One shock after another; simulation can prevent fixation errors: A case report

Abstract

Introduction: Safety is essential in all the anesthesiologists’ activity. Anesthesiology pioneered the use of simulation in training. Human factors play a big part in critical incidents. Understanding and identifying key cognitive errors specific to anesthesiology is the first step in metacognition training and strategies to prevent these errors and improve patient safety.

A 64y female patient, ASA III, submitted to emergency laparotomy with right hemicolectomy. Surgery went uneventful until wound closure. After metamizole administration, the patient had had generalized skin rash, hypoxemia, bradycardia and hypotension, treated as an anaphylactic shock. In the recovery room, she had another episode of severe She had cardiac arrest. Advanced life support was successful. Ecofast (acronym for “The Focused Abdominal Sonography for Trauma Scan") revealed intraperitoneal fluid compatible with massive hemoperitoneum. Hemorrhagic shock was treated with exploratory laparotomy and hemodynamic support with progressive improvement.

It is important to note that a possible fixation error could have delayed the diagnosis of the hemorrhagic shock that overlapped the first anaphylactic shock and culminated in cardio-respiratory arrest. Fixation errors occur when one focuses only on one factor rather than other equally relevant and more predictable ones. Training through simulation increases awareness of potential problems in routine and non-routine settings and allows faster skill acquisition and recognition of problems. ACRM programs where the CRM model is applied to anesthesiology, allows the teaching and training of team behaviors in crisis situations.     

Citation: Husson N, Carreira C, Babo N. One shock after another; simulation can prevent fixation errors: A case report. Anaesth pain & intensive care 2019;23(4)__