ANESTHESIOLOGISTS, DON’T BE AFRAID TO CUT INTO A PATIENT’S NECK

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

You’re an anesthesiologist. You’ve lost the airway on your obese anesthetized gynecology patient, your multiple attempts to intubate the trachea have failed, you cannot mask ventilate the patient, and insertion of a laryngeal mask airway did not help. Your patient’s skin and lips are purple and you are terrified. What do you do?

  1. Call a surgeon stat to do a tracheostomy
  2. Ask the gynecologist to cut an airway into the patient’s neck
  3. Keep trying to intubate the trachea yourself
  4. Insert a needle into the cricothyroid membrane, and begin jet ventilation
  5. Cut an airway into the neck yourself.

A study in the October 2019 issue of Anesthesiology showed that when a “can’t intubate, can’t oxygenate” crisis occurred, there were delays finding someone prepared to cut a surgical airway into the front of the neck in time to save the patient’s life. The study looked at malpractice closed claims and found: 1) Outcomes remained poor in malpractice closed claims related to difficult tracheal intubation; 2) The incidence of brain damage or death at induction of anesthesia was 5.5 times greater in the years 2000 – 2012 than in the years 1993 – 1999; 3) Inadequate planning and judgement errors contributed to the bad outcomes; and 4) Delays in placing a surgical airway during “can’t intubate, can’t oxygenate” emergencies were a major issue.

A closed claims study is akin to a large mortality and morbidity (M & M) conference. A closed claims study tells us which complications led to malpractice settlements. Each malpractice closed claim marks a negligent practice which caused an adverse outcome.

I’d like to focus on one specific aspect of this important study: anesthesiologists need to lose their reluctance to cut a surgical airway into a patient’s neck in a “can’t intubate, can’t oxygenate” airway emergency. A surgical airway is an invasive airway via the front of the patient’s neck into their trachea. Waiting for a surgeon to cut a surgical airway, or fearing to cut a surgical airway yourself, could cost your patient his or her life. Delay or failure in placing a surgical airway was described in 10 of the specific 12 cases listed in the Appendix of this Anesthesiology closed claims study, as follows:

Case 1: “Eventually a surgical airway was performed after the patient arrested.”

Case 2: “A surgical airway was performed after the patient arrested.”

Case 3: “The surgeon was called to the room to perform an emergency surgical airway, but there were not any instruments available in the room. The patient sustained anoxic brain injury and later died.”

Case 4: “Ventilation was difficult and the patient arrested. The surgeon arrived and attempted to perform an emergency surgical airway, at which time the anesthesiologist successfully intubated the patient’s trachea as the hematoma was drained. The patient was resuscitated but later died of anoxic brain damage.”

Case 5: “The anesthesiologist asked the surgeon to perform an emergency cricothyrotomy. However, the surgeon insisted that an electrocautery to be set up first. Nine minutes after cardiac arrest, a surgical airway was secured by the surgeon. The patient was resuscitated but remained in a persistent vegetative state.”

Case 6: “An ear-nose-throat surgeon was called to perform a surgical airway, who suggested a supraglottic airway be inserted instead. After the supraglottic airway was placed, the patient became impossible to ventilate and went into cardiac arrest. The surgical airway was placed with some difficulty. The patient sustained severe hypoxic brain and died.”

Case 8: “The surgeon performed a cricothyrotomy after the patient had marked bradycardia and hypotension.”

Case 10: “A surgeon was called to place a cricothyrotomy. The patient was resuscitated but had severe anoxic brain damage and died.”

Case 11: “Multiple intubation attempts and supraglottic airway insertion were made for more than an hour before a surgical airway was performed. At that time, the patient was asystolic and had a tension pneumothorax. The patient died.”

Case 12: “The patient had a hypoxic cardiac arrest. The surgeon arrived 22 min after induction and secured an emergency surgical airway. The patient was resuscitated but sustained hypoxic brain damage requiring assistance with activities of daily living.”

