TERMINOLOGY

CICO Rescue is the term used by the Vortex Approach to describe emergency cannula or scalpel cricothyroidotomy/tracheotomy. Unlike many other terms applied to this procedure (emergency surgical airway, emergency front-of-neck access, invasive airway access, infraglottic rescue, etc) CICO Rescue satisfies the criteria required of such a term in being simple, intuitive, precise, unintimidating and inclusive of both cannula/scalpel techiques performed on either the cricothyroid membrane or trachea. 

There is considerable variation in the way the CICO acronym is verbalised by clinicians. In addition to spelling out C-I-C-O, phonetics range across Kick-Koh, See-Koh, Chee-Koh, Sic-Koh and Psy-Koh. To facilitate clear, efficient communication during an airway crisis, the Vortex Approach encourages consistent prounciation of the CICO acronym as Ky-Koh.

TRIGGER

According to the Vortex Approach the trigger for initiating CICO Rescue is the inability to confirm alveolar oxygen delivery following completed best efforts at all three upper airway lifelines.

Note that this trigger is independent of the oxygen saturations since, even in the unusual situation where following best efforts at all three lifelines the oxygen saturations remain high, the inability to confirm alveolar oxygen delivery following best efforts at all three lifelines means that eventual desaturation is inevitable. Rather then being a deterrent to its performance, recognition of the need for CICO Rescue while the oxygen saturations remain high should be viewed as advantageous - providing increased time to perform this confronting procedure in a more controlled manner, thereby increasing the chance of success.

Conversely a critically low oxygen saturation is not in itself a trigger to initiate CICO Rescue if best efforts at all three lifelines have not been completed. While legitimate opportunities to enter the Green Zone in a timely fashion via the familiar upper airway lifelines remain, these should be exploited as they are more likely to be successful than resorting to an unfamiliar and more traumatic technique.

Thus oxygen saturations are not a relevant consideration in deciding the trigger for CICO Rescue - they are, however, a relevant consideration for determining how many attempts are reasonable before declaring a best effort at a lifeline in a particular situation. When the oxygen saturations are critically low it might be reasonable to have only one attempt at each lifeline before proceeding to CICO Rescue.

The accompanying video (left) addresses a number of concerns raised with the Vortex Approach including a detailed discussion of the rationale for performing CICO Rescue if the oxygen saturations are still high (note that this video refers to an older version of the Vortex that uses a slightly different graphich and nomenclature to the current version).

technique

The Vortex Approach does not advocate a particular technique for CICO Rescue, either cannula or scalpel techniques can be used if best efforts at all three lifelines are unsuccessful. More important than the specific technique selected is that the clinician has decided, in advance, on the technique for CICO Rescue that is most likely to succeed in their hands and that they are willing to implement when it is required. In making this decision the following considerations are important:

  • Cognisance: the clinician must be well informed of the benefits/disadvantages of different techniques.
  • Competence: the clinician and their team must be adequately trained in their chosen technique.
  • Capability: the clinician must have immediate access to the equipment required to perform their chosen technique.

It is recommended that pre-packaged CICO Rescue kits are immediately available to facilitate access to the equipment required for whatever technique is preferred.

The above principles are consistent with the position of the Australian & New Zealand College of Anaesthetists in relation to CICO Rescue.