Results of a surgical cricothyrotomy workshop with a pig trachea model | Revista Española de Anestesiología y Reanimación (English Edition)

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Añez Simón, V. Serrano Gonzalvo, L.H. Carrillo Luna, V. Farré Nebot, C.M. Holgado Pascual" "autores" => array:6 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Añez Simón" "email" => array:1 [ 0 => "cristobal.anez@urv.cat" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "V." "apellidos" => "Serrano Gonzalvo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "L.H." "apellidos" => "Carrillo Luna" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "V." "apellidos" => "Farré Nebot" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "C.M." "apellidos" => "Holgado Pascual" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:2 [ "colaborador" => "Members of the ANESTARRACO group (IISPV)" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "1" "identificador" => "fn1" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hospital Universitari Joan XXIII, Tarragona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidad Rovira y Virgili, Tarragona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resultados de un taller de cricotiroidotomía quirúrgica con un modelo de tráquea de cerdo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1300 "Ancho" => 2500 "Tamanyo" => 151350 ] ] "descripcion" => array:1 [ "en" => "Students’ assessment of difficulty in each attempt." ] ] ] "textoCompleto" => "IntroductionCricothyroidotomy is a procedure that involves placing a cannula or tube in the airway through a hole and/or incision made in the cricothyroid membrane for the purpose of oxygenating and ventilating a patient.<a class="elsevierStyleCrossRef" href="#bib0065">1</a> In all airway management algorithms, cricothyroidotomy is the last resort in the management of unanticipated difficult airway.<a class="elsevierStyleCrossRef" href="#bib0070">2</a> It is an emergency procedure that is performed in cannot intubate, cannot oxygenate (CICO) situations. It is rarely needed, but when it is, it must be performed as soon as possible, as any delay can result in death or irreparable brain injury.There are currently 3 approaches to cricothyroidotomy: puncture with a cannula, puncture with a large bore cannula or percutaneous techniques (Seldinger technique), and surgical airway techniques. Following publication of the 4th National Audit Project (NAP4), there has been growing interest among anaesthesiologists in surgical cricothyroidotomy, because of its high success rate (100%) compared with 67% for percutaneous techniques and 37%% for cannula cricothyroidotomy.<a class="elsevierStyleCrossRef" href="#bib0075">3</a> As a result of this study, the Difficult Airway Society (DAS) recommended surgical airway as the technique of choice.<a class="elsevierStyleCrossRef" href="#bib0070">2</a>The aim of this study is to evaluate the learning outcomes of 8 surgical cricothyroidotomy (SCt) workshops using a pig trachea model. The results were determined by analysing the success rate and the time needed to perform a standard SCt.Material and methodsIn late 2013, we developed a model for training clinicians to perform SCt based on a pig trachea covered with a 3–4mm thick layer of skin from the pig's abdomen. The material needed, besides the pig trachea model, consists of a 5mm internal diameter reinforced tracheal tube, gloves, scalpel with a number 15 blade, a tracheal hook, a pair of Trousseau forceps, a 5ml syringe, and a self-inflating bag for ventilation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). We created a checklist with all the steps needed to perform a standard SCt. Using gloves, the student palpates the thyroid and cricoid cartilages and the cricothyroid membrane, holds the larynx between the thumb and middle finger and palpates the cricothyroid membrane with the index finger of the non-dominant hand. Using the dominant hand, he or she makes a longitudinal midline incision using a number 15scalpel between 2.5 and 3cm above the site where the cricothyroid membrane was palpated, inserts the index finger through the incision to palpate and locate the cricothyroid membrane and makes a transverse incision in the cricothyroid membrane. He or she then introduces the tracheal hook in a cephalad direction, introduces the Trousseau forceps laterally through the incision and uses them to enlarge access to the tracheal lumen. With the help of the Trousseau forceps, the distal end of the number 5 reinforced tracheal tube is inserted in the trachea, the Trousseau forceps are rotated counter-clockwise while the tube is pushed into the trachea. The tube's cuff is inflated and ventilation is checked by inflating the balloon after blowing air through the endotracheal tube using a self-inflating bag (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<a class="elsevierStyleCrossRef" href="#bib0065">1</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>We organised a workshop attended by anaesthesiology residents and study researchers consisting of general theoretical training and practical training with the model. After training the team in the use of all the material, we designed a 4-h SCt workshop.At the start of the workshop, all students were informed that data would be collected during the workshop, and may be used anonymously for scientific or teaching purposes, and were asked to sign an informed consent form. Following this, each student filled in a form giving their demographic data, such as time since qualifying as an anaesthesiologist, size of the hospital, whether they performed anaesthesia for procedures in patients at high-risk of difficult airway, previous experience with retrograde intubation, cricothyroid membrane puncture, and cricothyroidotomy in mannequins, models and patients. They also completed a questionnaire to assess their theoretical knowledge of cricothyroidotomy, with a maximum score of 19 points. Then, a 1-h presentation was given explaining the theory of cricothyroidotomy, following which they were shown the model and an SCt was demonstrated using the standard technique described above (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).The students were then divided into groups of 3 or 4 with an instructor, and performed 6 SCts each. We used a checklist to remind the students of each step involved in a standard SCt, and the instructor noted the following actions: achievement of SCt and ventilation of the model, which was checked by observing that the balloon connected to the distal end of the trachea inflated when ventilated with the self-inflatable bag; the time needed to perform the SCt, counting from start of tracheal palpation to successful ventilation by inflating the tube's cuff; and the degree of difficulty of the procedure, assessed by both the student and the instructor on a 4-point Likert scale (very easy, easy, difficult, very difficult). This variable enables us to determine whether the student's subjective perception of the simplicity or difficulty of the procedure improved after completing the workshop.Finally, the students completed the theoretical questionnaire again, and both students and instructors pooled their experience.Data were analysed using Statsdirect version 3.1.18. A descriptive statistical analysis was performed, and variables were checked for normal distribution using the Shapiro–Wilk test. If variables were non-normally distributed, the results were presented as median and 25–75% interquartile range. The Friedman test was used to compare numerical variables, and Fisher's exact test and McNemar's test were used in the case of categorical variables. Statistical significance was set at p<0.05.ResultsA total of 8 workshops with 91 students were held from March 2014 to May 2016. The demographic data obtained are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>By the end of the workshop, the students had improved their theoretical knowledge, and increasing their score from 10 [8–14] points to 17 [15–19] points, the maximum score being 19 points; this difference is statistically significant (p<0.0001).Of the 91 students, 86% managed to successfully perform SCt and ventilate on the first attempt, and 92% on the sixth attempt. The difference between percentage of successful procedures on the first and the sixth attempt is statistically significant (p<0.0001) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>).When we evaluated the success rate relative to professional experience, the percentage of successful SCt procedures on the first and the sixth attempt increased in all groups, except the group of anaesthesiologists with 10–15 years of experience, in which the success rate was 100% in both the first and sixth SCt (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>). There were no differences between groups at the first attempt and sixth attempt.The size of the hospital where the students worked did not appear to influence the SCt success