Click to view the ANZCA transition document

Click to view the ANZCA transition document

Transition is defined by the Vortex Approach as "the phase of care leading up to the potential declaration of a CICO event and the initiation of CICO Rescue". In recognition of the fact that there are both practical and psychological barriers to puncturing the anterior neck that must be negotiated even after a committed declaration of a CICO event, this definition is broader than that used by the Australian and New Zealand College of anaesthetists in their transition document (right). Transition is an key concept in management of the challenging airway which acknowledges that the shift in focus from attempts to enter the Green Zone via the upper airway lifelines to achieving this via CICO Rescue should be a process rather than occurring at an instant in time.


The Vortex Approach specifies four elements that are required for effective transition: 

  1. Prevention: for transition to be effective it must only culminate in the initiation of CICO Rescue when absolutely necessary. Prevention of a CICO event depends on both maximising opportunities to establish airway alveolar oxygen delivery via the upper airway lifelines as well as avoiding precipitating loss of the ability to achieve alveolar oxygen delivery when this has previously been established. The process of prompting for optimisation of the three upper airway lifelines specified by the Vortex addresses the former aspect and the Green Zone addresses the latter.
  2. Priming: the process of priming for CICO Rescue outlined above must occur in parallel with recognition of the diminishing likelihood of success at achieving alveolar oxygen delivery via any of the upper airway lifelines. The CICO Status tool is used by the Vortex Approach to facilitate priming.
  3. Permission: clear recognition that a CICO event exists and declaration of its occurrence to the team contribute to clinician confidence that it is appropriate to perform this confronting procedure and thus their willingness to commit to initiating CICO Rescue. The Vortex implementation tool facilitates permission for CICO Rescue by providing a defined endpoint to optimisations for each lifeline and enhancing team situational awareness of the occurrence of a CICO event.
  4. Puncture: refers to the technical aspects of initiation and performance of CICO Rescue and is not addressed by the Vortex Approach.

While the Vortex Approach addresses many aspects of the first three elements, other factors also have significant contributions to make. In addition to the implementation tools provided by the Vortex Approach, successfully executing the transition process requires attention to all of the above elements using an integrated approach that addresses both technical and human factors in relation to training, planning, monitoring and equipment.