Hyperventilation in Cardiac Arrest: the Messy Reality

The application of contemporary human factors & ergonomics concepts to healthcare should be considered as essential to the task of improving patient safety. Furthermore, they are crucial to our developing understanding of clinical behaviours. Accordingly, Safety-II approaches should be at the forefront of our thinking and I direct you to this excellent summary > Safety-I and Safety-II

As a fundamental method of understanding human performance variability (and therefore safety), a key concept in Safety-II thinking is to consider the nature of our work and how it varies from the perspective of what we think we will do / have done  – that is, ‘work-as-imagined’ compared the actuality of  what we really did – that is ‘work-as-done’. The following clinical vignette represents an example of ‘work-as-imagined’ virus ‘work-as-done’ from clinical resuscitation practice.

Hyperventilation in Cardiac Arrest : The Messy Reality

The ‘normalised’ unsafe practice of hyperventilation during cardiac arrest management provides a comprehensive example of ‘The messy reality’ . It has become evident, from analysing retrospective observational data, that during the procedure of cardiopulmonary resuscitation (CPR), medical practitioners (usually anaesthetists) almost always deliver too much pressurized oxygen/air to the lungs of patients (both adults and children).

Traditional Safety-I concepts may regard this as a ‘violation’, in that this practice continues to occur despite a succession of recommendations in international guidelines to the contrary, supported by the established and widespread provision of systematic, organised education and training. However, when directly questioned, anaesthetists demonstrate a clear, functional knowledge that such practice is detrimental to patient outcome.

When contemplating this behaviour, we must consider the following. Firstly, there is no intention for airway management practitioners to deliberately hyperventilate a patient. Secondly, these clinicians do not know that they are hyperventilating patients during the period that it is happening.  Thirdly, at the point where the work has been completed (after the clinical intervention has been discontinued) there is not ordinarily any recognition that the patient may have been hyperventilated. Fourthly, despite the fact that this issue is widely known amongst anaesthetists, others (particularly those at the bunt end) would be generally ignorant that such an issue occurs.

[Originally published as part of a series of clinical vignettes at Steven Shorrock’s excellent  blog site (reproduced by kind permission) Humanistic Systems

Recommended further reading varieties of human work

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