The Impact of CICO Kit Ergonomic Design on the Timed Responses of Participants in Simulated Can’t Intubate Can’t Oxygenate Crisis: A Randomised, Cross-over Pilot Study

The 'Can't Intubate, Can't Oxygenate' (CICO) crisis is a serious airway emergency that anaesthetists are trained to rapidly recognise and manage. In a CICO situation, the anaesthetist and their assistant seeks to secure an airway through a front of neck access technique, which is known as an infraglottic rescue. This is required when upper airway techniques have been unsuccessful (e.g. best optimised attempts at bag-mask ventilation, laryngeal mask airway, endotracheal or breathing tube airway). Infraglottic rescue involves the use of CICO equipment and rescue techniques with the aim of establishing oxygenation and / or ventilation. Whilst every hospital institution has a variety of equipment available to help anaesthetists achieve an infraglottic rescue airway, equipment may be stored on different trolleys or packaged and presented in different ways. The location of such equipment may also be distant, in different drawers or limited to certain areas in a clinical workspace. From an ergonomic perspective, packaging equipment into a uniform kit may enable faster accessibility of essential equipment to provide the practitioner with the best chance for responding rapidly to this evolving airway emergency. It is postulated that the strategic storage, organisation and uniformity of pre-packaged essential CICO equipment within a CICO folder kit will serve to enhance accessibility and also act as a visual-cognitive aid in a crisis, which may reduce the cognitive burden, attenuate the stress response and enhance performance of practitioners and their assistants. This project primarily aims to compare the physiologic and timed responses of participants in a simulated CICO crisis using institutional specific equipment versus a pre-packaged CICO equipment kit. Timing responses would involve the following: - Time to recognition of CICO situation - Time to obtaining infraglottic rescue equipment from request - Time to performing successful CICO rescue including infraglottic rescue technique, oxygenation and ventilation. - Time to conversion between CICO rescue techniques Physiologic responses will comprise of: - Heart rate electronic monitoring. - Physiological responses detailed in pre-and-post crisis questionnaires and may be related to: i. General health such as diet, sleep and level of arousal. ii. Current level of stress. iii. Specific times of stress during the simulation. iv. Perceptions of the level of stress of other participants during the simulation. Participants will be recruited from the department of Anaesthesia, Pain and Perioperative Medicine at Fiona Stanley Hospital: i. This may include consultant anaesthetists, registrars and technicians. ii. Inclusion criteria will be a staff member who is fit and able to perform their ordinary professional duties that is expected and within their scope of current practice. iii. Exclusion criteria will be a staff member who expresses a desire to not participate in this study or who is otherwise unfit or unable to safely carry out their expected and ordinary professional duties at work. A participant may withdraw at any stage of the study. Data up to the point of withdrawal will remain as part of the study to ensure internal validity. This has been outlined in the consent information sheet and consent to participate agreement. After simple randomisation of participants to either institutional CICO equipment or a pre-packaged CICO kit, this is to be then followed immediately by the alternate equipment arm. This is an intentional crossover of equipment arms to reduce bias associated with the study. The location of the simulations will occur in the usual work environment of participants such as the surgical theatre area with access to an anaesthetic ventilator, airway trolley, difficult airway trolley, other airway equipment (e.g. video laryngoscopy, fiberoptic scopes) and visual cognitive aids (e.g. Vortex Approach) as would be normally available at Fiona Stanley Hospital. Scenarios used will be standardised (see Appendix 1 below). A simulation pre-brief and debrief session will be conducted by simulation anaesthesia fellows to ensure that participant physical and psychological safety as well as confidentiality is maintained. In order to ensure a certain level of realism as does occur in real-life practice, it will be at the discretion of the simulation anaesthesia fellows to adapt the scenarios in response to the actions of participants to ensure a high fidelity is achieved. Simulation anaesthesia fellows will not be blinded to scenarios performed. A simple stop-clock device and manual recording of times will be used to record observations. Overall, the simulation anaesthesia fellows will be supervised by a consultant anaesthetist with simulation fellowship experience. Appendix 1: - Scenario: For participants using CICO equipment at their institution or pre-packaged CICO kit: - A 35-year-old male is planned for an emergency laparotomy on the background of acute perforated small bowel obstruction. The patient is morbidly obese but without any past medical history, medication history or allergy. Documented airway assessment consisted of Mallampatti grade 4, shortened thyromental distance <6cm, reduced mouth opening and limited neck extension. Please plan and prepare for a general anaesthetic. 1) Trigger 1: Failure of best optimised upper airway techniques (e.g. bag mask ventilation, laryngeal mask insertion, endotracheal tube insertion). Progress to CICO rescue on neck mannequin. 2) Trigger 2: If needle cricothyroidotomy is used, trigger is for simulation fellows to explain procedure needs to proceed. Decision to convert to Melker may then be made by participants. 3) Trigger 3: If either needle or scalpel-bougie technique is used, then time for response of pulse oximetry saturations to rise should occur within 30 seconds. 4) Trigger 4: At the discretion of simulation anaesthesia fellows, if there remains no decision by participants to proceed with an airway that provides effective ventilation in addition to oxygenation, the participants may be prompted to do so. 5) Settings on mannequin: Pre-induction SIM-man 3G settings included a blood pressure of 130/80 mmHg, sinus rhythm heart rate of 130 beats per minute and oxygen saturations of 98%. On successive failed attempts at supraglottic airway management, oxygen saturations were gradually decreased from 98% down to 82% with a concomitant rising tachycardia. The crisis evolved over a period of 90 seconds from the start of simulation. Successful cricothyroidotomy resulted in an initial rise of oxygen saturations by 5%. Oxygen saturations were intentionally kept at a minimum of 82% to avoid inadvertently distracting participants into preparing for a cardiac arrest scenario.