The Anaesthetic resident was called to the Coronary Care Unit (CCU) for a patient with cardiogenic shock receiving continuous positive airway pressure (CPAP) and metaraminol infusion initiated overnight.  Electrocardiograms were highly suggestive of left main stem coronary artery disease.  The patient required urgent intubation and transfer to the cardiac catheter lab for percutaneous coronary intervention.  The cardiac catheter lab was put on hold whilst waiting for the patient to be intubated.

However, 30 minutes later, the patient had not been intubated as a transfer ventilator was unavailable, and the anaesthetist was unwilling to proceed without appropriate equipment.  The CCU Nurse-in-charge and cardiologist requested assistance via the designated anaesthetic contact number, to which the Anaesthetic resident responded that he was the contact and no additional support was available.  The urgency of the situation was explained, including the fact that a catheterisation laboratory was being held for the patient.  The cardiologist escalated a request to the cardiothoracic intensive care unit to borrow their transfer ventilator. In the meantime, the catheter labs resumed their list of work.

The patient became increasingly fatigued and urgent escalation was made to the Anaesthetic Consultant.  A recommendation was made to transfer the patient to the Cardio-Thoracic Intensive Care Unit (CTICU) but the anaesthetic team maintained the plan to intubate only when the catheterisation laboratory was available.  Whilst awaiting further action, the patient experienced a pulseless electrical activity cardiac arrest and was transferred to the catheter lab with ongoing cardiopulmonary resuscitation.  The patient was subsequently transferred to the CTICU.

Commentary

Creating a safe environment to intubate an emergency patient in a remote site is a challenge, particularly in patients who are at high risk of peri-intubation cardiac arrest.  This is compounded when working across different specialities such as cardiology, cardiac surgery and intensive care.  Interprofessional, in situ simulation team training can be a helpful way to examine barriers to patient safety including the logistics of ensuring that all the essential drugs, equipment and personnel are available in a timely fashion¹.

Reference:

1. Burnett GW, Goldhaber-Fiebert SN. The role of simulation training in patients’ safety in anaesthesia and perioperative medicine. BJA Education 2024;24:7–12.