rate, since no statistically significant inter- or intra-group differences were observed between the first and the sixth SCt (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>).Previous experience in performing surgery in patients with difficult airway risk factors did not influence previous knowledge; there were no differences between the two groups either in the first or the sixth SCt. However, we did observe differences when comparing the first with the sixth attempt in each group; these were statistically significant (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>).The group that had not previously performed cricothyroid membrane puncture in a model showed a better first SCt success rate than that who had practised previously (p=0.01). There were no differences in the sixth SCt between groups. We observed evidence of learning, since the results improved in a statistically significant way when comparing the first SCt with the sixth in each group (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>).When we compared the SCt success rates between students who had performed cricothyroid membrane puncture in patients and those who had not, we observed no significant differences between the first SCt or the last. However, intra-group analysis showed significant differences in success rates between the first and sixth SCt (p<0.001) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>).Previous cricothyroidotomy in a model did not affect the success rate on the first or sixth SCt. However, intra-group analysis showed an improvement in success rates from the first to the sixth SCt attempt in both groups (p<0.0001) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>).There were no significant differences in the number of successful SCts at the first attempt or sixth attempt between the group that had performed cricothyroidotomy in a patient versus the group that had not. However, intra-group analysis showed differences in success rates between the first and the sixth SCt (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>).The time needed to perform SCt, expressed as interquartile range [IQR 25–75%], improved from 163 [107–211]s in the first attempt to 70 [55–85]s in the sixth, p<0.0001 (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>The time needed to perform SCt did not vary significantly in respect of the student's experience when we compared the first and the sixth attempt in each of the two groups. However, intra-group analysis showed a significant improvement in SCt performance time from the first to the sixth SCt in each group (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>).The size of the hospital did not affect the time needed to perform either the first or sixth SCt. However, there was a major improvement in time in students from each type of hospital; this improvement was statistically significant (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>).The time needed to perform SCt in the group that did not perform high risk surgery was shorter in the first SCt, with a statistically significant difference (p=0.03). We observed no difference when comparing the performance time at the sixth attempt between the two groups. The difference in time between the first and the sixth SCt was significant in both groups (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>).Previous experience in performing cricothyroid membrane puncture in models improved the time needed to perform the first SCt, but the difference was not statistically significant (p=0.33); this was also true of the sixth attempt. However, we did observe a significant improvement between the first and sixth SCt in each group (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>).Students who had previously performed cricothyroid membrane puncture needed less time to perform the first SCt than those who had not, but the difference was not statistically significant (p=0.58). There were no differences in the sixth SCt between groups. The SCt performance time at the sixth attempt decreased in both groups with respect to the first; this difference was statistically significant (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>).When we compared the time needed to perform cricothyroidotomy by students who had previously performed cricothyroidotomy in models with those who had not, we observed no significant differences in the first SCt or the sixth between both groups. However, there were statistically significant differences between the first and the sixth SCt in both groups (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>).When we compared the SCt performance time of students who had performed cricothyroidotomy in patients, we observed a shorter time at the first attempt, but the difference with those who had no such previous experience was not statistically significant. There were no differences when compared with the time to perform the sixth SCt, but we observed a difference between the first and the sixth attempt in both groups (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>).The degree of difficulty at the first and the sixth attempt, assessed by both the student and the instructor, also improved significantly; the difference was statistically significant, p<0.05 (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>DiscussionThe incidence of cannot intubate/cannot oxygenate status that requiring a surgical front of neck access varies in the literature from 0% to 18.5%. This incidence depends on the location of the patient, the qualifications and experience of the health personnel, and the patient's medical status. The only study performed by anaesthesiologists included in this review reported an incidence of 0.3%.<a class="elsevierStyleCrossRef" href="#bib0080">4</a> According to guidelines, cricothyroidotomy is the last resort airway when all other strategies have failed.<a class="elsevierStyleCrossRef" href="#bib0070">2</a>In their latest guidelines, the DAS recommends that every anaesthesiologist should be able to perform SCt.<a class="elsevierStyleCrossRef" href="#bib0070">2</a> These guidelines recommend bougie-guided cricothyroidotomy, since the necessary material can be found in any operating room.<a class="elsevierStyleCrossRefs" href="#bib0070">2,5</a>We started our workshops before the DAS made this recommendation, and we opted for the standard surgical technique. In a study comparing the Melcker kit (for the Seldinger technique) with Surgicric 2 (equipment for standard SCt) and a scalpel-bougie-tube surgical technique, the fastest cricothyroidotomy times were recorded with the bougie-guided technique, followed by Surgicric 2, and finally Melcker. The timing difference between the first two was not statistically significant, with a mean of 62 vs 82s.<a class="elsevierStyleCrossRef" href="#bib0090">6</a> These times are similar to those obtained in the sixth attempt by the students in our workshop: median 70s.In all technical procedures, it is essential to first understand the theoretical basis behind the technique. Our students’ theoretical knowledge of cricothyroidotomy improved, with significant differences observed between the score obtained in the preliminary and the final questionnaire.The workshop significantly improved the SCt success rate: from 86% to 92%. The anaesthesiologist's years of experience, experience performing surgery in patients with difficult airway management, previous experience with cricothyroid membrane puncture in a model or a patient, or experience in performing cricothyroidotomy in a model or in a patient did not significantly affect the outcome at the first attempt. The workshop, however, did significantly improve the success rate at the sixth attempt in all groups. The size of the hospital where the student works had no effect on the results of the workshop (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>).The time needed to perform SCt improved to a clinically acceptable level, going from 163s [107–211] at the first SCt attempt to 70 [55–85]s at the sixth attempt (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>). The performance time at the sixth attempt in our group corresponds to the mean performance time observed in other studies evaluating the surgical technique in similar models included in a systematic review on cricothyroidotomy training: 70 [55–85]s in our study vs. 94 [77–132]s or 52 [38–77]s.<a class="elsevierStyleCrossRef" href="#bib0080">4</a> Studying our results shows that 75% of cricothyroidotomies performed at the sixth attempt were completed in less than 90s.Cricothyroid membrane puncture is a technique that is rarely performed. Overall, anaesthesiologists have little experience in performing cricothyroidotomy in patients. Experience is somewhat greater in mannequins and models, but it is still scant considering the importance of the technique and its inclusion in all airway management algorithms; as such, it is a required skill for every anaesthesiologist. In our study, experience in performing cricothyroid membrane puncture or cricothyroidotomy in models does not appear to affect the SCt success rate, although we do not know the effect it would have on the performance of needle cricothyroidotomy, including the Seldinger technique.In our workshop, students performed the standard surgical technique, which requires specific material such as a scalpel, tracheal hook, Trousseau clamp and tracheal tube or cannula.