered members of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) via email. The participants were asked about their personal and institutional background, adherence to recommendations of the current German S1 guidelines and availability of airway devices. A total of 1862 DGAI members completed the questionnaire (response rate 17%). The main outcome was that anesthesiologists mostly adhered to the guidelines, yet certain recommendations, particularly pertaining to specifics of preoxygenation and training, showed asafety gap. More than 90% of participants had avideo laryngoscope and half had performed more than 25 awake intubations using aflexible endoscope; however, only 81% had avideo laryngoscope with ahyperangulated blade. An estimated 16% of all intubations were performed with avideo laryngoscope, and 1 in 4 participants had performed awake intubation with it. Nearly all participants had cared for patients with suspected difficult airways. Half of the participants had already faced a"cannot intubate, cannot oxygenate" (CICO) situation and one in five had to perform an emergency front of neck access (eFONA) at least once. In this case, almost two thirds used puncture-based techniques and one third scalpel-based techniques. Current practice of airway management showed overall adherence to the current German guidelines on airway management, yet certain areas need to be improved.

Scalpel cricothyroidotomy: The importance of bougie coude tip and scalpel blade characteristics

Scalpel cricothyroidotomy is a life-saving emergency procedure used for accessing the airway in a ‘can't intubate, can't oxygenate’ scenario. To date, various patient characteristics and imaging modalities have been investigated for improving emergency Front of Neck Access (eFONA) attempts. However, there is still a lack of consensus in determining the most effective bougie and scalpel to use. This study analysed six readily available bougies and three broad-based scalpels. We found significant heterogeneity between the coude tip angles and the depth of the bougies, as well as the cutting depth of the scalpels. Some of the bougies and scalpel blades currently available on the market may therefore be unsuitable for eFONA attempts in patients with a high body mass index (BMI) as the depth of the cricothyroid membrane is likely to be increased. We recommend anaesthetic departments, emergency departments and critical care units should review their current eFONA equipment to assess the suitability for use, particularly in patients with a raised BMI.

Accuracy of cricothyroid membrane identification using ultrasound and palpation techniques in obese obstetric patients: an observational study

BackgroundDuring performance of emergency front of neck access, the final step in management algorithms for the ‘can’t intubate, can’t oxygenate’ scenario, accurate identification of the cricothyroid membrane is crucial. Accurate identification using palpation techniques is low, with highest failure rates occurring in obese females. MethodsThis prospective observational study recruited 28 obese obstetric patients. The cricothyroid membrane was identified using ultrasound, marked with an ultraviolet pen and covered with a dressing. The candidate was asked to perform cricothyroid membrane identification using landmark technique (group L) followed by ultrasound (group U). The primary outcome was the distance between the actual and estimated cricothyroid membrane midpoint. Secondary outcomes were the proportion of accurate assessments, time taken, and subjective ease of identification using a visual analogue score. ResultsDistance from the cricothyroid membrane midpoint was shorter in group U than Group L (2.5 mm vs 5.5 mm, P=0.002). The proportion of correctly identified cricothyroid membranes was greater in group U than group L (71% vs 39%, P=0.015). Time required for identification was shorter in group L than group U (16.9 s vs 23.5 s, P=0.001). Visual analogue scores for ease of identification were lower in group U than group L (2.4 cm vs 4.2 cm, P=0.013). ConclusionsUltrasound-guided cricothyroid membrane localisation was significantly more accurate but slower than the landmark technique in obese obstetric patients. As such, we recommend the use of pre-procedural identification of the cricothyroid membrane in this patient population and formal training of anaesthetists in airway ultrasound.

Becoming the temporary surgeon: A grounded theory examination of anaesthetists performing emergency front of neck access in inter-disciplinary simulation-based training.

The time-critical 'can't intubate, can't oxygenate' [CICO] emergency post-induction of anaesthesia is rare, but one which, should it occur, requires Anaesthetists to perform rapid emergency front of neck access [FONA] to the trachea, restoring oxygenation, and preventing death or brain hypoxia. The UK Difficult Airway Society [DAS] has directed all Anaesthetists to be trained with surgical cricothyroidotomy [SCT] as the primary emergency FONA method, sometimes referred to as 'Cric' as a shorthand. We present a longitudinal analysis using a classical approach to Grounded Theory methodology of ten Specialist Trainee Anaesthetists' data during a 6-month training programme delivered jointly by Anaesthetists and Surgeons. We identified with a critical realist ontology and an objectivist epistemology meaning data interpretation was driven by participants' narratives and accepted as true accounts of their experience. Our theory comprises three themes: 'Identity as an Anaesthetist'; 'The Role of a Temporary Surgeon'; and 'Training to Reconcile Identities', whereby training facilitated the psychological transition from a 'bloodless Doctor' (Anaesthetist) to becoming a 'temporary Surgeon'. The training programme enabled Specialist Trainees to move between the role of control and responsibility (Identity as an Anaesthetist), through self-described 'failure' and into a role of uncertainty about one's own confidence and competence (The Role of a Temporary Surgeon), and then return to the Anaesthetist's role once the airway had been established. Understanding the complexity of an intervention and providing a better insight into the training needs of Anaesthetic trainees, via a Grounded Theory approach, allows us to evaluate training programmes against the recognised technical and non-technical needs of those being trained.

