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///2016 Abstract Details
2016 Abstract Details2019-07-15T10:10:51-05:00

Seizure in a parturient: Fixation as potential cause for a near miss

Abstract Number: F-76
Abstract Type: Case Report/Case Series

Mary DiMiceli-Zsigmond M.D.1

A 37 year old G1P0 with hypothyroidism was admitted for induction of labor for uncontrolled gestational diabetes. Epidural analgesia was initiated uneventfully prior to insertion of a foley bulb. Electronic fetal monitoring demonstrated a category 1 tracing. Seven hours later the OB emergency response team was called for fetal deceleration and maternal seizure. Transfer to the OR for a STAT cesarean without monitors or supplemental O2 was in progress until arrival of the OB anesthesiology team. Upon our arrival, she was noted to be unresponsive and apneic. Midazolam was administered intravenously without improvement. PEA arrest was eventually diagnosed, ACLS was initiated and a STAT cesarean was performed. Endotracheal intubation was successful after four attempts, complicated by an esophageal intubation and aspiration. APGAR scores were 1, 5 and 7 at 1, 5 and 10 min. She received a total of 5mg IV epinephrine, after which she resumed spontaneous return of circulation (ROSC). TTE demonstrated RV strain with LV under-filling, concerning for embolic event. She was transferred to the SICU, at which time she demonstrated signs and symptoms consistent with disseminated intravascular coagulation. She required ionotropic support overnight. Her coagulopathy slowly improved, and she finally was extubated on POD#3. A CT-angiogram was negative for significant pulmonary embolism, confirming the initial suspicion of amniotic fluid embolism. She initially demonstrated severe cognitive impairment with deficits in orientation, memory and reasoning, but had significantly improved by time of discharge on POD#15. Fixation error or getting “cognitively stuck” can occur more commonly during a crisis or times of stress resulting in focusing on a single source of information, missing a crucial piece of information, failing to revise one’s cognitive processes, or failing to accept the most likely etiology. This leads to fixating on a diagnosis, treatment or avoidance in requesting additional help resulting in significant morbidity and mortality unless harm is avoided, in which case it is a near miss. Near misses provide opportunities to: 1) learn about our systems, abilities, vulnerabilities, and structure 2) identify problems 3) formulate plans to mitigate errors. Seizure in a parturient inspires the diagnosis of preeclampsia. This avoids all other potential causes and misses the appropriate treatment, which almost occurred until PEA arrest was recognized. Fixation is a natural by-product of specialty training and of guidelines created to deal with crises and uncertainty, i.e. anesthesiologists are trained to manage airway and circulation, and thus focus on maintaining hemodyamic stability and airway patency, often forgetting in utero resuscitation. Using this reasoning, fixation on fetal deceleration almost resulted in a timely and costly transfer to the OR that would have likely resulted in maternal and fetal mortality.

SOAP 2016