It’s tragic that 10 of the 12 listed cases involved delayed or failed front of neck access to the airway. In an editorial in the same issue of Anesthesiology, authors Takashi and Hillman wrote, “Decision to provide a surgical airway was frequently delayed by repeated attempts at tracheal intubation, anesthesia care providers being hesitant to initiate surgical procedures, or surgeons being reluctant to perform tracheostomy or simply not available.”

The American Society of Anesthesiologists Difficult Airway Algorithm, shown below, clearly describes invasive airway (i.e. surgical airway) access via the front of the neck when attempts to intubate the trachea and oxygenate the patient both fail.

“Can’t intubate, can’t oxygenate” events are rare, but they do occur with a published incidence of 1 in 50,000 anesthetics, per the fourth national audit project in the United Kingdom.  

The brain can be permanently damaged following episodes in which the brain sees no oxygen for five minutes or longer.

Approaches to front of neck access include either cannula techniques or surgical techniques, with significant differences:

Cannula Technique:

This involves inserting a large bore IV catheter through the cricothyroid membrane.

Because the lumen of a 14-gauge IV catheter is small, ventilation requires a high-pressure jet oxygen delivery system. In a publication from 2016, the failure rate with cannula techniques was 42% in “can’t intubate, can’t oxygenate” emergencies. Failure can occur because of kinking, malposition, or displacement of the needle/cannula. Because of the high failure rates, use of the cannula technique is discouraged.

Surgical Technique:

Most surgeons are trained to perform tracheostomies during their residencies, but when a “can’t intubate, can’t oxygenate” emergency occurs, tracheostomy is not the preferred procedure.

Tracheostomy – tube is inserted between tracheal rings

  Cricothyroidotomy, a technique which is faster and requires less surgical skill, can be performed by anesthesiologists, and is the preferred procedure.

In a cricothyroidotomy, the cricothyroid membrane is divided by a surgical incision made with a wide scalpel (#10 scalpel).

a cricothyrotomy is inserted in the cricothyroid space, cephalic to the trachea

Using the scalpel, bougie, tube (SBT) technique,

a bougie is inserted into the trachea through the incision. A lubricated 6.0 mm cuffed endotracheal tube is advanced over the bougie into the trachea, and the bougie is removed as demonstrated in this video link: 

This technique has been specifically endorsed in the United Kingdom in the algorithm from their Difficult Airway Society.  The British Difficult Airway Society guideline for a Can’t Intubate, Can’t Oxygenate crisis follows: 

How to train anesthesiologists to perform SBT cricothyroidotomy:

Are anesthesiologists trained to perform cricothyroidotomy? Not really. Even though the procedure is the last safety valve on the Difficult Airway Algorithm, most anesthesiologists have minimal or no experience in this life-saving procedure. How can we train anesthesiologists to perform cricothyroidotomies? 

In my residency in the 1980s we were trained to do cricothyroid injections of cocaine prior to awake fiberoptic intubation procedures. Each resident performed dozens of these injections, and I became extremely comfortable locating and piercing the cricothyroid membrane with a needle. In 35 years and 25,000+ anesthetics, I’ve never needed to place a surgical airway through that same membrane, but I feel confident I could do so with the scalpel, bougie, tube technique. 

The problem is that most anesthesiologists have never had to perform this front of neck access procedure on a patient. The stakes are high, because there is little time for failure. After several minutes of “can’t intubate, can’t oxygenate,” someone needs to take a scalpel to the cricothyroid membrane. That someone can and often should be the anesthesiologist.

