Performance of Emergency Surgical Front of Neck Airway Access by Head and Neck Surgeons, General Surgeons, or Anaesthetists: an In-situ Simulation Study

 Groom P, Schofield L, Hettiarachchi N et al.

British Journal of Anaesthesia 2019, 123 (5): 696-703. doi: 10.1016/j.bja.2019.07.011.

Aim of Study

Stated hypothesis: Head and neck surgeons would have superior performance compared to anaesthetists and general surgeons

Design and Location

Cohort study, Aintree University Hospital


3 groups of consultants: head and neck surgeons, general surgeons, anaesthetists. 15 in each cohort.

In situ high fidelity simulation of CICO situation. Told to perform emergency FONA using standard equipment.

Time to achieve ventilation of the lungs after declaration of CICO.

Qualitative data: interviews conducted post simulation into attitudes surrounding FONA

Primary Outcome

Time to achieve ventilation of the lungs after declaration of CICO.

Secondary Outcomes

Knowledge of guidelines of CICO management

Method of emergency surgical FONA

Qualitative enquiry into attitudes towards FONA


STATA 13.1

X2 test for categorical data

Kruskal-Wallis and Dunn’s test for non-parametric data

P < 0.05

Qualitative data

Thematic framework devised for identifying themes.


Median surgical time for FONA: anaesthetists 50s, general surgeons 86s, head and neck surgeons 74s

Anaesthetists more likely to use method of FONA as per DAS guidelines and had better awareness of guidelines.

Attitudes: person most suited depended on skillset, confidence, setting, seniority, speciality, willingness to lead. BUT a lot of anaesthetists felt that surgeons would still be better placed to perform FONA. Head and neck surgeons generally felt they were best suited to perform FONA


Anaesthetists performed emergency surgical FONA significantly faster than general surgeons but there was no significant difference between anaesthetist and head and neck surgeons.

Anaesthetists still perceive surgeons to be better placed to perform FONA

Stated Limitations from the Study

Small sample

Tertiary Hospital

Lack of retention of participants for qualitative analysis

?high fidelity

Discussion from Journal Club Meeting (?Change of Practice)

Study doesn’t address decision making skill in a CICO situation which is very relevant

Clinically significant? – depends on how long it has taken to get to Plan D and how the patient is clinically.

Overall, anaesthetist demonstrated performance of emergency surgical FONA comparable to head and neck surgeons.

These anaesthetists had twice yearly simulation training in FONA which was likely a contributing factor to these results.

Journal Club Summary by Dr J Sandhu. Meeting on 24 November 2022.

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