RESUMO
The COVID-19 pandemic has had an unprecedented impact on the delivery of healthcare services around the globe. This has resulted in important loss of life for our communities, including health professionals that have been exposed to the disease in their workplace. A human factors approach to the recent changes introduced due to the pandemic can help identify how we can minimize the impact of human error in these circumstances. We hereby present a case study illustrating the application of human factors in the difficult times we are going through at present.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Assuntos
Infecções por Coronavirus/epidemiologia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Erros Médicos/prevenção & controle , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Cirurgia Plástica/métodos , COVID-19 , Infecções por Coronavirus/prevenção & controle , Feminino , Humanos , Controle de Infecções/organização & administração , Masculino , Saúde Ocupacional , Pandemias/prevenção & controle , Segurança do Paciente , Pneumonia Viral/prevenção & controle , Medição de Risco , Cirurgia Plástica/estatística & dados numéricosRESUMO
Transjugular intrahepatic portosystemic shunt (TIPS) is a safe and effective procedure for the treatment of complications of liver cirrhosis, such as refractory ascites, hepatic hydrothorax and refractory variceal bleeding. The aim of this paper is to describe a rare case of liver failure after a TIPS procedure. A 38-year-old diabetic male with Child-Pugh C liver cirrhosis due to chronic hepatitis C infection who had developed refractory ascites was scheduled for a TIPS procedure. Within 24 h following TIPS placement, the patient developed distributive shock, jaundice, persistentgrade 3 hepatic encephalopathy, severe coagulopathy and acute renal failure. He was treated with lactulose enemas, broad-spectrum antibiotics and blood-derived products. Laboratory data revealed a 100-fold increase in aminotransferases and a non-enhanced computed tomography showed an irregular hypodense area in the right posterior segment of the liver. Despite being initially being in a stable condition, the patient developed progressive liver failure and died 2 mo later. Hepatic infarction is an uncommon phenomenon after a TIPS procedure; however, it can greatly complicate the course of a disease in a patient with an already compromised liver function.