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Chapter 13
been placed next to the patient but not been connected with his IV line. After realising this
omission, the patient received 1l of NaCl 0,9% and 1l of colloids within 10 min. Starting from
here, blood pressure stabilised (98/67 mmHg).
The second omission was “consider corticosteroids to decrease biphasic response”. The
attending anaesthetist had assumed that application of corticosteroids was a standard
procedure before percutaneous hydatid cyst drainage. However, this was not the case.
Thereupon the patient received 50 mg prednisolone iv. Ten minutes later the patient was
in haemodynamic stable condition transferred to the ICU. The trachea was successfully
extubated the following day, and the patient discharged home two days later.
Percutaneous treatment of a hydatid cyst is usually performed under deep sedation outside
theORwith a teamconsistingof a sedation specialist, a radiologist and a radiology technician.
Anaphylactic reactions during the procedure are rare (1.7%), but carry a mortality rate of
0.03%.
1
In such a critical situation it is important that all members of this multidisciplinary
team speak the same “language” and use the same approach. Although in the presented
case the medical team managed this emergency in a professional manner, two important
things – fluid therapy and corticosteroids – would have been missed without the critical
aids.
The literature shows that multidisciplinary teams dealing with emergency situations
frequently omit critical treatment steps.
2
Cognitive aids can help to reduce the number
of omitted steps and improve communication within the team during a crisis.
2-5
Cognitive
aids should provide a framework with all the cardinal treatment steps of a crisis to off-load
some of the teams cognitive duties. This will allow the team to increase its bandwidth to
more effectively deal with the more complicated issues like e.g. underlying causes of the
crisis. In our hospital, the Academic Medical Centre in Amsterdam, cognitive aids have been
implemented since 2013 and are routinely used during clinical emergencies.
6
They also
have a central role in teaching, for residents and staff, as well as for nurse anaesthetists.
7
In
the presented case we cannot be certain that the outcome of the patient would have been
less good without the use of a cognitive aid. However, with the cognitive aid the omitted
steps were identified intermediately. We know that the human brain is fallible, especially
under stress and in situations with a high cognitive load.
8
Cognitive aids can never replace
the expertise or skills of medical personnel, however they can reduce human error and
hereby improve quality of care.