Procedure-Associated Shock: Clinical and System Review, Incident Analysis

Given the broad range of potential causes of Procedure-Associated Shock, clinical and system reviews should be conducted 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.

To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for conducting chart audits and analysis methods are included in the Hospital Harm Improvement Resource Introduction.

If your review reveals that your cases of Procedure-Associated Shock are linked to specific processes or procedures, you may find these resources helpful:

• Agency for Healthcare Research and Quality www.ahrq.gov
• AHRQ. Introduction to the toolkit for using the AHRQ quality indicators: How to improve hospital quality and safety. AHRQ; 2013. Available at: https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/combined_toolkit.pdf
• Agency for Healthcare Research and Quality (AHRQ). PSI (Patient Safety Indicator) 09: Postoperative hemorrhage or hematoma. Selected best practices and suggestions for improvement. AHRQ; 2013. Available at: https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4f_combo_psi09-postophemorrhage-bestpractices.pdf
• American Academy of Orthopaedic Surgeons (AAOS) www.aaos.org
• Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty: Evidence-based guideline and evidence report. 2nd edition. Rosemont, IL; AAOS: 2011. https://www.aaos.org/globalassets/quality-and-practice-resources/vte/vte_full_guideline_10.31.16.pdf
• American College of Surgeons https://www.facs.org/
• American College of Surgeons. ATLS^® Advanced Trauma Life Support^® 10th Edition https://viaaerearcp.files.wordpress.com/2018/02/atls-2018.pdf
• American Society of Anesthesiologists, Standards and Guidelines https://www.asahq.org/standards-and-guidelines
• American Society for Gastrointestinal Endoscopy (ASGE) Guidelines https://www.asge.org/home/practice-support/guidelines
• Anderson MA, Ben-Menachem T, Gan SI, et al. American Society of Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009; 70(6):1060-70. doi: 10.1016/j.gie.2009.09.040.
• Association of Anaesthetists of Great Britain and Ireland https://anaesthetists.org/
• Association of Anaesthetists of Great Britain and Ireland, Thomas D, Wee M, et al. Blood transfusion and the anaesthetist: management of massive haemorrhage. Anaesthesia. 2010; 65 (11): 1153-1161. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3032944/
• Blood Transfusion
• Theusinger, O. M., Kind, S. L., Seifert, B., Borgeat, L., Gerber, C., Spahn, D. R. (2014). Patient blood management in orthopaedic surgery: a four-year follow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland. Blood Transfusion, 12, 195-203. https://dx.doi.org/10.2450/2014.0306-13 Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4039701/
• British Journal of Haematology https://onlinelibrary.wiley.com/journal/13652141
• Hunt BJ, Allard S, Keeling David, et al. A practical guideline for the haematological management of major haemorrhage. Br J Haematol. 2015; 170 (6): 788-803. doi: 10.1111/bjh.13580. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/bjh.13580
• Clinical Obstetrics and Gynecology https://journals.lww.com/clinicalobgyn/pages/default.aspx
• Yu, S. P., Cohen, J. G., Parker, W. H. (2015). Management of hemorrhage during gynecologic surgery. Clinical Obstetrics & Gynecology, 58, 718-1. https://dx.doi.org/10.1097/GRF.0000000000000147
• Critical Care Clinics www.criticalcare.theclinics.com
• Cantle PM, Cotton BA. Prediction of massive transfusion in trauma. Crit Care Clin. 2017; 33(1): 71-84. doi: 10.1016/j.ccc.2016.08.002
• Current Opinion in Anesthesiology https://journals.lww.com/co-anesthesiology/pages/default.aspx
• Butwicka AJ, Goodnough LT. Transfusion and coagulation management in major obstetric hemorrhage. Curr Opin Anesthesiol 2015, 28:275–284. doi: 10.1097/ACO.0000000000000180. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4567035/
• ERAS (Enhanced Recovery After Surgery) Society Guidelines http://erassociety.org/guidelines/list-of-guidelines/
• Kozek-Langenecker SA, Ahmed AB, Afshari A, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: First update 2016. European Journal of Anaesthesiology | EJA. 2017;34(6). doi:10.1097/EJA.0000000000000630
• European Society of Intensive Care Medicine https://www.esicm.org
• Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014;40(12):1795-1815. doi: 10.1007/s00134-014-3525-z
• Institute for Healthcare Improvement (IHI) www.ihi.org
• Institute for Healthcare Improvement (IHI). How-to guide: Prevent harm from high-alert medications. Cambridge, MA: IHI; 2012. http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventHarmfromHighAlertMedications.aspx
• Journal of Emergency Trauma Shock www.onlinejets.org/
• Balvers K, Coppens M, van Dieren S, et al. Effects of a hospital-wide introduction of a massive transfusion protocol on blood product ratio and blood product waste. J Emerg Trauma Shock. 2015;8(4):199-204. doi:10.4103/0974-2700.166597
• Merck Manual Professional Version www.merckmanuals.com
• Procter LD. Shock. Merck Manuals Professional Edition. Merck Manuals Professional Edition. Published October 2020. Accessed March 2021. https://www.merckmanuals.com/professional/critical-care-medicine/shock-and-fluid-resuscitation/shock
• National Institute for Health and Care Excellence (NICE) www.nice.org.uk
• New England Journal of Medicine www.nejm.org
• Vincent J-L, De Backer D. Circulatory Shock. N Engl J Med. 2013;369(18):1726-1734. doi:10.1056/NEJMra1208943
• Royal College of Anaesthetists www.rcoa.ac.uk
• Seminars in Thrombosis and Hemostatsis
• James AH, Grotegut C, Ahmadzia H, Peterson-Layne C, Lockhart E. Management of Coagulopathy in Postpartum Hemorrhage. Semin Thromb Hemost. 2016;42(7):724-731. doi:10.1055/s-0036-1593417
• Society of Critical Care Medicine https://www.sccm.org/Research/Journals/Critical-Care-Medicine
• Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017;45(3). doi:10.1097/CCM.0000000000002255
• UPTODATE www.uptodate.com
• Gaieski DF, Mikkelsen ME. Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock. UpToDate. 2018 October, last updated. https://www.uptodate.com/contents/evaluation-of-and-initial-approach-to-the-adult-patient-with-undifferentiated-hypotension-and-shock

• Hrymak C, Funk DJ, O'Connor MF, Jacobsohn E. Intraoperative management of shock in adults. UpToDate. 2018 July, last updated. https://www.uptodate.com/contents/intraoperative-management-of-shock-in-adults?search=Intraoperative%20management%20of%20shock%20in%20adults&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
• Parker WH, Wagener WH. Management of hemorrhage in gynecologic surgery. UpToDate. 2018 May, last updated. https://www.uptodate.com/contents/management-of-hemorrhage-in-gynecologic-surgery
• Siparsky N. Overview of postoperative fluid therapy in adults. UpToDate. 2018 May, last updated. https://www.uptodate.com/contents/overview-of-postoperative-fluid-therapy-in-adults

• For additional references you may also find the following Hospital Harm Improvement Resources helpful:
• Obstetric Hemorrhage
• Venous Thromboembolism
• Electrolyte and Fluid Imbalance
• Sepsis
• Anemia - Hemorrhage (Procedure-Associated Condition)