<a class="elsevierStyleCrossRef" href="#bib0065">1</a> The articles reviewed suggest that at least 5 attempts are needed for two thirds of the participants to secure a surgical airway.<a class="elsevierStyleCrossRefs" href="#bib0080">4,7</a> In our workshop, each student performed 6 cricothyroidotomies in order achieve an acceptable level of skill. Our model standardises teaching by allowing students to repeat the procedure several times with few anatomical changes. In contrast, the use of cadavers introduces anatomical differences; therefore, each attempt is different. Although this more closely mirrors clinical practice, it makes the procedures difficult to compare.<a class="elsevierStyleCrossRef" href="#bib0095">7</a>The recommendation of SCt as the technique of choice is controversial, and there are arguments in favour of one technique or another.<a class="elsevierStyleCrossRefs" href="#bib0090">6,8</a> Arguments in favour of puncture techniques include the anaesthesiologist's familiarity with the Seldinger technique, and the possibility of training them to perform cricothyroid membrane puncture in much the same way, to block the airway for fibreoptic intubation, although this has also been criticised, since there is a less invasive technique to anaesthetise the airway for fibreoptic bronchoscopy: topical anaesthesia.<a class="elsevierStyleCrossRefs" href="#bib0100">8–12</a> An algorithm to deal with cannot intubate cannot oxygenate situations has been developed in which puncture cricothyroidotomy is performed first, proceeding to SCt if this fails.<a class="elsevierStyleCrossRef" href="#bib0115">11</a> Other authors do not propose any specific technique, and suggest that the person in charge of performing the procedure should choose the technique he or she is most comfortable using.<a class="elsevierStyleCrossRef" href="#bib0085">5</a> In our study, previous experience with puncture techniques made no difference, and we cannot know if there would be differences in the case of performing cricothyroid membrane puncture. In our opinion, the results of NAP4 clearly tip the balance in favour of the surgical technique, since the data were collected from real practice, and are therefore more reliable.<a class="elsevierStyleCrossRefs" href="#bib0070">2,5,10</a> The results of the NAP4 prompted us to create this workshop. Other authors suggest taking human factors into account, such as the standardisation of the task, minimising the necessary material, focusing the training on a single technique – since a crisis is no time to start weighing up whether to perform SCt or puncture – training all the team in a single technique, and following guidelines such as the DAS or the hospital's own protocols.<a class="elsevierStyleCrossRef" href="#bib0110">10</a> Simulation plays a very important role in training the whole team both in performing the technique and in taking the decision to perform SCt – quick decision-making is essential to avoid anoxic brain injury.Students were asked to assess the perceived degree of difficulty in order to detect whether this perception changed between the first and sixth SCt – although the monitor's opinion in this case, being objective, could be more valuable. We observed that the perceived difficulty improved from the first to the sixth attempt, as did the student's confidence in their ability to perform the technique (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>).This study has certain limitations. We used a dead pig trachea model that, therefore, does not bleed, and precludes the possibility of finding access to the trachea blocked by other structures, such as thyroid tissue or blood vessels. Although our study groups were heterogeneous, we analysed our data by groups in order to detect any effect these differences might have had on our results. Data were collected from a series of workshops and analysed retrospectively, with data losses of around 6–8%. It should also be noted that the stress experienced in the workshop cannot be compared with that experienced in a real life CICO situation; nevertheless, the aim of the workshop was not to generate this stress, but to acquire competence in the performance of the technique. The workshop does not include training in CICO diagnosis and rapid decision-making to perform a cricothyroidotomy. This must be addressed in a simulation environment involving a multidisciplinary team that includes nurses and other professionals.<a class="elsevierStyleCrossRefs" href="#bib0110">10,11</a>ConclusionsOur workshop improves theoretical knowledge, which was evaluated by means of a questionnaire. It significantly improves SCt skills, which were evaluated on the basis of the success rate and the time needed to perform SCt. Factors such as years of professional experience, the size of the hospital, experience in the performance of surgery in patients with difficult airway risk factors, previous experience performing cricothyroid membrane puncture in models or patients, or previous experience performing cricothyroidotomy in models or patients did not influence outcomes.FundingThis study has been self-funded by the ANESTARRACO Anaesthesia Research Group (IISPV).Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1160497" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1086796" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1160498" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1086797" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-04-18" "fechaAceptado" => "2018-09-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1086796" "palabras" => array:4 [ 0 => "Surgical cricothyrotomy" 1 => "Airway management" 2 => "Simulation" 3 => "Pig model" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1086797" "palabras" => array:4 [ 0 => "Cricotiroidotomía quirúrgica" 1 => "Manejo de la vía aérea" 2 => "Simulación" 3 => "Modelo porcino" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundThe latest Difficult Airway Society (DAS) guidelines recommend that all anaesthesiologists should to be trained in the performing of a surgical cricothyrotomy (CtQ). The aim of this study was to analyse the learning results of a CtQ workshop by assessing the success rate and time to perform CtQ on a porcine tracheal model. Material and methodsA workshop was designed in which each student completed a questionnaire with demographic data and theoretical knowledge about surgical approaches of airway. During the following hour, a review was presented theoretical aspects of CtQ. The model was shown and a CtQ was performed using a classical technique. Afterwards, in groups of 3–4 students with an instructor, each one of the students performed 6 CtQ. A record was made on whether the ventilation was correct, the time to perform CtQ, and the ease of performing the CtQ by the students and instructors. Finally, students completed a questionnaire on the theoretical aspects. Students and instructors performed a workshop debriefing. A statistical analysis was performed, considering a p-value<0.05 as statistically significant. ResultsA total of 8 workshop sessions were held with a total of 91 students. At first attempt, 86% of students performed a CtQ with successful ventilation, and 92% at the sixth attempt (p<0.0001). Time taken was 163 [107–211]s at first attempt, and 70 [55–85]s at the sixth (p<0.0001). At the end of workshop, students had improved their theoretical knowledge (p<0.0001) and perception of the ease of the technique. ConclusionWorkshop performance improved theoretical knowledge and competence in surgical cricothyrotomy." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLas últimas guías de la Difficult Airway Society recomiendan que todos los anestesiólogos deberían estar entrenados para la realización de una cricotiroidotomía quirúrgica (CtQ). El objetivo de este estudio es analizar los resultados de aprendizaje de un taller de CtQ mediante la evaluación de la tasa de éxito y el tiempo necesario para realizarla en un modelo de tráquea porcina. Material y métodosDiseñamos un taller en el que cada alumno respondía un cuestionario con datos demográficos y conocimientos teóricos sobre el abordaje quirúrgico de la vía aérea. Durante la hora siguiente se revisaron aspectos teóricos. Se mostró el modelo y realizamos una CtQ siguiendo la técnica clásica. Después, en grupos de 3-4 alumnos con un instructor, los alumnos realizaron 6 CtQ cada uno. Registramos si la ventilación era correcta, el tiempo necesario para realizarla y la facilidad de realización evaluada por alumno e instructor. Finalmente, los alumnos respondieron un cuestionario de aspectos teóricos. Realizamos un análisis estadístico, considerando estadísticamente significativo un valor de p<0,05. ResultadosLlevamos a cabo 8 ediciones del taller, con 91 alumnos. Consiguieron hacer la CtQ y ventilar correctamente el 86% en el primer intento y el 92% en el sexto (p<0,0001). El tiempo necesario para hacer una CtQ pasó de 163 [107-211] a 70 [55-85] segundos (p<0,0001). Al final del taller los alumnos habían mejorado sus conocimientos teóricos (p<0,0001) y la percepción de facilidad de la técnica. ConclusiónEl taller realizado mejora los conocimientos teóricos y la competencia en la realización de una CtQ." