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Hospital Harm: Procedure-Associated Shock

Shock is a state of organ hypoperfusion with resultant cellular dysfunction and death. Mechanisms may involve decreased circulating volume, decreased cardiac output, and vasodilation, sometimes with shunting of blood to bypass capillary exchange beds (Procter, 2020). It is a clinical state that occurs when a mismatch arises between oxygen supply and metabolic demand, resulting in cellular hypoxia. If not recognized and treated appropriately, shock will ultimately progress to organ failure (Broussard & Ural, 2018; Gaieski & Mikkelsen, 2018; Vincent & De Backer, 2013). It is one of the leading causes of death in hospitalized patients (Nichol & Ahmed, 2014).

Topics
  • Patient safety
  • Hospital harm
Audience

  • Point of care provider

  • Quality or safety improvement lead

  • Policy advisor or analyst

Goal

Reduce the incidence of procedure-associated shock.

Overview and Implications

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

There are several types of shock that a patient may experience during or after a procedure. Mechanisms of organ hypoperfusion and shock may be due to a low circulating volume (hypovolemic shock), vasodilation (distributive shock), a primary decrease in cardiac output (both cardiogenic and obstructive shock), or a combination of all of them. Untreated shock is usually fatal. Even with treatment, mortality from cardiogenic shock after myocardial infarction [MI] (60 to 65 per cent) and septic shock (30 to 40 per cent) is high. Prognosis depends on the cause, preexisting or complicating illness, time between onset and diagnosis, and promptness and adequacy of therapy (Procter, 2020).

Organ dysfunction in patients can be represented by an increase in the Sequential Organ Failure Assessment (SOFA) score (Vincent et al., 1996) of two points or more, which is associated with an in-hospital mortality greater than 10 per cent. Patients with septic shock can be identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater AND serum lactate level greater than 2 mmol/L in the absence of hypovolemia (i.e. after adequate fluid resuscitation). This combination is associated with hospital mortality rates greater than 40 per cent (Singer et al., 2016).

Table 1 was created by Dr. Denny Laporta at the Jewish General Hospital, McGill University, Montreal, QC (Laporta, 2018). The table summarizes the various types of shock that may be encountered in the peri-procedure period. In hypovolemic shock the reduced cardiac output is due to a reduction in circulating volume and consequent venous return. It may be due to hemorrhage or when large volumes of fluid are lost perioperatively – expectedly or unexpectedly.

Table 1: Examples of shock1 occurring during or after a procedure

Peri-Procedure Period

Type of shock

Causes

Hypovolemic

Bleeding

Excess loss of non-blood fluid:

  • Drainage

  • 3rd-spacing

Cardiogenic

Myocardial Infarction

Pre-existing:

  • Cardiomyopathy (hypertrophic dilated)

  • Valvulopathy

Obstructive

Pulmonary embolism

  • Tension pneumothorax

  • Cardiac tamponade

Distributive

Septic syndrome

Other (non-infectious) causes of systemic inflammatory response (SIRS):

  • Anaphylaxis

  • Transfusion reaction

Other adverse drug reactions:

  • Antihypertensives

  • Anesthetics

Spinal shock (neuraxial blockade)

Adrenal insufficiency (chronic steroid use)

Miscellaneous:

  • Burns

  • Liver failure

  • Thyroid storm

1These may occur as single causes or in combination.

Importance to Patients and Families

Procedure related shock can cause serious harm and death if not treated quickly. Knowing the signs to watch for, along with a prompt and appropriate response, can help save lives.

Family members will often identify changes in the patient's alertness and level of awareness, as well as the patient's restlessness and agitation. Deterioration may not be recognized or acted upon by healthcare providers, resulting in preventable patient safety incidents. Monitoring, observation, family consultation and communication are key to managing this risk (HIROC, 2020).

Patient Stories

Hear, and feel free to share Erin's and Jen's powerful stories via "Sepsis Emergency™" as provided by the Sepsis Alliance (Sepsis Alliance, 2014). https://www.youtube.com/watch?v=DnsQ4RlXsZY

Clinical and System Reviews, Incident Analyses

Given the broad range of potential causes of Procedure-Associated Shock, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

Measures

Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). In selecting your measures, consider the following:

You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.

Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.

Whenever possible, use measures you are already collecting for other programs.

Try to include both process and outcome measures in your measurement scheme.

Discharge Abstract Database

Discharge Abstract Database (DAD) Codes included in this clinical category: D25: Procedure-Associated Shock

Concept: Shock during or resulting from a procedure.

Success Stories

Surviving Sepsis

In April 2008, a 70-year-old independent lady with no previous comorbidities became a grandmother for the first time and was looking forward to watching her family grow-up. She developed a cough' became breathless and presented to her local hospital. She was admitted and developed severe sepsis and septic shock secondary to her community-acquired pneumonia; she died within seven hours. Her sepsis was not recognized, and antibiotics and fluids were not given in a timely manner. The patient's family and the well-meaning and competent medical and nursing team were devastated.

So begins the account of a real patient story that compelled Dr. Matt Inada-Kim and colleagues to tackle the problem of managing sepsis within their practice (Patient Stories, 2020).

https://www.patientstories.org.uk/recent-posts/surviving-sepsis-a-human-factors-approach/

References

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