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COGNITIVE AIDS„A MUST“ FOR PROCEDURES?
13
We all know, the human brain might not perform optimally during stressful situations.
Therefore, essential steps in the treatment of unexpected periprocedural situations and
emergencies especially in unfamiliar surroundings outside the operation room (OR) may be
missed. Cognitive aids help health care providers to take all treatment steps in correct order,
to use the same terminology in multidisciplinary teams, and thereby to improve the quality
of patient treatment in critical situations outside the OR.
We present the case of a severe anaphylactic reaction during a radiologic intervention to
drain an echinococcosis cyst outside the OR, in which cognitive aids were successfully used
to optimise patient care.
A 35-year-old male, ASA physical status II (85 kg, 180 cm) was scheduled for percutaneous
transhepatic drainage under deep sedation of a multivesicular hydatid cyst located in the
right liver lobe in close contact to the bifurcation of the vena porta.
On admission, the patient was normotensive (112/62 mmHg), in sinusrhythm (75 bpm), and
with a peripheral oxygen saturation (SpO
2
) of 100%.
In the radiology suite an 18-gauge IV was inserted and lidocaine 50 mg and clemastin 2 mg
were given intravenously. Two L/min of oxygen were administered by nasal cannula. Heart
rate (HR), SpO
2
, electrocardiogram (ECG), non-invasive blood pressure (NIBP), and exhaled
carbon dioxide (exCO
2
) were constantly monitored. After time-out with the radiologist,
the sedation specialist – a sedation trained anaesthesia nurse - injected 250 mcg alfentanil
and started propofol infusion aiming for an Modified Observer’s Assessment of Alertness/
Sedation (MOAA/S) score of 2, meaning that the patient responds only after mild shaking.
After achieving this sedation level, the radiologist started the procedure. Immediately after
injecting contrast material into the cyst, spill from the cyst occurred towards the right
vena portae. Simultaneously, the patient developed a sinus-tachycardia (106 bpm) and
hypotension (41/16 mmHg).
The sedation specialist directly called for help and started mask ventilation. At arrival of
the anaesthesiologist, sinus-tachycardia had increased to 140 bpm, while NIBP and SpO
2
were unrecordable. No pulsations of the carotid artery or femoral artery were palpable. A
cardiac arrest scenario secondary to an anaphylactic reaction was declared and cardiac
compressions were started. For treatment of the anaphylactic shock, 1 mg adrenaline
was administered intravenously. The patient was intubated without any problems and
ventilated with a FiO
2
of 1.0. A further 1 mg adrenaline and 2 mg phenylephrine was given iv.
during CPR. Shortly thereafter the patient regained return of spontaneous circulation with
low systemic pressure (52/32 mmHg). Continuous infusions of 0.1 mcg/kg/min adrenaline
and 0.08 mcg/kg/min noradrenaline were started and an attending medical student was
asked to read aloud the cognitive aids concerning anaphylactic reaction to ensure that all
required actions have been taken. It turned out that two treatment interventions had been
missed. First, no additional intravenous fluids had been given. Four bags of NaCl 0,9% had