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Añez Simón C, Serrano Gonzalvo V, Carrillo Luna LH, Farré Nebot V, Holgado Pascual CM, y grupo de investigación ANESTARRACO (IISPV). Resultados de un taller de cricotiroidotomía quirúrgica con un modelo de tráquea de cerdo. Rev Esp Anestesiol Reanim. 2019;66:129–136." ] 1 => array:3 [ "etiqueta" => "1" "nota" => "The members of the ANESTARRACO group (IISPV) are shown in <a class="elsevierStyleCrossRef" href="#sec0040">Annex</a>." "identificador" => "fn1" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>" "etiqueta" => "Annex" "titulo" => "Members of the ANESTARRACO group (IISPV)" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 645 "Ancho" => 900 "Tamanyo" => 51556 ] ] "descripcion" => array:1 [ "en" => "Model and instrumentation for surgical cricothyroidotomy." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1126 "Ancho" => 1500 "Tamanyo" => 170860 ] ] "descripcion" => array:1 [ "en" => "Standard surgical cricothyroidotomy technique." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1300 "Ancho" => 2500 "Tamanyo" => 151350 ] ] "descripcion" => array:1 [ "en" => "Students’ assessment of difficulty in each attempt." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1355 "Ancho" => 2502 "Tamanyo" => 164765 ] ] "descripcion" => array:1 [ "en" => "Instructors’ assessment of difficulty in each attempt." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Cric.: cricothyroidotomy; CTM: cricothyroid membrane; NS: not significant." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Ventilation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">n (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="7" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Criterion</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Cric. 1</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Cric. 6</th><th class="td" title="table-head " align="left" valign="top" scope="col">Cric. 1 vs Cric. 6 \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% success \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% success \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91 (100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Resident \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (35) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaesthesiologist<10 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (24) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaesthesiologist>10 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaesthesiologist>15 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.0004 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Small hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (27) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Medium sized hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33(36) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Large hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (28) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Airway risk surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 (73) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No airway risk surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CTM puncture on model \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (55) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No CTM puncture on model \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 (39) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CTM puncture on patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.004 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No CTM puncture on patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68 (74) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cricothyroidotomy on model YES \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 (45) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cricothyroidotomy on model NO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 (44) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cricothyroidotomy on patient YES \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cricothyroidotomy on patient NO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76 (83) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1981124.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "Intergroup comparison: p=0.01." ] ] ] "descripcion" => array:1 [ "en" => "Student demographics and cricothyroidotomy success rate." ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Cric.: cricothyroidotomy; CTM: cricothyroid membrane.Median [interquartile range 25–75%]." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time (s) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cric. 1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cric. 6 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">163.5 [107.5–211.5] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 [55–85] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Resident anaesthesiologist \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">160 [131–177] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74 [57–87] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0002 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaesthesiologist<10 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">151 [88.5–213.5] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72 [55–98] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaesthesiologist 10–15 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95.5 [62.5–238] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69.5 [45.5–86.5] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaesthesiologist>15 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">171 [128–192] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59.5 [55–79] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Small hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">162.5 [126–205] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 [55–92] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Medium sized hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">168.5 [112–205.5] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.5 [48–81] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Large hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">156 [89–200] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79 [55–95] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0048 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Airway risk surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">160 [105–210]<a class="elsevierStyleCrossRef" href="#tblfn0015">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70.5 [56.5–89] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No airway risk surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">157 [114–179]<a class="elsevierStyleCrossRef" href="#tblfn0015">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 [41–64] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CTM puncture on model \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">148.5 [96–210]<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69.5 [55–86]<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No CTM puncture on model \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">170 [138–213] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 [55–85] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CTM puncture on patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">145 [101–190] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63.5 [48–87] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No CTM puncture on patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">165 [110–215] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 [57–85] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cricothyroidotomy on model YES \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">165.5 [98–217]<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 [50–87]<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cricothyroidotomy on model NO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">162 [126–205] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 [55–85] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cricothyroidotomy on patient YES \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">145 [114–170]<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 [49–85]<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cricothyroidotomy on patient NO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">162 [105–210] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 [55–87] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1981122.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "*" "nota" => "p=0.01." ] 1 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "**" "nota" => "p=0.03." ] ] ] "descripcion" => array:1 [ "en" => "Time needed to perform surgical cricothyroidotomy." ] ] 6 => array:5 [ "identificador" => "tbl0005" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; 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Results of a surgical cricothyrotomy workshop with a pig trachea model