In the October 2013 American Society of Anesthesiologists Monitor we read, “Perhaps the most important problem encountered in “can’t intubate, can’t oxygenate”  is a delay in recognition or institution of emergency airway management. . . . While someone clearly needs to make the decision to obtain a surgical airway, both the surgeons and the anesthesiologist may feel uncomfortable in this role. Retrospective studies, including closed claims analysis, demonstrate that most patients are already in cardiac arrest before emergency invasive airway attempts are performed. While decisive and timely action is clearly needed, the decision to pursue a surgical airway is not an easy one; . . . In fact, there is little legal risk from a surgical airway attempt – no matter how messy – if the patient survives, but enormous liability if the procedure is not attempted.”

In a study from Great Britain, 104 anaesthetists received a structured training session on performing cricothyrotomy. These anaesthetists then took part individually in a simulated “can’t intubate, can’t oxygenate” event using simulation and airway models, to evaluate how well they could perform front‐of‐neck access techniques. First‐pass tracheal tube placement was obtained in 101 out of the 104 cricothyroidotomies (p = 0.31). They concluded that anaesthetists can be trained to perform surgical front of neck access to an acceptable level of competence and speed via simulator training

What needs to happen? Anesthesiology residents need to be trained to do front of neck access, and they need to be trained not to delay if the procedure is indicated. This training needs to be a requirement for all anesthesia professionals. Mid-career anesthesiologists pay for weekend Continuing Medical Education courses on subjects such as ultrasound-directed regional blocks or transesphogeal echocardiography. While these topics are important, they are not life-saving skills such as front of neck access. Anesthesiologists in training, practicing anesthesiologists, and Certified Registered Nurse Anesthetists (CRNAs) must receive hands-on education on performing front of neck access, as well as the reasoning behind not delaying the procedure. 

You’re an anesthesiologist or a CRNA. What should you do now?

  1. Familiarize yourself with the anatomy of the cricothyroid membrane on each of your patients.
  2. Have a scalpel, bougie, tube kit containing a #10 scalpel, a bougie, and a #6 cuffed endotracheal tube included with each difficult airway cart at each facility you anesthetize at.
  3. I now carry a scalpel, bougie, tube kit in my briefcase which I take with me every day at work. In the current model of private practice in California, where we work at multiple different freestanding surgery centers and surgeon offices, this is a reliable means to assure that I have front of neck access equipment with me wherever I anesthetize patients.
  4. Review and rehearse the anatomy and skills necessary to perform front of neck surgical cricothyroidotomy.
  5. Work to avoid “can’t intubate, can’t oxygenate” events. Evaluate each airway prior to surgery. If a significant concern exists regarding a difficult intubation, a difficult mask ventilation, or difficult front of neck access, use your judgment and perform an awake intubation. Securing an airway prior to anesthesia induction is a reliable way to avoid “can’t intubate, can’t oxygenate” disasters.

The closed claims study on difficult tracheal intubation in the October 2019 issue of Anesthesiology should serve as a bellwether for our profession. The practices of waiting for surgeons to arrive to do front of neck access, or of anesthesiologists delaying front of neck access in a “can’t intubate, can’t oxygenate” emergency must cease. Emergency front of neck access must be a core skill that all anesthesiologists are both willing and able to perform when a patient is turning purple before their eyes. 

We owe it to our patients to be ready to save their lives.


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FRONT OF NECK ACCESS

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Can you perform an emergency surgical cricothyroidotomy? In the dreaded Can’t Intubate, Can’t Oxygenate (CICO) scenario, if your patient has no airway, you must immediately establish a front of neck access (FONA) to save your patient’s life.

SCALPEL, BOUGIE, TUBE APPROACH TO CRICOTHYROIDOTOMY

SCALPEL, BOUGIE, TUBE APPROACH TO CRICOTHYROIDOTOMY

This week I attended an outstanding Stanford Anesthesia Grand Rounds delivered by Drs. Jeremy Collins, Susan Galgay, and Tom Bradley. The lecture reviewed the literature regarding CICO events, and concluded that performing a surgical airway through the cricoid membrane is an essential skill for anesthesiologists.

