The 'Can't Intubate Can't Oxygenate' scenario in Pediatric Anesthesia: a comparison of different devices for needle cricothyroidotomy.
BACKGROUND
Little evidence exists to guide the management of the 'Can't Intubate, Can't Oxygenate' (CICO) scenario in pediatric anesthesia.


OBJECTIVE
To compare two intravenous cannulae for ease of use, success rate and complication rate in needle tracheotomy in a postmortem animal model of the infant airway, and trial a commercially available device using the same model.


METHODS
Two experienced proceduralists repeatedly attempted cannula tracheotomy in five postmortem rabbits, alternately using 18-gauge (18G) and 14-gauge (14G) BD Insyte(™)  cannulae (BD, Franklin Lakes, NJ, USA). Attempts began at the first tracheal cartilage, with subsequent attempts progressively more caudad. Success was defined as intratracheal cannula placement. In each rabbit, an attempt was then made by each proceduralist to perform a cannula tracheotomy using the Quicktrach Child(™)  device (VBM Medizintechnik GmbH, Sulz am Neckar, Germany).


RESULTS
The rabbit tracheas were of similar dimensions to a human infant. 60 attempts were made at cannula tracheotomy, yielding a 60% success rate. There was no significant difference in success rate, ease of use, or complication rate between cannulae of different gauge. Successful aspiration was highly predictive (positive predictive value 97%) and both sensitive (89%) and specific (96%) for tracheal cannulation. The posterior tracheal wall was perforated in 42% of tracheal punctures. None of 13 attempts using the Quicktrach Child(™)  were successful.


CONCLUSIONS
Cannula tracheotomy in a model comparable to the infant airway is difficult and not without complication. Cannulae of 14- and 18-gauge appear to offer similar performance. Successful aspiration is the key predictor of appropriate cannula placement. The Quicktrach Child was not used successfully in this model. Further work is required to compare possible management strategies for the CICO scenario.
Department of Anesthesia and Pain Management, Princess Margaret Hospital for Children, Perth, WA, Australia.
Jonathan
J
Stacey
Andrew M B
AM
Heard
Gordon
G
Chapman
Catherine J
CJ
Wallace
Mary
M
Hegarty
Shyan
S
Vijayasekaran
Britta S
BS
von Ungern-Sternberg
D058109:Airway Management; D000402:Airway Obstruction / Q000601:surgery; D000758:Anesthesia; D000818:Animals; D002404:Catheterization / Q000295:instrumentation* / Q000379:methods; D002983:Clinical Competence; D003413:Cricoid Cartilage / Q000601:surgery*; D007442:Intubation, Intratracheal; D009339:Needles; D010100:Oxygen / Q000008:administration & dosage / Q000627:therapeutic use*; D010372:Pediatrics; D011817:Rabbits; D015656:Respiratory Mechanics; D013965:Thyroidectomy / Q000295:instrumentation* / Q000379:methods; D014140:Tracheotomy
D010100:Oxygen