CICO: Lessons from the NAP4
Airway emergencies are rare, but when they unfold, they unfold fast. A can’t intubate can’t oxygenate situation is one of the most confronting moments in perianaesthesia care, demanding calm thinking, shared understanding and decisive action.
NAP4 brought uncomfortable clarity to how airway crises evolve. Repeated attempts at familiar techniques, delayed recognition of failure, and hesitation to move to front of neck access all featured heavily. In many cases, what began as difficulty progressed into full CICO because the team did not change course early enough.
Physiologically, CICO represents complete loss of effective gas exchange. Hypoxia develops quickly, especially in obese patients or those with limited physiological reserve. Once ventilation and oxygenation are lost, time becomes the most critical factor. This is where preparation and team readiness matter more than technical perfection.
🔹 Poor airway assessment and planning increased the risk of CICO
🔹 Multiple repeated intubation attempts often worsened airway trauma and obstruction
🔹 Delay in moving to emergency surgical airway was linked to poor outcomes
🔹 Cannula cricothyroidotomy had a high failure rate compared with surgical techniques
For perianaesthesia nurses, NAP4 reinforces the importance of shared mental models. Knowing where emergency airway equipment is kept, recognising when oxygenation is failing, and confidently escalating concerns can change the trajectory of a crisis. Clear communication during airway difficulty supports earlier transitions to rescue strategies.
The key lesson from NAP4 is not about blame. It is about readiness. CICO outcomes improve when teams anticipate failure, practice emergency pathways, and act decisively when oxygenation is lost.
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References
Cook, T., Woodall, N. and Frerk, C. (2011). Major complications of airway management in the United Kingdom. The Royal College of Anaesthetists and the Difficult Airway Society.
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