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Case Report

One shock after another - simulation to avoid fixation errors - Case report.

Natacha Husson, Claudia Carreira, Nuno Babo.


Introduction: Safety is essential in all the anesthesiologists activity. Anesthesiology pioneered the use of simulation in training. Human factors play a 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.
Case report: 64yo female, ASA III, submitted to emergency laparotomy with right hemicolectomy. Surgery went uneventful until wound closure. After metamizole administration, the patient begins generalized cutaneous rash, hypoxemia, bradycardia and hypotension, treated as an anaphylactic shock, with hemodynamic parameters improvement. During the patient's stay in the recovery room, she exhibited once more severe hypotension and tachycardia, with refractory hemodynamic response to adrenaline perfusion and the patient arrested. Advanced life support was successful. Ecofast revealed intraperitoneal fluid compatible with massive hemoperitoneum. Hemorragic shock was treated with exploratory laparotomy and hemodynamic support with progressive improvement.
Discussion: The case report depicts a situation in which a possible fixation error would 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 data rather than other equally relevant and are predictable when a new emergent event occurs. Mistakes due to tiredness are also frequently observed. Inattention blindness is more difficult to avoid when the event is unexpected, unnoticed or concurrent with other tasks, distractions, intellectual overload, stress or tiredness. 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. Anesthesiology pioneered in the use of simulation and training for emergency scenarios and exceptional situations, as it represents a medical specialty in which safety plays a very important role given the complexity of anesthesiologist's decisions and tasks.

Key words: anesthesiology; human factors; fixation errors; simulation; emergency; anaphylactic shock; hemorrhagic shock

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