CICO and front of neck access

ANZCA has clarified its position on can't intubate, can't oxygenate (CICO) front of neck access in response to a statement by the Royal College of Anaesthetists.
The release of the Royal College of Anaesthetists’ (RCoA) statement “Anaesthetists and surgeons reach agreement on front of neck emergency techniques in life-threatening ‘CICO’ situations” , associated with a BJA editorial “Surgical intervention during a can’t intubate can’t oxygenate (CICO) event: emergency front of neck airway (FONA)?” has raised a number of questions about the current view of ANZCA on the optimal technique for FONA. This is in the context of our trainee education and also the Emergency Responses CICO training guidelines.

These articles highlight the importance of oxygenating the patient as the primary priority and then securing a definite airway, which ANZCA strongly supports. The "scalpel-bougie" technique has been advocated because it can be performed at most locations, with readily available equipment, by both surgical and anaesthetic teams. Importantly it is also recognised that other techniques can be used depending on individual experience, training, comfort of use, and case specifics.

ANZCA is aware that expert opinion differs on the preferred management of securing a surgical airway, but recognises the need for clinicians to be familiar with at least one.

The College does not "mandate" one approach to FONA over the other. Both are part of CICO training, and individual circumstances will likely direct a preference for one over the other (including department and individual training, patient factors, and the presence of surgical assistance). This is acknowledged in the RCoA release as well.

However, given the limited evidence and lack of consensus among experts in this field, the following important points are noted:
  1. It is fully accepted that individual situations, skills and environments will differ and a specialist is unquestionably entitled to choose either a ‘scalpel-first’ or a ‘needle-first’ approach.
  2.  All specialists and all trainees should continue to learn both needle and scalpel techniques. 
  3. It is fully accepted that in running courses and teaching both techniques, specialists are entitled to use their personal experience and preferences and this will continue to be encouraged until the evidence is clear.
ANZCA has advocated that institution-specific education sessions are developed that satisfies local needs, incorporating local staff, work environments, non-technical skills and point-of-care equipment and resources.  

Based on the current evidence, ANZCA recognises three algorithms as being suitable for the front of neck access performed by anaesthetists. This includes the Royal Perth CICO Algorithm with its stepwise progression from needle -based technique to the definitive airway, DAS 2015 Guidelines and the Canadian Difficult Airway Focus Group 2013 Guidelines.

Specific ANZCA resources relating to airway management and CICO:
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