Anesthesia in the News
  • Study Finds Gap in Emergency CICV Skills Among Anesthesia Providers

    Expertise in management of the airway is, to some extent, the prime clinical skill of the anesthesia provider.  Yet while major complications of airway management, such as “can’t intubate, can’t ventilate” (CICV), are rare, they can be among the most life-threatening in medicine (Cook et al, 2011; Cook et al, 2012).  Further, the American Society of Anesthesiology Closed Claims Study data show that adverse respiratory events are the most common type of injury, with difficult intubation and ventilation contributing to most of these cases.

    One such airway management complication is CICV, which occurs in fewer than 1 in 5,000 routine general anesthetics and requires an emergency surgical airway (ESA) in ~1 in 50,000 but accounts for up to 25% of anesthesia-related deaths (Nagaro et al, 2003; Frerk C et al, 2011).  The literature reflects that the rate of CICV cases requiring ESA may rise to 1 in 200 in the emergency department (Bair et al, 2002; Graham et all, 2003).

    A new study, published in the March 2022 issue of Cureus, evaluated the prior training, exposure, and self-confidence of anesthesia providers in handling the CICV scenario at Henry Ford Hospital in Detroit, MI.

    Critical CICV knowledge gaps

    The results of the non-interventional quality improvement project revealed significant differences in anesthesia providers’ self-reported experience with CICV and confidence in their own ability to perform the surgical airway technique.  While the responses varied with their number of years in practice and their respective roles as residents, CRNAs, or attending physicians, a surprisingly high number of respondents in all categories expressed a lack of training, experience, and self-confidence in performing this technique, indicating a need for improved education.

    Of the participants, 52% did not know how to perform the emergent surgical airway procedure.  The majority (75%) did not know where the surgical airway kit was located, and 87% had not performed the surgical airway procedure before.  The vast majority recommended annual simulation training (96.7%) as part of an annual training experience compared to online training or a lecture series provided less frequently or as needed.

    Discovery process details

    To obtain the data, the research team distributed an emailed questionnaire to all anesthesia providers which asked about their prior training and exposure to handling a CICV scenario, self-reported confidence in managing this kind of situation, and preference of format for a CICV training initiative.

    The sample size was limited to the number of anesthesiology residents, CRNAs, and anesthesiology attendings at Henry Ford Hospital, a total of 176 potential subjects, so a formal a priori sample size calculation was not performed.  Univariate group comparisons were carried out between the respondents’ role (attending, CRNA, resident), as well as between the number of years that the respondents had been in practice (< 5 years, 5-10 years, > 10 years) using the chi-square or Fisher’s exact test for categorical variables. Statistical significance was set at p < 0.05.  All analyses were performed using SAS 9.4 (SAS Institute Inc., Cary, NC).

    Of the 176 total anesthesia providers at their institution, 119 (67.6%) participated in the study by responding to the questionnaire.  Fifty-four of the respondents (45%) were attendings, 44 (37%) were residents, and 21 were (18%) CRNAs.  Fifty-three percent had been in practice for fewer than 5 years

    Variance among roles

    When a univariate comparison was made to evaluate the differences in responses between the 3 provider roles (CRNA, resident, or attending), significant differences between the groups were observed for the number of years in practice, knowledge of how to perform the surgical airway procedure for CICV, knowledge of where the CICV kit was, prior training in the CICV scenario, previous performance of the surgical airway technique during a CICV scenario, and confidence in performing the surgical airway technique in a CICV scenario.

    Overall, the attendings who responded were in practice longer than residents and CRNAs.  Of the attendings, the majority knew how to perform the surgical airway technique while most residents and CRNAs did not know how to perform the technique.  Across all roles, the majority did not know where to locate the CICV kit.  More attendings had been trained in the surgical airway technique than CRNAs and residents.  Across all groups, most providers had not performed the surgical airway technique during a CICV scenario, and most do not feel confident in performing the surgical airway technique in a CICV scenario.

    There was not a significant difference in the preferred optimal teaching method or preferred frequency of CICV training between the different provider roles.  Most of the respondents preferred annual simulation training, except for attendings of whom 50% preferred training every 2 years.

    For CICV: ‘Semper paratus’

    The Henry Ford research underscores the medical maxim “Learn techniques you think you will never use” and the authors express their full intent to apply their findings at their own institution.  They conclude, “These findings highlight a need for better emergency airway teaching and training…[and] will be used to guide the design and implementation of improved surgical airway training for residents, CRNAs, and attending anesthesiologists with the goal of better preparedness for handling a CICV scenario.”

    How does your institution’s CICV competence compare with Henry Ford Hospital’s?  Find their complete survey results, “Emergent Surgical Airway Skills: Time to Re-evaluate the Competencies” at

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