PS61 2017: CICO



·         Background

o   Definition

o   Significance

·         Management

o   Ways to oxygenate

o   Process of transition

o   Optimisation of attempts

·         Prevention: technical

o   Airway pre-assessment

o   Chickening out

o   Airway timeout

o   Pre-oxygenation

·         Prevention: non-technical

o   Organisational errors

o   Team errors

o   Individual errors





·         Upper airway obstructed

·         Supraglottic techniques failed

·         SpO2 <90%



·         High mortality

·         More common in ICU and A&E

·         Research suggests our technical and non-technical preparation is poor




Ways to oxygenate:

·         Mask

·         LMA

·         ETT

·         Hole


Process of transition:

·         If fail at 1: declare problem + get help + consider wakeup (yeah, right)

·         If fail at 2: prepare for FONA

·         If fail at 3: declare CICO + do FONA


Optimisation of attempts:

·         General: positioning, suction, muscle relaxant

·         Bag-mask: different size mask, OPA, NPA, two hands, clear oropharynx

·         LMA x 2: different size or type

·         ETT x 3: BURP, bougie, different size direct laryngoscope, video laryngoscope, bronchoscope via ILMA


PREVENTION OF CICO: technical aspects


[A] Airway pre-assessment:

1.       Are there any red flags?

a.       Airway infection

b.       Airway cancer

c.       Airway trauma

d.       Congenital abnormality

2.       Will airway procedures be difficult?

a.       Bag-mask ventilation? (elderly, obese, no teeth, beard, snorer)

b.       LMA insertion? (small mouth)

c.       LMA ventilation? (obese, stiff neck, abnormal anatomy, stiff lungs)

d.       Intubation? (MP, TMD, IID, neck ROM)

e.       Extubation?

f.        FONA? (obesity)

3.       What are the stakes?

a.       Does surgery affect the airway?

b.       What is the aspiration risk?

c.       What is the patient’s cardioresp reserve?


[B] Consider chickening out:

·         Consider AFOI

·         Consider awake tracheostomy

·         Consider regional

·         Consider postponing


[C] Airway time-out always:

·         Plan A + B + C + D

·         Discuss with team

·         Ensure equipment available

·         Consider pre-rehearsal


[D] Pre-oxygenation +/- apnoeic oxygenation:

·         Face mask or HFNP

·         Big breaths in and out


PREVENTION OF CICO: non-technical aspects


Preventing organizational errors:

·         Adherence to best practice guidelines

·         Standardised equipment

·         Airway registry and alerts

·         Letters for tricky patients

·         Checklists

·         Audit

·         Incident reporting

·         Safety culture


Preventing team errors: simulation training

·         Application of cognitive aids

·         Emergency planning

·         Airway timeout

·         Allocation of roles

·         Procedural skills

·         Use of equipment


Preventing individual cognitive errors:

·         Leadership

o   Create shared mental models

o   Allocation of roles

o   Regular status updates

·         Communication

o   Use standardized definition to recognize and declare CICO

o   Closed-loop communication

·         Humility

o   Call for help early

o   Invite others to speak up

·         Navel gazing

o   Self-awareness

o   Preventing fatigue

o   Preventing high task workload


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