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Can’t Intubate, Can’t Oxygenate | Teaching Invasive Airway With Impalpable Neck Anatomy

March 29, 2022

Written by Clay Smith

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Scalpel-finger-cannula (SFC) was faster and had a higher first-attempt success rate than scalpel-finger-bougie (SFB) for front-of-neck access (FONA) in simulated obese, bleeding manikin models.

Why does this matter?
Can’t intubate, can’t oxygenate (CICO) is rare – 1:50,000 – but in these cases, emergency FONA is lifesaving. FONA is more difficult in patients with a short, obese neck, with difficult or impossible to palpate landmarks. Which is better, SFC – SFC video link – (favored by Royal Perth Hospital) or SFB – SFB video link – favored by the Difficult Airway Society? Be sure to watch this second video all the way through for the vertical incision, obese patient demonstration. SFC is an 8-10cm vertical incision, finger blunt dissection, and a 14 gauge needle cric (with Rapid-O2 device) for oxygenation, followed by a wire plus Melker cricothyrotomy kit once 95% is reached. SFB is an 8-10cm vertical incision, finger blunt dissection, scalpel incision of the cricothyroid membrane, bougie, 6-0 tube for ventilation/oxygenation. Which is better when we compare them head-to-head?

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I’m sweating just thinking of cutting through this mess…
This was a crossover randomized controlled trial with 65 experienced anesthesiologists who performed two techniques on a modified Tru-Cric manikin model to simulate obese patients with impalpable neck anatomy who then “bled” from a bleeding pack that oozed simulated blood when cut, further obscuring landmarks. Here is what the set-up looked like.

From cited article

This disastrous 5cm squishiness was then secured over an anterior neck manikin model. Each participant performed SFC and SFB for FONA in random order. SFC was 61.5 seconds faster to initial oxygen delivery than SFB but took longer overall if the second step of the Melker cric kit was considered (which is arguably less important in a CICO scenario). Participants were systematically faster on their second attempts, but SFC remained quicker even after adjustment. Also, first attempt success was higher in the SFC group: 72.3% SFC vs 27.7% SFB; overall success was higher as well: 84.6% SFC vs 63.1% SFB. Also notable, “88% of participants who chose SFB as their preferred technique changed their preference to SFC after completing the simulation, whereas only 14% of participants who initially chose SFC changed their preference.”

I would have thought SFB would win the day but apparently not. However, there is a big concern I have. In order to do the SFC technique, you need the Rapid-O2 equipment or some sort of jet ventilator set-up. This means more equipment and more room for mistakes. The stuff to do SFB is usually lying around in a resuscitation room. Personally, I have practiced on SFB in the cadaver lab, and that is my go to. But this study makes a compelling case for SFC.

Success and Time to Oxygen Delivery for Scalpel-Finger-Cannula and Scalpel-Finger-Bougie Front-of-Neck Access: A Randomized Crossover Study With a Simulated “Can’t Intubate, Can’t Oxygenate” Scenario in a Manikin Model With Impalpable Neck Anatomy. Anesth Analg. 2022 Mar 3. doi: 10.1213/ANE.0000000000005969. Online ahead of print.

What are your thoughts?