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