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Sydney Clinical Skillsand Simulation Centre
Can’t Intubate Can’t Oxygenate (CICO)
Management of the Critically Obstructed AirwaySession 6: Managing Transition - 7 failure factors and strategies
Acknowledgement: Leonie Watterson
Background
Incidence of CICO 1/50,000 NAP4
While I am not satisfied that any one person caused or contributed to the problems incurred, I do consider the community does not expect a (healthy young person) to die in a major teaching hospital from airway compromise in these circumstances.
Coroner for Jankowski case
CICO – 7 failure factors
Uncertainty
Ambiguous communication
Human factors
Team assertiveness
Preparation
Time
Neglect of supraglottic rescue
CICO: 7 failure factors – 7 strategies
1 Uncertainty
CICO: 7 failure factors – 7 strategies
1 Uncertainty
Make decisions methodically
- Reduce uncertainty with systems design
- Use an algorithm
- Speak up and share information so everyone understands the situation
- Invite input from people
- Seek help from experts as time permits
Have clear triage criteria for the obstructed airway Prioritise urgency of surgery Do a good pre-op assessment and choose an intubation
technique that corroborates with pre-op findings Have a clinical guideline for steroids, Abs, drains etc Be aware of risks of extubation and have broad criteria for
extubation Be aware of delayed obstruction from and have broad
criteria for discharge from ICU and post-op monitoring Have some agreed principles of activating a CICO
Reducing uncertainty with system design (avoiding CICO)
Best attempt at:• Face-mask ventilation?• LMA ventilation? • Endotracheal intubation? AND
Oxygen saturations falling or persistently low?
Is this a CICO situation?
INFRAGLOTTIC RESCUE
YES
Continue Supraglottic
rescue
Consider waking patient
Review again in 1 min
With permission A. Heard and Working group for the Rural Health Continuing Education (RHCE) (Stream 1) ‘Critically Obstructed Airway Workshop’. Contact smsc@nsccahs.health.nsw.gov.au. 2013
SUPRA-GLOTTIC RESCUE
NO
TR
AN
SIT
ION
‘Transition’ protocol - CICO
MOBILISE RESOURCES
FOR CICO
CICO: 7 failure factors – 7 strategies
2 Ambiguous communication
CICO: 7 failure factors – 7 strategies
2 Ambiguous communication
Commit to your decisionDeclare CICO clearly
CICO: 7 failure factors – 7 strategies
3 Human factors
Inadequate experience First time with a situation Time pressure Bad ‘learnt’ behaviours Cultural norms Reckless/disrespectful attitude Complex system (inheriting bad situations) H.A.L.T (Hungry, Angry, Late, Tired) IM SAFE (Illness, Medication, Stress, Alcohol, Fatigue,
Emotion) Anxiety
Human factors - What drives us to underperform?
CICO: 7 failure factors – 7 strategies
3 Human factors
Practice mindfulness to manage your performance- Manage your stress- Control your voice- Ask for assistance- Accept input from others
Staying calm and in control
Appear calm • Speak calmly: a low and slow voice • Use calming body language (lowering hands)• Avoid offensive language• Use humour • Provide updates and reassure people E.g., ‘Everything is
going well’, ‘That’s great’, Everything’s fine’, ‘The situation is under control’
Stay calm• Apply H.A.L.T• Take deep breaths• Practice self-talk (Don’t lose control!!!!)
CICO: 7 failure factors – 7 strategies
4 Team assertiveness
Assertiveness – Why is it difficult to speak up?
Personality factors Cultural factors
• Fear of confrontation, ostracism, chastisement from management
Situational factors• Shock• Uncertainty• Not in the best interests of the patient• Opportunity passes
Mitigation – ‘Hint & Hope’
1. Command – ‘You must...’
2. Crew obligation statement – ‘We need to...’
3. Crew suggestion – ‘Why don’t we...?’
4. Query – ‘What would you like to?’
5. Preference – ‘I think It would be a good idea to...’
6. Hint – (obtuse reference to cause of problem)
In the event of a hypothetical evolving potentially fatal accident pilots indicated they would: Captains - command (Level 1) First officers - hint (Level 6) Judith Orasanu
Graded assertiveness
Express initial concern (‘I’ statement)
‘I notice that…that seems a little unusual’
Make an enquiry or offer an alternative
‘Why don’t we try …’
Ask for an explanation
‘I don’t understand – please explain your actions to me’
Demand a response or take control of the case
‘Stop - you must listen to me!’
7 failure factors – 7 strategies
4 Team assertiveness
Keep the situation calm Think aloud Invite colleagues to speak up Have a non-procedural teamleaderAvoid conflict - negotiate differences
CICO: 7 failure factors – 7 strategies
5 Preparedness
CICO: 7 failure factors – 7 strategies Equipment –
familiar to all and readily availableStaff – trained Plan – known to everyoneTeamwork – roles and leadership clarifiedResources – assistance on standby
5 Preparedness
CICO: 7 failure factors – 7 strategies
6 Time
Can the plan be carried out in 45 secs? Call it a CICO and call for help Get the cricothyroidotomy kit, set it up Get the jet ventilation device and set it up Perform the technique and oxygenate the patient
CICO: 7 failure factors – 7 strategies
6 Time
During supraglottic rescue…- Ensure that help has been called for- Mobilise resources- Forecast the (possible) need for infraglottic rescue
CICO: 7 failure factors – 7 strategies
7 Neglect of supraglottic rescue
CICO: 7 failure factors – 7 strategies
7 Neglect of supraglottic rescue
Continue supraglottic rescue in parallel with infraglottic rescue
CICO: 7 failure factors – 7 strategies
1 Uncertainty
2 Ambiguous communication
3 Human factors
4 Team assertiveness
5 Preparation
6 Time
7 Neglect of supraglottic rescue
1 Use an algorithm
2 Declare CICO clearly
3 Practice mindfulness to manage your performance
4 Invite input from team members
5 Always be prepared for CICO and infraglottic rescue
6 Mobilise resources for infraglottic rescue during supraglottic rescue
7 Continue supraglottic rescue in parallel with infraglottic rescue
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