Cant Intubate Cant Oxygenate (CICO)

Last updated 12/06/19

Definition

• Inability to intubate or oxygenate a patient

Features

• Anaesthetic emergency
• Cognitive aid assists in appropriate timing of responses
• Task fixation and loss of situational awareness significant barriers to success
• Inherent reluctance to opt for a surgical airway
• Repeated laryngoscopy may cause oedema and trauma and make oxygenation more difficult
• May make rescue with LMA/SGA more difficult
• Consider Vortex model for progression though airway techniques

Risk Factors

• Mallampati Score III or IV
• Emergency General Anaestehtic (GA) Caesarean section
• Obesity
• Obstructive Sleep Apnoea (OSA)

Management

• Prevention
• Pre-operative assessment
• Airway assessment
• Appropriate planning
• Difficult airway trolley
• Stylet or bougie
• Videolaryngoscope (VL)
• Discuss with assistant
• Make the first attempt the best attempt
• Consideration of Rocuronium with rescue dose of Sugammadex 16mg/kg
• Propofol provides good condition for intubation
• Cognitive aids improve outcomes
• Unanticipated Difficult Tracheal Intubation in Adults
• Plan A: Bag Valve Mask (BVM) ventilation and intubation
• Optimise head and neck position
• Pre-oxygenate with 100% FiO2
• +/- Apnoeic oxygenation if able
• Adequate muscle relaxation
• Maximum 3 attempts at laryngoscopy
• One further attempt if someone more experienced available
• Improve conditions between each attempt
• Consider changing laryngoscope
• BVM ventilation between attempts
• External laryngeal manipulation/BURP
• Bougie
• Remove cricoid pressure if applied
• If successful confirm intubation with capnography
• If unsuccessful declare failed intubation and move to Plan B
• Plan B: maintain oxygenation, LMA/SGA
• 2nd generation LMA/SGA recommended
• Greater protection from aspiration
• Cricoid pressure should remain off
• Maximum 3 attempts: change size and/or type
• If successful stop and think
• Options to consider
• Waken patient up: non-urgent surgery
• Intubation via LMA/SGA: fibre-optic guided
• Proceed with LMA/SGA without intubation
• Elective tracheostomy or cricothyroidotomy
• If unsuccessful declare failed LMA/SGA ventilation and move to Plan C
• Plan C: BVM ventilation
• If unsuccessful use muscle relaxant to improve chance of success
• 2 person technique with adjuncts: Guedel, nasopharyngeal
• If able to maintain oxygentation awaken patient
• If unsuccessful move to Plan D
• Plan D: surgical airway (front of neck) = CICO situation
• Scalpel cricothyroidotomy
• Summary
• A: Optimised laryngoscopy with intubation
• B: 2nd generation LMA/SGA
• C: Bag Valve Mask (BVM) ventilation
• D: Cricothyroidotomy (scalpel bougie technique)

Complications

• Hypoxia
• Hypoxia Induced Encephalopathy (HIE)
• Respiratory arrest
• Airway trauma

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References

1. BJA: Difficult Airway Society 2015 Guidelines for Management of Unanticipated Difficult Intubation in Adults, 10/11/2015