Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley and Fremantle Hospitals, Murdoch, Australia.
School of Veterinary and Life Sciences, Murdoch University, Murdoch, Australia.
Anaesth Intensive Care. 2022 Sep;50(5):368-379. doi: 10.1177/0310057X211066927. Epub 2022 May 12.
Live animal models can be used to train anaesthetists to perform emergency front-of-neck-access. Cannula cricothyroidotomy success reported in previous wet lab studies contradicts human clinical data. This prospective, observational study reports success of a cannula-first 'can't intubate, can't oxygenate' algorithm for impalpable anatomy during high fidelity team simulations using live, anaesthetised pigs.Forty-two trained anaesthesia teams were instructed to follow the Royal Perth Hospital can't intubate, can't oxygenate algorithm to re-oxygenate a desaturating pig with impalpable neck anatomy (mean (standard deviation, SD) 16.2 (3.5) kg); mean (SD) tracheal internal diameter 11 (1.4) mm. Teams were informed that failure would prompt veterinary-led euthanasia.All teams performed percutaneous cannula cricothyroidotomy as the initial technique, with a median (interquartile range, IQR (range)) start time of 42 (35-50 (24-93)) s. First-pass percutaneous cannula success was 29% to both insufflate tracheal oxygen and re-oxygenate. Insufflation success improved with repeated percutaneous attempts (up to three), but prolonged hypoxia time increasingly necessitated euthanasia (insufflation 57%; re-oxygenation 48%). First, second and third percutaneous attempts achieved insufflation at median (IQR (range)) 74 (64-91 (46-110)) s, 111 (95-136 (79-150)) s and 141 (127-159 (122-179)) s, respectively. Eighteen teams failed with percutaneous cannulae and performed scalpel techniques, predominantly dissection cannulation ( = 17) which achieved insufflation in all cases (insufflation 100%; re-oxygenation 47%). Scalpel attempts were started at median (IQR (range)) 142 (133-218 (97-293)) s and achieved insufflation at 232 (205-303 (152-344)) s.While percutaneous cannula cricothyroidotomy could rapidly re-oxygenate, the success rate was low and teams repeated attempts beyond the recommended 60 s time frame, delaying transition to the more successful dissection cannula technique. We recommend this 'cannula-first' can't intubate, can't oxygenate algorithm adopts a 'single best effort' strategy for percutaneous cannula, with failure prompting a scalpel technique.
活体动物模型可用于培训麻醉师进行紧急前颈部通道操作。先前在湿实验室研究中报道的气管切开管置管术成功与人体临床数据相矛盾。本前瞻性观察研究报告了在使用活体麻醉猪进行高保真团队模拟时，对于触诊不可得的解剖结构，采用“无法插管，无法给氧”的气管切开管优先算法的成功。
42 个经过培训的麻醉团队被指示遵循皇家珀斯医院的“无法插管，无法给氧”算法，用触诊不可得的颈部解剖结构（平均（标准差，SD）16.2（3.5）kg）使缺氧的猪重新供氧；气管内直径平均（SD）11（1.4）mm。团队被告知，如果失败，将由兽医进行安乐死。
所有团队都将经皮气管切开管置管术作为初始技术，中位（四分位距，IQR（范围）（24-93））开始时间为 42（35-50（24-93））s。首次经皮穿刺管成功为 29%，可同时进行气管内氧吹入和重新给氧。重复经皮尝试（最多三次）可提高吹入成功率，但延长缺氧时间会越来越需要安乐死（吹入 57%；再给氧 48%）。首次、第二次和第三次经皮尝试的中位（IQR（范围））分别为 74（64-91（46-110））s、111（95-136（79-150））s 和 141（127-159（122-179））s。18 个团队在经皮套管失败后采用了手术刀技术，主要采用解剖套管置管（ = 17），所有情况下均实现了吹入（吹入 100%；再给氧 47%）。手术刀尝试的中位（IQR（范围））开始时间为 142（133-218（97-293））s，达到吹入的中位时间为 232（205-303（152-344））s。
虽然经皮气管切开管置管术可快速重新给氧，但成功率较低，团队在推荐的 60 秒时间框架之外重复尝试，延迟了向更成功的解剖套管技术的过渡。我们建议，这种“套管优先”的“无法插管，无法给氧”算法采用经皮套管的“单次最佳努力”策略，失败后提示采用手术刀技术。
