CICO and human factors: cognitive overload, fixation and delay

Jan 15, 2026

CICO is rarely just a technical failure. In perianaesthesia settings, it often unfolds under pressure, noise, urgency, and rising stress. When time feels compressed and stakes feel high, human factors begin to shape decisions just as much as airway anatomy.

Cognitive overload occurs when the brain is asked to process too much information at once. During an airway crisis, this may include deteriorating physiology, multiple airway attempts, equipment changes, and team communication. As mental load increases, decision making narrows. Fixation can develop, where attention becomes locked onto one plan or technique, even when it is no longer effective.

Fixation delays escalation. Repeating upper airway attempts can feel productive, yet each attempt consumes time and oxygen. The longer fixation persists, the harder it becomes to recognise that the situation has changed. Declaring CICO then feels abrupt or premature, even when physiology clearly supports it.

Human factors commonly seen in CICO events include:

🔹 Task saturation with loss of situational awareness
🔹 Repetition of failed airway strategies
🔹 Delayed declaration of CICO
🔹 Hierarchy limiting challenge or escalation
🔹 Unclear leadership or role allocation

Understanding these patterns helps teams respond earlier. Cognitive aids, shared language, and predefined triggers reduce reliance on memory under stress. Clear statements such as “ventilation is failing” help reset team focus and interrupt fixation.

Perianaesthesia nurses play a vital role in recognising overload and speaking into the pause. Naming concern, prompting reassessment, and supporting escalation are powerful safety actions. When human factors are anticipated and managed, CICO becomes easier to recognise and faster to act on.

References

Cook, T.M., Woodall, N. and Frerk, C. (2011). Major complications of airway management in the UK. British Journal of Anaesthesia.
Chrimes, N. and Higgs, A. (2020). Human factors and airway management. British Journal of Anaesthesia.

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