Resultados de un taller de cricotiroidotomía quirúrgica con un modelo de tráquea de cerdo

C. Añez Simóna,b,

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cristobal.anez@urv.cat

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, V. Serrano Gonzalvoa, L.H. Carrillo Lunaa, V. Farré Nebota, C.M. Holgado Pascuala, Members of the ANESTARRACO group (IISPV) 1

a Hospital Universitari Joan XXIII, Tarragona, Spain

b Universidad Rovira y Virgili, Tarragona, Spain

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workshops using a pig trachea model&#46; The results were determined by analysing the success rate and the time needed to perform a standard SCt&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">In late 2013&#44; we developed a model for training clinicians to perform SCt based on a pig trachea covered with a 3&#8211;4<span class="elsevierStyleHsp" style=""></span>mm thick layer of skin from the pig&#39;s abdomen&#46; The material needed&#44; besides the pig trachea model&#44; consists of a 5<span class="elsevierStyleHsp" style=""></span>mm internal diameter reinforced tracheal tube&#44; gloves&#44; scalpel with a number 15 blade&#44; a tracheal hook&#44; a pair of Trousseau forceps&#44; a 5<span class="elsevierStyleHsp" style=""></span>ml syringe&#44; and a self-inflating bag for ventilation &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; We created a checklist with all the steps needed to perform a standard SCt&#46; Using gloves&#44; the student palpates the thyroid and cricoid cartilages and the cricothyroid membrane&#44; holds the larynx between the thumb and middle finger and palpates the cricothyroid membrane with the index finger of the non-dominant hand&#46; Using the dominant hand&#44; he or she makes a longitudinal midline incision using a number 15<span class="elsevierStyleHsp" style=""></span>scalpel between 2&#46;5 and 3<span class="elsevierStyleHsp" style=""></span>cm above the site where the cricothyroid membrane was palpated&#44; inserts the index finger through the incision to palpate and locate the cricothyroid membrane and makes a transverse incision in the cricothyroid membrane&#46; He or she then introduces the tracheal hook in a cephalad direction&#44; introduces the Trousseau forceps laterally through the incision and uses them to enlarge access to the tracheal lumen&#46; With the help of the Trousseau forceps&#44; the distal end of the number 5 reinforced tracheal tube is inserted in the trachea&#44; the Trousseau forceps are rotated counter-clockwise while the tube is pushed into the trachea&#46; The tube&#39;s cuff is inflated and ventilation is checked by inflating the balloon after blowing air through the endotracheal tube using a self-inflating bag &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We organised a workshop attended by anaesthesiology residents and study researchers consisting of general theoretical training and practical training with the model&#46; After training the team in the use of all the material&#44; we designed a 4-h SCt workshop&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">At the start of the workshop&#44; 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the students completed the theoretical questionnaire again&#44; and both students and instructors pooled their experience&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Data were analysed using Statsdirect version 3&#46;1&#46;18&#46; A descriptive statistical analysis was performed&#44; and variables were checked for normal distribution using the Shapiro&#8211;Wilk test&#46; If variables were non-normally distributed&#44; the results were presented as median and 25&#8211;75&#37; interquartile range&#46; The Friedman test was used to compare numerical variables&#44; and Fisher&#39;s exact test and McNemar&#39;s test were used in the case of categorical variables&#46; Statistical significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 8 workshops with 91 students were held from March 2014 to May 2016&#46; The demographic data obtained are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">By the end of the workshop&#44; the students had improved their theoretical knowledge&#44; and increasing their score from 10 &#91;8&#8211;14&#93; points to 17 &#91;15&#8211;19&#93; points&#44; the maximum score being 19 points&#59; this difference is statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Of the 91 students&#44; 86&#37; managed to successfully perform SCt and ventilate on the first attempt&#44; and 92&#37; on the sixth attempt&#46; The difference between percentage of successful procedures on the first and the sixth attempt is statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">When we evaluated the success rate relative to professional experience&#44; the percentage of successful SCt procedures on the first and the sixth attempt increased in all groups&#44; except the group of anaesthesiologists with 10&#8211;15 years of experience&#44; in which the success rate was 100&#37; in both the first and sixth SCt &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>&#41;&#46; There were no differences between groups at the first attempt and sixth attempt&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The size of the hospital where the students worked did not appear to influence the SCt success rate&#44; since no statistically significant inter- or intra-group differences were observed between the first and the sixth SCt &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Previous experience in performing surgery in patients with difficult airway risk factors did not influence previous knowledge&#59; there were no differences between the two groups either in the first or the sixth SCt&#46; However&#44; we did observe differences when comparing the first with the sixth attempt in each group&#59; these were statistically significant &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The group that had not previously performed cricothyroid membrane puncture in a model showed a better first SCt success rate than that who had practised previously &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; There were no differences in the sixth SCt between groups&#46; We observed evidence of learning&#44; since the results improved in a statistically significant way when comparing the first SCt with the sixth in each group &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">When we compared the SCt success rates between students who had performed cricothyroid membrane puncture in patients and those who had not&#44; we observed no significant differences between the first SCt or the last&#46; However&#44; intra-group analysis showed significant differences in success rates between the first and sixth SCt &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Previous cricothyroidotomy in a model did not affect the success rate on the first or sixth SCt&#46; However&#44; intra-group analysis showed an improvement in success rates from the first to the sixth SCt attempt in both groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">There were no significant differences in the number of successful SCts at the first attempt or sixth attempt between the group that had performed cricothyroidotomy in a patient versus the group that had not&#46; However&#44; intra-group analysis showed differences in success rates between the first and the sixth SCt &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The time needed to perform SCt&#44; expressed as interquartile range &#91;IQR 25&#8211;75&#37;&#93;&#44; improved from 163 &#91;107&#8211;211&#93;<span class="elsevierStyleHsp" style=""></span>s in the first attempt to 70 &#91;55&#8211;85&#93;<span class="elsevierStyleHsp" style=""></span>s in the sixth&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#46;0001 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The time needed to perform SCt did not vary significantly in respect of the student&#39;s experience when we compared the first and the sixth attempt in each of the two groups&#46; However&#44; intra-group analysis showed a significant improvement in SCt performance time from the first to the sixth SCt in each group &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The size of the hospital did not affect the time needed to perform either the first or sixth SCt&#46; However&#44; there was a major improvement in time in students from each type of hospital&#59; this improvement was statistically significant &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The time needed to perform SCt in the group that did not perform high risk surgery was shorter in the first SCt&#44; with a statistically significant difference &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#46; We observed no difference when comparing the performance time at the sixth attempt between the two groups&#46; The difference in time between the first and the sixth SCt was significant in both groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Previous experience in performing cricothyroid membrane puncture in models improved the time needed to perform the first SCt&#44; but the difference was not statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;33&#41;&#59; this was also true of the sixth attempt&#46; However&#44; we did observe a significant improvement between the first and sixth SCt in each group &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Students who had previously performed cricothyroid membrane puncture needed less time to perform the first SCt than those who had not&#44; but the difference was not statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;58&#41;&#46; There were no differences in the sixth SCt between groups&#46; The SCt performance time at the sixth attempt decreased in both groups with respect to the first&#59; this difference was statistically significant &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">When we compared the time needed to perform cricothyroidotomy by students who had previously performed cricothyroidotomy in models with those who had not&#44; we observed no significant differences in the first SCt or the sixth between both groups&#46; However&#44; there were statistically significant differences between the first and the sixth SCt in both groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">When we compared the SCt performance time of students who had performed cricothyroidotomy in patients&#44; we observed a shorter time at the first attempt&#44; but the difference with those who had no such previous experience was not statistically significant&#46; There were no differences when compared with the time to perform the sixth SCt&#44; but we observed a difference between the first and the sixth attempt in both groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The degree of difficulty at the first and the sixth attempt&#44; assessed by both the student and the instructor&#44; also improved significantly&#59; the difference was statistically significant&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#46;05 &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0145" class="elsevierStylePara elsevierViewall">The incidence of cannot intubate&#47;cannot oxygenate status that requiring a surgical front of neck access varies in the literature from 0&#37; to 18&#46;5&#37;&#46; This incidence depends on the location of the patient&#44; the qualifications and experience of the health personnel&#44; and the patient&#39;s medical status&#46; The only study performed by anaesthesiologists included in this review reported an incidence of 0&#46;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> According to guidelines&#44; cricothyroidotomy is the last resort airway when all other strategies have failed&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In their latest guidelines&#44; the DAS recommends that every anaesthesiologist should be able to perform SCt&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> These guidelines recommend bougie-guided cricothyroidotomy&#44; since the necessary material can be found in any operating room&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2&#44;5</span></a>We started our workshops before the DAS made this recommendation&#44; and we opted for the standard surgical technique&#46; In a study comparing the Melcker kit &#40;for the Seldinger technique&#41; with Surgicric 2 &#40;equipment for standard SCt&#41; and a scalpel-bougie-tube surgical technique&#44; the fastest cricothyroidotomy times were recorded with the bougie-guided technique&#44; followed by Surgicric 2&#44; and finally Melcker&#46; The timing difference between the first two was not statistically significant&#44; with a mean of 62 vs 82<span class="elsevierStyleHsp" style=""></span>s&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> These times are similar to those obtained in the sixth attempt by the students in our workshop&#58; median 70<span class="elsevierStyleHsp" style=""></span>s&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In all technical procedures&#44; it is essential to first understand the theoretical basis behind the technique&#46; Our students&#8217; theoretical knowledge of cricothyroidotomy improved&#44; with significant differences observed between the score obtained in the preliminary and the final questionnaire&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The workshop significantly improved the SCt success rate&#58; from 86&#37; to 92&#37;&#46; The anaesthesiologist&#39;s years of experience&#44; experience performing surgery in patients with difficult airway management&#44; previous experience with cricothyroid membrane puncture in a model or a patient&#44; or experience in performing cricothyroidotomy in a model or in a patient did not significantly affect the outcome at the first attempt&#46; The workshop&#44; however&#44; did significantly improve the success rate at the sixth attempt in all groups&#46; The size of the hospital where the student works had no effect on the results of the workshop &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 1</a>&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The time needed to perform SCt improved to a clinically acceptable level&#44; going from 163<span class="elsevierStyleHsp" style=""></span>s &#91;107&#8211;211&#93; at the first SCt attempt to 70 &#91;55&#8211;85&#93;<span class="elsevierStyleHsp" style=""></span>s at the sixth attempt &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#41;&#46; The performance time at the sixth attempt in our group corresponds to the mean performance time observed in other studies evaluating the surgical technique in similar models included in a systematic review on cricothyroidotomy training&#58; 70 &#91;55&#8211;85&#93;<span class="elsevierStyleHsp" style=""></span>s in our study vs&#46; 94 &#91;77&#8211;132&#93;<span class="elsevierStyleHsp" style=""></span>s or 52 &#91;38&#8211;77&#93;<span class="elsevierStyleHsp" style=""></span>s&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> Studying our results shows that 75&#37; of cricothyroidotomies performed at the sixth attempt were completed in less than 90<span class="elsevierStyleHsp" style=""></span>s&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Cricothyroid membrane puncture is a technique that is rarely performed&#46; Overall&#44; anaesthesiologists have little experience in performing cricothyroidotomy in patients&#46; Experience is somewhat greater in mannequins and models&#44; but it is still scant considering the importance of the technique and its inclusion in all airway management algorithms&#59; as such&#44; it is a required skill for every anaesthesiologist&#46; In our study&#44; experience in performing cricothyroid membrane puncture or cricothyroidotomy in models does not appear to affect the SCt success rate&#44; although we do not know the effect it would have on the performance of needle cricothyroidotomy&#44; including the Seldinger technique&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">In our workshop&#44; students performed the standard surgical technique&#44; which requires specific material such as a scalpel&#44; tracheal hook&#44; Trousseau clamp and tracheal tube or cannula&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> The articles reviewed suggest that at least 5 attempts are needed for two thirds of the participants to secure a surgical airway&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4&#44;7</span></a> In our workshop&#44; each student performed 6 cricothyroidotomies in order achieve an acceptable level of skill&#46; Our model standardises teaching by allowing students to repeat the procedure several times with few anatomical changes&#46; In contrast&#44; the use of cadavers introduces anatomical differences&#59; therefore&#44; each attempt is different&#46; Although this more closely mirrors clinical practice&#44; it makes the procedures difficult to compare&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">The recommendation of SCt as the technique of choice is controversial&#44; and there are arguments in favour of one technique or