[Comparison of ready-to-use devices for emergency cricothyrotomy : randomized and controlled feasibility study on a mannequin]

Necessity to depict difficult neck anatomy for training of cricothyroidotomy: A pilot study evaluating two surgical devices on a new hybrid training model

BACKGROUND

Everyone dealing with airway emergencies must be able to accomplish cricothyroidotomy, which cannot be trained in real patients. Training models are necessary.

OBJECTIVE

To evaluate the suitability of a hybrid training model combining synthetic and porcine parts to depict variable neck anatomy.

DESIGN

Model-based comparative trial.

SETTING

Armed Forces Hospital Ulm, Germany, August 2018.

INTERVENTION

On four anatomical neck variations (long slim/long obese/short slim/short obese) we performed two surgical approaches to cricothyroidotomy (SurgiCric II vs. ControlCric).

PARTICIPANTS

Forty-eight volunteers divided into two groups based on their personal skill level: beginners group and proficient performers group.

MAIN OUTCOME MEASURES

Time to completion was recorded for each procedure. Once the operator had indicated completion, the correct anatomical tube placement was confirmed by dissection and structures were inspected for complications. Primary outcomes were successful tracheal placement of an airway tube and time needed to achieve a patent airway. Secondary outcome was assessment of complications.

RESULTS

Overall, 384 procedures were performed. Median time to completion was 74 s. In total, 284 procedures (74%) resulted in successful ventilation. Time to completion was longer in short obese than in long slim and the risk of unsuccessful procedures was increased in short obese compared with long slim. Even if ControlCric resulted in faster completion of the procedure, its use was less successful and had an increased risk of complications compared with SurgiCric II. Proficient performers group performed faster but had an increased risk of injuring the tracheal wall compared with beginners group.

CONCLUSION

Participants had difficulties in performing cricothyroidotomy in obese models, but various and difficult anatomical situations must be expected in airway management and therefore must be taught. A new hybrid model combining porcine and synthetic materials offers the necessary conditions for the next step in training of surgical airway procedures.

TRIAL REGISTRATION

The study was performed without human tissue or living animals, and was therefore exempted from ethical review by the University of Ulm Ethical Committee, Germany (Chairperson Prof Dr C. Lenk) on 9 August 2018. Hence a protocol number was not attributed.

A Randomized Comparison of Bougie-Assisted and TracheoQuick Plus Cricothyrotomies on a Live Porcine Model

Objectives

Cricothyrotomy is a rescue procedure in “cannot intubate, cannot oxygenate” scenarios where other methods of nonsurgical airway management have failed. We compared 2 cuffed cricothyrotomy sets, bougie-assisted cricothyrotomy (BACT) and novel percutaneous TracheoQuick Plus, on a live porcine model in a simulated periarrest situation.

Methods

Thirty-four anesthetized minipigs were randomly allocated into two groups: BACT technique (n = 17) and TracheoQuick Plus (n = 17). The primary outcome was duration of cricothyrotomy while secondary outcomes were total success rate, number of attempts, location of incision, changes in heart rate, oxygen saturation, and the incidence of complications.

Results

BACT was significantly faster than TracheoQuick Plus cricothyrotomy, with a median time of 69 sec (IQR 56–85) versus 178 sec (IQR 152–272). The total success rate was without difference. 94% of BACT was performed successfully on the first attempt, while in the TracheoQuick Plus group, it was only 18% (P < 0.001). Trauma to the posterior tracheal wall was observed once in the BACT group and 5 times in the TracheoQuick Plus group. Oxygen saturation was significantly higher in the BACT group both during and after the procedure.

Conclusions

BACT is superior to TracheoQuick Plus cricothyrotomy on a live animal model.

Emergency cricothyrotomy--a systematic review

Background

An emergency cricothyrotomy is the last-resort in most airway management protocols and is performed when it is not possible to intubate or ventilate a patient. This situation can rapidly prove fatal, making it important to identify the best method to establish a secure airway. We conducted a systematic review to identify whether there exists superiority between available commercial kits versus traditional surgical and needle techniques.

Methods

Medline, EMBASE and other databases were searched for pertinent studies. The inclusion criteria included manikin, animal and human studies and there were no restrictions regarding the professional background of the person performing the procedure.

Results

In total, 1,405 unique references were identified; 108 full text articles were retrieved; and 24 studies were included in the review. Studies comparing kits with one another or with various surgical and needle techniques were identified. The outcome measures included in this systematic review were success rate and time consumption. The investigators performing the studies had chosen unique combinations of starting and stopping points for time measurements, making comparisons between studies difficult and leading to many conflicting results. No single method was shown to be better than the others, but the size of the studies makes it impossible to draw firm conclusions.

Conclusions

The large majority of the studies were too small to demonstrate statistically significant differences, and the limited available evidence was of low or very low quality. That none of the techniques in these studies demonstrated better results than the others does not necessarily indicate that each is equally good, and these conclusions will likely change as new evidence becomes available.