Evaluation of a novel emergency front of neck access device in a benchtop model of obesity.

Emergency front of neck access (eFONA) is a critical step in oxygenation in cases of unrelieved airway obstruction. Multiple techniques are used in clinical practice without agreement regarding the optimal approach. We evaluated a novel device, the Cric-Guide (CG), a channelled bougie introducer that enters the airway in a single action and compared it with a scalpel-bougie-tube (SBT) technique in laboratory benchtop model. Seven anaesthesiologists attempted eFONA on both obese and non-obese models using both techniques in randomized order on an excised porcine trachea with an intact larynx with variable subcutaneous tissue depth. The primary outcome was successful tracheal cannulation. Secondary outcomes included false passage rate, time and tissue injury. Anaesthesiologists performed 4 cricothyroidotomies on each model with each device. The CG was more successful in airway cannulation (47/56 [89.4%] vs. 33/56 [58.9%], P=0.007). This difference was observed in the obese model only. The CG was associated with fewer false passages than the standard technique in the obese model (8/56 [14.3%] vs. 23/56 [41.1%], P=0.006). There were no significant differences in time to completion or injury patterns between the techniques in the obese model, but the SBT was faster in the non-obese model. There was no difference in the proportion of specimens injured. The Cric-Guide device was more successful than the standard SBT technique in airway cannulation in an obese neck model and with equivalent frequency and distribution of injury but performed equivalently in the non-obese model.

Rabbit training model for establishing an emergency front of neck airway in children

BackgroundA ‘cannot intubate, cannot oxygenate’ (CICO) situation is rare in paediatric anaesthesia, but can always occur in children under certain emergency situations. There is a paucity of literature on specific procedures for securing an emergency invasive airway in children younger than 6 yr. A modified emergency front of neck access (eFONA) technique using a rabbit cadaver model was developed to teach invasive airway protection in a CICO situation in children. MethodsAfter watching an instructional video of our eFONA technique (tracheotomy, intubation with Frova catheter over which a tracheal tube is inserted), 29 anaesthesiologists performed two separate attempts on rabbit cadavers. The primary outcome was the success rate and the performance time overall and in subgroups of trained and untrained participants. ResultsThe overall success rate across 58 tracheotomies was 95% and the median performance time was 67 s (95% confidence interval [CI], 56–76). Performance time decreased from the first to the second attempt from 72 s (95% CI, 57–81) to 61 s (95% CI, 50–81). Performance time was 59 s (95% CI, 49–79) for untrained participants and 72 s (95% CI, 62–81) for trained participants. Clinical experience and age of the participants was not correlated with performance time, whereas the length of the tracheotomy incision showed a significant correlation (P=0.006). ConclusionThis eFONA training model for children facilitates rapid skill acquisition under realistic anatomical conditions to perform an emergency invasive airway in children younger than 2 yr.

Current Recommendations for Airway Management Techniques in COVID-19 Patients without Respiratory Failure Undergoing General Anaesthesia: A Nonsystematic Literature Review.

Summary. Background.Since severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first emerged, many articles have been published on airway management for coronavirus disease 2019 (COVID-19) patients. However, there is a lack of clear and concise conceptual framework for working with infected patients without respiratory failure undergoing general anaesthesia compared to noninfected patients. The aim of this article is to review current literature data on new challenges for anaesthesia providers, compare standard airway management techniques protocols with new data, and discuss optimisation potential.Materials and methods.Literature search was performed in Google Scholar and PubMed databases using these keywords and their combinations: anaesthesia, preoxygenation, airway management, difficult airway, SARS-CoV-2, COVID-19. The following nonsystematic review is based on a comprehensive literature search of available data, wherein 41 articles were chosen for detailed analysis. Summarised and analysed data are presented in the article.Results.SARS-CoV-2 has unique implications for airway management techniques in patients without respiratory failure undergoing general anesthesia. Main differences with the standard practice include: institutional preparedness, team composition principles, necessary skills, equipment, drugs, intubation and extubation strategies. Failed or difficult intubation is managed with predominance of emergency front of neck access (FONA) due to increased aerosol generation.Conclusions.Airway management techniques in COVID-19 patients without respiratory failure are more challenging than in noninfected patients undergoing general anaesthesia. Safe, accurate and swift actions avoid unnecessary time delay ensuring the best care for patients, and reduce risk of contamination for staff. Appropriate airway strategy, communication, minimisation of time for aerosol generating procedures and ramped-up position aid to achieve these goals. During the pandemic, updated available literature data may change clinical practice as new evidence emerges.

Emergency Front of Neck Access: Anaesthetic experience in Thames Valley

Emergency Front of Neck Access: Anaesthetic experience in Thames Valley

FONA with friends: in-situ interdisciplinary simulation of emergency front of neck access

FONA with friends: in-situ interdisciplinary simulation of emergency front of neck access

Emotional responses to performing emergency front of neck access (eFONA)

Emotional responses to performing emergency front of neck access (eFONA)