The worst case scenario - Paediatric CICO 👶
Difficult airways in paediatrics are rare, and are most often anticipated due to congenital abnormalities or acute pathology. Even more rare is the airway rescue that requires front of neck access (FONA) - however, as clinicians we must always be prepared for the worst case scenario! ⚠️
Paediatric FONA is difficult to perform, even in the most experienced and well-trained clinician. Every attempt to provide oxygenation should be made, and an ENT surgeon should be mobilised to perform a formal tracheostomy 🩺. However, in the event that this is not possible, the responsibility of FONA falls to the anaesthetic team 🧑⚕️.
Indications for declaring CICO scenario in paediatrics:
🟢 The child is anaesthetised and cannot be woken rapidly, or is unconscious with a GCS <8 🧠
🟢 Unable to be intubated despite best attempts 💉
🟢 Unable to oxygenate/ventilate with either bag/mask ventilation or an LMA (think vortex approach!) 💨
🟢 Oxygen saturation is < 80% 🫣
🟢 All reversible causes have been excluded 🔍
FONA can be achieved by either the cannula or scalpel method, and whilst the guidelines are very similar to adults, there are some differences, mainly in relation to the equipment used ⚙️.
🟠For the cannula method, a 16g cannula should be used. Flow rates for the insufflation device is based on the age of the child, with a recommended flow of 1L/min/year of age (minimum 4L flow) 🌬️
🟠For the scalpel/bougie technique, a range of paediatric bougies and tubes should be available for use:
🟢 Size 3 ETT with 5Fr bougie for neonates and infants 👶
🟢 Size 4 ETT with 8Fr bougie for children 👦👧
🟢 Size 5 ETT with 11Fr airway exchange catheter for teenagers 🧑👨
Check out our previous articles under the CICO category for detailed guides relating to the different techniques that can be performed, and how to prepare for them! 📚
Build Knowledge ✅
Improve Safety ✅
References:
RCH (2021) Can’t Intubate can’t oxygenate (CICO) airway management emergency - clinical practice guideline. https://www.rch.org.au/clinicalguide/guideline_index/CICO/
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