Most anesthesia professionals have never cut into a patient’s neck, but we must own this skill if the necessity arises. I’ve done thousands of cases over 34 years. I have never performed a surgical cricothyroidotomy, but I may need to do one tomorrow. It’s essential expertise for myself and for every anesthesiologist.

As I’ve reviewed in previous columns, a lack of oxygen to the brain for five minutes can cause anoxic brain damage—a disaster all anesthesiology professionals must avoid. The specter that someday we will induce and paralyze a morbidly obese patient, and then be unable to intubate or oxygenate that patient, is in the back of the mind of every anesthesia professional. If and when this happens, we must be able to act without hesitation to oxygenate the patient via FONA.

CICO events are rare, but they do occur with a published incidence of 1 in 50,000 anesthetics, per the fourth national audit project in the United Kingdom (NAP4).  Approaches to FONA include either cannula techniques or surgical techniques, with significant differences.

Cannula Techniques:

These involve inserting a large bore IV catheter through the cricothyroid membrane. Because the lumen of a 14-gauge IV catheter is small, ventilation requires a high- pressure jet oxygen delivery system. In Duggan’s publication from 2016, the failure rate with cannula techniques was 42% in CICO emergencies. In addition, barotrauma occurred in 32% of CICO emergency procedures. Fifty-one percent of CICO emergency events managed with a FONA cannula had a complication. Several reports described trans-tracheal jet ventilation-related subcutaneous emphysema hampering subsequent attempts at surgical airway or tracheal intubation. Failure can also occur because of kinking, malposition, or displacement of the needle/cannula. The Stanford Anesthesia Grand Rounds concluded that these failure rates and complications with cannula FONA techniques were prohibitively high.

Surgical Techniques:

The cricothyroid membrane is divided by a surgical incision made with a wide scalpel (#10 scalpel). With the scalpel, bougie, tube (SBT) technique, a bougie is inserted into the trachea through the incision. A lubricated 6.0 mm cuffed endotracheal tube is advanced over the bougie into the trachea, and the bougie is removed.

There are contrasting difficult airway algorithms algorithms for different English-speaking countries around the globe. See this link for the algorithms from the United States, Australia, Canada, and United Kingdom. Each has unique recommendations for CICO emergencies.

The American Society of Anesthesiologists Difficult Airway Algorithm outlines an approach to airway management, but at the bottom right of the chart, the plan for the CICO situation is “Emergency Invasive Airway Access.” A footnote reads “invasive airway access includes surgical or percutaneous airway, jet ventilation, and retrograde intubation.” The algorithm gives no definitive choice of which technique to use. This is a shortcoming of the American algorithm. There are invasive airway options, and in an emergency there can be no wavering or doubts regarding what to do. Per the data above, percutaneous airway and jet ventilation carry high failure and complication rates. Per discussion at the Stanford Anesthesia Grand Rounds, retrograde intubation is too slow, too difficult, and should be eliminated from the recipe for emergency lifesaving treatment.

The Australian algorithm uses the Vortex approach to managing an unexpected difficult airway.

the vortex approach

THE VORTEX APPROACH

Three options (face mask, endotracheal intubation, and laryngeal mask airway) are all attempted, in any order, to establish a patent airway. If all three methods fail to establish a patent airway, this (not the occurrence of oxygen desaturation) is the trigger to establish an emergency surgical airway (ESA). ESA techniques include either cannula or scalpel cricothyroidotomy to provide a patent airway as rapidly as possible. Note that the Australian Vortex approach endorses either cannula or scalpel cricothyroidotomy, and recommends that anesthesiologists be familiar with both FONA techniques.

