Impact of cardiopulmonary resuscitation on a cannot intubate, cannot oxygenate condition: a randomised crossover simulation research study of the interaction between two algorithms

Abstract

ObjectivesDuring a ‘cannot intubate, cannot oxygenate’ situation, asphyxia can lead to cardiac arrest. In this stressful situation, two complex algorithms facilitate decision-making to save a patient’s life: difficult airway management and cardiopulmonary resuscitation. However, the extent to which competition between the two algorithms causes conflicts in the execution of pivotal treatment remains unknown. Due to the rare incidence of this situation and the very low feasibility of such an evaluation in clinical reality, we decided to perform a randomised crossover simulation research study. We propose that even experienced healthcare providers delay cricothyrotomy, a lifesaving approach, due to concurrent cardiopulmonary resuscitation in a ‘cannot intubate, cannot oxygenate’ situation.DesignDue to the rare incidence and dynamics of such a situation, we conducted a randomised crossover simulation research study.SettingWe collected data in our institutional simulation centre between November 2016 and November 2017.ParticipantsWe included 40 experienced staff anaesthesiologists at our tertiary university hospital centre.InterventionThe participants treated two simulated patients, both requiring cricothyrotomy: one patient required cardiopulmonary resuscitation due to asphyxia, and one patient did not require cardiopulmonary resuscitation. Cardiopulmonary resuscitation was the intervention. Participants were evaluated by video records.Primary outcome measuresThe difference in ‘time to ventilation through cricothyrotomy’ between the two situations was the primary outcome measure.ResultsThe results of 40 participants were analysed. No carry-over effects were detected in the crossover design. During cardiopulmonary resuscitation, the median time to ventilation was 22 s (IQR 3–40.5) longer than that without cardiopulmonary resuscitation (p=0.028), including the decision-making time.ConclusionCricothyrotomy, which is the most crucial treatment for cardiac arrest in a ‘cannot intubate, cannot oxygenate’ situation, was delayed by concurrent cardiopulmonary resuscitation. If cardiopulmonary resuscitation delays cricothyrotomy, it should be interrupted to first focus on cricothyrotomy.

A Proposed Guideline for Performance of Emergency Surgical Airways in Small Animals: Analysis of Five Unsuccessfully Managed Cannot Intubate, Cannot Oxygenate Cases

“…If CPA is a result of myocardial hypoxia secondary to CICO, immediate oxygen supplementation via eFONA during CPR is vital to establish return of spontaneous circulation (ROSC). There are sentiments in human medicine that chest compressions should even be ceased to ensure timely airway control by cricothyrotomy if CPA is a result of CICO [22]. Further, one human study demonstrated early invasive airway access had the potential to improve the outcome of CPR for patients suffering from in-hospital CPA [23].…”

Current practice of German anesthesiologists in airway management

“…In the study by Ott et al., 11 of 40 participants had already performed an eFONA in real patient care. The authors were surprised about the high rate (27.5%) and underlined as cause a potential bias of their sample, as experienced providers could have more quickly decided to perform a cricothyrotomy [ 16 ]. The current rate of this survey was approximately one fifth.…”

Exchange of a Tracheal Tube and Supraglottic Airway Device: Evaluation of Different Techniques in Three Simulated Airway Scenarios (TUBE Study)—A Prospective, Randomised Controlled Study

“…Simulation-based research always suffers from a lack of haptic feedback and clinical signs of a real patient, and the results are difficult to translate directly into patient care [ 27 , 28 ]. This is a general concern and has to be taken into account for any interpretation.…”

“…Thus, we decided to design a controlled simulation-based study to evaluate techniques and airway devices applied successfully by anaesthesiologists. We chose the use of simulation for this study to collect data, and recruited anaesthesiologists with different levels of experience in a controlled and safe environment [ 28 ]. The aim of the study was to evaluate which airway technique offers the highest success rate concerning a secure airway in established SGA and TT airway exchange scenarios.…”