another&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6&#44;8</span></a> Arguments in favour of puncture techniques include the anaesthesiologist&#39;s familiarity with the Seldinger technique&#44; and the possibility of training them to perform cricothyroid membrane puncture in much the same way&#44; to block the airway for fibreoptic intubation&#44; although this has also been criticised&#44; since there is a less invasive technique to anaesthetise the airway for fibreoptic bronchoscopy&#58; topical anaesthesia&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">8&#8211;12</span></a> An algorithm to deal with cannot intubate cannot oxygenate situations has been developed in which puncture cricothyroidotomy is performed first&#44; proceeding to SCt if this fails&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> Other authors do not propose any specific technique&#44; and suggest that the person in charge of performing the procedure should choose the technique he or she is most comfortable using&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> In our study&#44; previous experience with puncture techniques made no difference&#44; and we cannot know if there would be differences in the case of performing cricothyroid membrane puncture&#46; In our opinion&#44; the results of NAP4 clearly tip the balance in favour of the surgical technique&#44; since the data were collected from real practice&#44; and are therefore more reliable&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2&#44;5&#44;10</span></a> The results of the NAP4 prompted us to create this workshop&#46; Other authors suggest taking human factors into account&#44; such as the standardisation of the task&#44; minimising the necessary material&#44; focusing the training on a single technique &#8211; since a crisis is no time to start weighing up whether to perform SCt or puncture &#8211; training all the team in a single technique&#44; and following guidelines such as the DAS or the hospital&#39;s own protocols&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> Simulation plays a very important role in training the whole team both in performing the technique and in taking the decision to perform SCt &#8211; quick decision-making is essential to avoid anoxic brain injury&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Students were asked to assess the perceived degree of difficulty in order to detect whether this perception changed between the first and sixth SCt &#8211; although the monitor&#39;s opinion in this case&#44; being objective&#44; could be more valuable&#46; We observed that the perceived difficulty improved from the first to the sixth attempt&#44; as did the student&#39;s confidence in their ability to perform the technique &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">This study has certain limitations&#46; We used a dead pig trachea model that&#44; therefore&#44; does not bleed&#44; and precludes the possibility of finding access to the trachea blocked by other structures&#44; such as thyroid tissue or blood vessels&#46; Although our study groups were heterogeneous&#44; we analysed our data by groups in order to detect any effect these differences might have had on our results&#46; Data were collected from a series of workshops and analysed retrospectively&#44; with data losses of around 6&#8211;8&#37;&#46; It should also be noted that the stress experienced in the workshop cannot be compared with that experienced in a real life CICO situation&#59; nevertheless&#44; the aim of the workshop was not to generate this stress&#44; but to acquire competence in the performance of the technique&#46; The workshop does not include training in CICO diagnosis and rapid decision-making to perform a cricothyroidotomy&#46; This must be addressed in a simulation environment involving a multidisciplinary team that includes nurses and other professionals&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">10&#44;11</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0195" class="elsevierStylePara elsevierViewall">Our workshop improves theoretical knowledge&#44; which was evaluated by means of a questionnaire&#46; It significantly improves SCt skills&#44; which were evaluated on the basis of the success rate and the time needed to perform SCt&#46; Factors such as years of professional experience&#44; the size of the hospital&#44; experience in the performance of surgery in patients with difficult airway risk factors&#44; previous experience performing cricothyroid membrane puncture in models or patients&#44; or previous experience performing cricothyroidotomy in models or patients did not influence outcomes&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0200" class="elsevierStylePara elsevierViewall">This study has been self-funded by the <span class="elsevierStyleGrantSponsor" id="gs1">ANESTARRACO Anaesthesia Research Group &#40;IISPV&#41;</span>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The latest Difficult Airway Society &#40;DAS&#41; guidelines recommend that all anaesthesiologists should to be trained in the performing of a surgical cricothyrotomy &#40;CtQ&#41;&#46; The aim of this study was to analyse the learning results of a CtQ workshop by assessing the success rate and time to perform CtQ on a porcine tracheal model&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A workshop was designed in which each student completed a questionnaire with demographic data and theoretical knowledge about surgical approaches of airway&#46; During the following hour&#44; a review was presented theoretical aspects of CtQ&#46; The model was shown and a CtQ was performed using a classical technique&#46; Afterwards&#44; in groups of 3&#8211;4 students with an instructor&#44; each one of the students performed 6 CtQ&#46; A record was made on whether the ventilation was correct&#44; the time to perform CtQ&#44; and the ease of performing the CtQ by the students and instructors&#46; Finally&#44; students completed a questionnaire on the theoretical aspects&#46; Students and instructors performed a workshop debriefing&#46; A statistical analysis was performed&#44; considering a <span class="elsevierStyleItalic">p</span>-value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 as statistically significant&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 8 workshop sessions were held with a total of 91 students&#46; At first attempt&#44; 86&#37; of students performed a CtQ with successful ventilation&#44; and 92&#37; at the sixth attempt &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; Time taken was 163 &#91;107&#8211;211&#93;<span class="elsevierStyleHsp" style=""></span>s at first attempt&#44; and 70 &#91;55&#8211;85&#93;<span class="elsevierStyleHsp" style=""></span>s at the sixth &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; At the end of workshop&#44; students had improved their theoretical knowledge &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; and perception of the ease of the technique&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Workshop performance improved theoretical knowledge and competence in surgical cricothyrotomy&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
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      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las &#250;ltimas gu&#237;as de la <span class="elsevierStyleItalic">Difficult Airway Society</span> recomiendan que todos los anestesi&#243;logos deber&#237;an estar entrenados para la realizaci&#243;n de una cricotiroidotom&#237;a quir&#250;rgica &#40;CtQ&#41;&#46; El objetivo de este estudio es analizar los resultados de aprendizaje de un taller de CtQ mediante la evaluaci&#243;n de la tasa de &#233;xito y el tiempo necesario para realizarla en un modelo de tr&#225;quea porcina&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Dise&#241;amos un taller en el que cada alumno respond&#237;a un cuestionario con datos demogr&#225;ficos y conocimientos te&#243;ricos sobre el abordaje quir&#250;rgico de la v&#237;a a&#233;rea&#46; Durante la hora siguiente se revisaron aspectos te&#243;ricos&#46; Se mostr&#243; el modelo y realizamos una CtQ siguiendo la t&#233;cnica cl&#225;sica&#46; Despu&#233;s&#44; en grupos de 3-4 alumnos con un instructor&#44; los alumnos realizaron 6 CtQ cada uno&#46; Registramos si la ventilaci&#243;n era correcta&#44; el tiempo necesario para realizarla y la facilidad de realizaci&#243;n evaluada por alumno e instructor&#46; Finalmente&#44; los alumnos respondieron un cuestionario de aspectos te&#243;ricos&#46; Realizamos un an&#225;lisis estad&#237;stico&#44; considerando estad&#237;sticamente significativo un valor de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Llevamos a cabo 8 ediciones del taller&#44; con 91 alumnos&#46; Consiguieron hacer la CtQ y ventilar correctamente el 86&#37; en el primer intento y el 92&#37; en el sexto &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; El tiempo necesario para hacer una CtQ pas&#243; de 163 &#91;107-211&#93; a 70 &#91;55-85&#93; segundos &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; Al final del taller los alumnos hab&#237;an mejorado sus conocimientos te&#243;ricos &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41; y la percepci&#243;n de facilidad de la t&#233;cnica&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El taller realizado mejora los conocimientos te&#243;ricos y la competencia en la realizaci&#243;n de una CtQ&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; A&#241;ez Sim&#243;n C&#44; Serrano Gonzalvo V&#44; Carrillo Luna LH&#44; Farr&#233; Nebot V&#44; Holgado Pascual CM&#44; y grupo de investigaci&#243;n ANESTARRACO &#40;IISPV&#41;&#46; Resultados de un taller de cricotiroidotom&#237;a quir&#250;rgica con un modelo de tr&#225;quea de cerdo&#46; Rev Esp Anestesiol Reanim&#46; 2019&#59;66&#58;129&#8211;136&#46;</p>"