The conclusions reached in the Stanford Grand Rounds most closely adhered to the British algorithm, which advocates the SBT (scalpel, bougie, endotracheal tube) method to securing a surgical airway. The SBT method has been specifically endorsed in the United Kingdom Difficult Airway Society algorithm. What follows is the text from the United Kingdom Difficult Airway Society guideline for a Can’t Intubate, Can’t Oxygenate event:

 

The United Kingdom Difficult Airway Society guideline for Failed intubation, failed oxygenation in the paralyzed, anaesthetised patient:

Fig5-Failed-intubation-failed-oxygenation-in-the-paralysed-anaesthetized-patient

Author’s addendum: Many or most patients who suffer CICO events will be obese and have thick or short necks. The cricothyroid membrane may not be easily palpable. Per the text above, the United Kingdom Difficult Airway Society guidelines recommend you make an 8-10 cm vertical skin incision, caudad to cephalad, over the cricothyroid area. This type of surgical maneuver is not a routine part of anesthetic practice, and it will require both skill and courage to commit to the incision. The guidelines next ask you to use blunt dissection with the fingers of both hands to separate tissues until you can identify the larynx and palpate the cricothyroid membrane. Once the cricothyroid membrane is identified, the scalpel incision is made through the cricothyroid membrane. This technique will no doubt create bleeding in the anterior neck, and will not be easy to perform. Enlisting the surgeon’s help during the procedure is advisable. Remember that controlling bleeding is not the primary issue—the primary goal is to locate the cricothroid membrane deep to the adipose of the anterior neck.

When I was a resident I was trained to give cricothyroid injections of lidocaine or cocaine to anesthetize the lumen of the trachea prior to awake fiberoptic intubations. The anatomy of the cricothyroid membrane in most patients is easily palpable, and it can be penetrated with minimal effort or bleeding. In a morbidly obese patient, this approach will be more difficult.

 

How to train anesthesiologists to perform SBT cricothyroidotomy:

This was the subject of discussion at the end of Grand Rounds. Because of the extreme rarity of CICO events, skills will be absent, lost, or dormant for many practitioners. Practice on simulators or plastic models at 6 months intervals was recommended. Dr. Bradley explained that in one approach in Britain, a two-person team traveled from operating room to operating room to teach the SBT method. One member of the teaching team relieved the anesthesiologist from the operating room, and the second member then took the anesthesiologist a room to enjoy a pot of tea and to learn from a plastic training model of the cricothyroid membrane. The final proposals for education and re-education to retain skills at Stanford and throughout the world are challenges for the future. Note that surgeons have almost no education at cricothyroid approaches. Head and neck surgeons are trained in tracheostomy, a different procedure that likely will take too much time to perform when compared to a cricothyroidotomy. Training of surgical colleagues also needs to be addressed in the future.

 

What You Should Do Now:

  1. Familiarize yourself with the anatomy of the cricothyroid membrane on each of your patients.
  2. Have an SBT kit containing a #10 scalpel, a bougie, and a #6 cuffed endotracheal tube included with each difficult airway cart at each facility you anesthetize at.
  3. I now carry an SBT kit in my briefcase which I take with me every day at work. In the current model of private practice in California, where we work at multiple different freestanding surgery centers and surgeon offices, this is a reliable means to assure that I have FONA equipment with me wherever I anesthetize patients.
  4. Be prepared. Review and rehearse the anatomy and skills necessary to perform front of neck surgical cricothyroidotomy in seconds.
  5. Work to avoid CICO events. Evaluate each airway prior to surgery. If a significant concern exists regarding a difficult intubation, a difficult mask ventilation, or a difficult FONA, use your judgment and perform an awake intubation. Securing an airway prior to anesthesia induction is a reliable way to avoid CICO disasters.

 

Two important take-home messages from this column are:

  1. Learn the specific the SBT recipe for front of neck access.
  2. Don’t hesitate and waste seconds—it will take courage to grab that scalpel, but that’s your job and your duty to your patient.

 

For further discussion and advice on airway emergencies, see my columns on Avoiding Airway Lawsuits, Airway Disasters, and The Most Important Technical Skill For an Anesthesiologist.

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The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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