Can’t intubate can’t oxygenate (CICO) scenarios

An introduction to can't intubate can't oxygenate (CICO) scenario


“CICO is failure to deliver oxygen as a result of upper airway obstruction (at or above the immediate subglottic region) which persists despite all reasonable airway rescue manoeuvres at or above this level”

ANZCA Professional Document PS61

Incidence and Outcome

Limited evidence – NAP 4, cohort studies, closed claim series

  • CICO is a rare event occurring in approximately 1:10,000 to 1:50,000 of routine GAs  
  • Overall incidence of CICO is very low compared to incidence of difficult intubation and prevalence of risk factors in patients therefore implies effective management in the majority of cases 
  • Outcomes are relatively poor, accounting for up to 25% of anaesthesia related deaths

What is the NAP 4

  • A randomized control trial looking at sleep derivation
  • 4th National Audit Project performed in the UK looking at airway complications during anaethesia

NAP 4 findings

  • 2.9 million GAs/yr in NHS
  • 133 anaesthesia related deaths
  • 184 serious airway complications
  • CICV situation related to multiple repeat attempts at difficult intubation 
  • Emergency cannula cricothyroidotomy failure rate high around 60%

The Elaine Bromiley Case

Just a Routine operation

Prevention of CICO

Be prepared

1. Assess the likelihood and clinical impact of basic management problems:

• Difficulty with patient cooperation or consent

• Difficult mask ventilation

• Difficult supraglottic airway placement

• Difficult laryngoscopy

• Difficult intubation

• Difficult surgical airway access

2. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management.

3. Consider the relative merits and feasibility of basic management choices:

• Awake intubation vs. intubation after induction of general anesthesia

• Non-invasive technique vs. invasive techniques for the initial approach to intubation

• Video-assisted laryngoscopy as an initial approach to intubation

• Preservation vs. ablation of spontaneous ventilation

When is it a CICO situation

  • Defining features differs between algorithms 

    • Failed ETT (max 3 attempts) 
    • Failed SGA (max 2 attempts) 
    • Failed BMV

  • SaO2 < 90% SaO2 and time is less clear in relation to transition to CICO 
    • Fall in oxygenation is probably imminent

How many attempts at intubation can occur before declaring a can't intubate scenario

  • One
  • Three
  • Two

DAS guidelines

DAS algorithm

A what point has a CICO situation occurred

  • Failure of Plan C
  • Failure of Plan D
  • Failure of Plan A

Front of neck access

Powerpoint presentation on FONA

Royal Perth Hospital - Cannula crico-thyroid

Royal Perth Hospital - Scalpel Bougie