      ]
      1 => array:3 [
        "etiqueta" => "1"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">The members of the ANESTARRACO group &#40;IISPV&#41; are shown in <a class="elsevierStyleCrossRef" href="#sec0040">Annex</a>&#46;</p>"
        "identificador" => "fn1"
      ]
    ]
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            "apendice" => "<p id="par0210" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p>"
            "etiqueta" => "Annex"
            "titulo" => "Members of the ANESTARRACO group &#40;IISPV&#41;"
            "identificador" => "sec0040"
          ]
        ]
      ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Model and instrumentation for surgical cricothyroidotomy&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Standard surgical cricothyroidotomy technique&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Students&#8217; assessment of difficulty in each attempt&#46;</p>"
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      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Instructors&#8217; assessment of difficulty in each attempt&#46;</p>"
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      4 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Cric&#46;&#58; cricothyroidotomy&#59; CTM&#58; cricothyroid membrane&#59; NS&#58; not significant&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="7" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Criterion</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Cric&#46; 1</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Cric&#46; 6</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Cric&#46; 1 vs Cric&#46; 6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; success&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; success&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Resident&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaesthesiologist<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaesthesiologist<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaesthesiologist<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;0004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Small hospital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Medium sized hospital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#40;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Large hospital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26 &#40;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Airway risk surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67 &#40;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No airway risk surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CTM puncture on model&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50 &#40;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No CTM puncture on model&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36 &#40;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CTM puncture on patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No CTM puncture on patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68 &#40;74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cricothyroidotomy on model YES&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41 &#40;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cricothyroidotomy on model NO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40 &#40;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cricothyroidotomy on patient YES&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cricothyroidotomy on patient NO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76 &#40;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Cric&#46;&#58; cricothyroidotomy&#59; CTM&#58; cricothyroid membrane&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Median &#91;interquartile range 25&#8211;75&#37;&#93;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time &#40;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cric&#46; 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cric&#46; 6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">163&#46;5 &#91;107&#46;5&#8211;211&#46;5&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70 &#91;55&#8211;85&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Resident anaesthesiologist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">160 &#91;131&#8211;177&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74 &#91;57&#8211;87&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaesthesiologist<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">151 &#91;88&#46;5&#8211;213&#46;5&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72 &#91;55&#8211;98&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anaesthesiologist 10&#8211;15 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&#46;5 &#91;62&#46;5&#8211;238&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&#46;5 &#91;45&#46;5&#8211;86&#46;5&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;01&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70 &#91;55&#8211;87&#93;&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Emergent surgical cricothyrotomy &#40;cricothyroidotomy&#41;&#46; UpToDate"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Difficult Airway Society 2015&#46; Guidelines for management of unanticipated difficult intubation in adults"
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                          "colaboracion" => "Difficult Airway Society Intubation Guidelines Working Group"
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                          "autores" => array:6 [
                            0 => "C&#46; Frerk"
                            1 => "V&#46;S&#46; Mitchell"
                            2 => "A&#46;F&#46; McNarry"
                            3 => "C&#46; Mendonca"
                            4 => "R&#46; Bhagrath"
                            5 => "A&#46; Patel"
                          ]
                        ]
                      ]
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                  ]
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                      "Revista" => array:5 [
                        "tituloSerie" => "Br J Anaesth"
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                        "paginaInicial" => "1"
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                      "titulo" => "Management of the &#8220;can&#8217;t intubate can&#8217;t ventilate&#8221; situation and the emergency surgical airway"
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                        0 => array:2 [
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                        "titulo" => "4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society&#46; Major Complications of Airway Management in the United Kingdom&#46; Report and Findings"
                        "fecha" => "2011"
                        "editorial" => "Royal College of Anaesthetists"
                        "editorialLocalizacion" => "London"
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                      "titulo" => "Emergency cricothyrotomy &#8212; a systematic review"
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                            0 => "S&#46; Langvad"
                            1 => "P&#46;K&#46; Hyldmo"
                            2 => "A&#46;R&#46; Nakstad"
                            3 => "G&#46;B&#46; Vist"
                            4 => "M&#46; Sandberg"
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                    0 => array:2 [
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                        "tituloSerie" => "Scand J Trauma Resusc Emerg Med"
                        "fecha" => "2013"
                        "volumen" => "21"
                        "paginaInicial" => "43"
                        "link" => array:1 [
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                        0 => array:2 [
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                            4 => "R&#46;J&#46; Marks"
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