Performance of emergency surgical front of neck airway access by head and neck surgeons, general surgeons, or anaesthetists: an in situ simulation study.
Groom P1, Schofield L2, Hettiarachchi N2, Pickard S2, Brown J3, Sandars J3, Morton B4.
Author information
1
Aintree University Hospital NHS Foundation Trust, Liverpool, UK. Electronic address: peter.groom@aintree.nhs.uk.
2
Aintree University Hospital NHS Foundation Trust, Liverpool, UK.
3
Postgraduate Medical Institute, Faculty of Health & Social Care, Edge Hill University, Ormskirk, UK.
4
Liverpool School of Tropical Medicine, Liverpool, UK; Critical Care Medicine, Aintree University Hospital NHS Foundation Trust, Liverpool, UK.
Abstract
BACKGROUND:
The 'cannot intubate cannot oxygenate' (CICO) emergency requires urgent front of neck airway (FONA) access to prevent death. In cases reported to the 4th National Audit Project, the most successful FONA was a surgical technique, almost all of which were performed by surgeons. Subsequently, UK guidelines adopted surgical cricothyroidotomy as the preferred emergency surgical FONA technique. Despite regular skills-based training, anaesthetists may still be unwilling to perform an emergency surgical FONA. Consultant anaesthetists, head and neck surgeons, and general surgeons were compared in a high-fidelity simulated emergency. We hypothesised that head and neck surgeons would successfully execute emergency surgical FONA faster than anaesthetists and general surgeons.

METHODS:
We recruited 15 consultants from each specialty (total of 45) at a single tertiary care hospital in the UK. All agreed to participate in an in situ high-fidelity simulation of an 'anaesthetic emergency'. Participants were not told in advance that this would be a CICO scenario.

RESULTS:
There were no significant differences in total time to successful ventilation between anaesthetists, head and neck surgeons and general surgeons (median 86 vs 98 vs 126 s, respectively, P=0.078). Anaesthetists completed the emergency surgical FONA procedure significantly faster than general surgeons (median 50 vs 86 s, P=0.018). Despite this strong performance, qualitative data suggested some anaesthetists still believed 'surgeons' best placed to perform emergency surgical FONA in a genuine CICO situation.

CONCLUSION:
Anaesthetists regularly trained in emergency surgical FONA function at levels comparable with head and neck surgeons and should feel empowered to lead this procedure in the event of a CICO emergency.

Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

KEYWORDS:
airway obstruction; cannot intubate cannot oxygenate; front-of-neck access; high-fidelity simulation training; surgical cricothyroidotomy; surgical training; tracheostomy

Comment in
Emergency front-of-neck airway: strategies for addressing its urgency. [Br J Anaesth. 2019]
PMID: 31451190 DOI: 10.1016/j.bja.2019.07.011