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September 03, 2006

小児の鼠径ヘルニア

小児の鼠径ヘルニア根治術の麻酔では迷うところが多い。大人ならルンバールだが小児なので全身麻酔となる。まず気道確保を気管挿管・ラリマ・フェイスマスクのいずれにするかで迷う。熟練した外科医が本気でやってくれるなら短時間なのでフェイスマスクでOKだが,研修医などに教えながらの手術だと結構時間がかかる。自動麻酔記録装置があったとしても両手がふさがるのが不安だ。昔はマスク麻酔しながら血圧を手動で測定し,麻酔記録もボールペンで書き込んだりしていたが,そんな曲芸は今はできない。

マスク麻酔の利点は気管挿管やラリマ挿入による合併症がないことと,筋弛緩を使用しないのでリバースする必要がないことである。小児は人生経験が短い。高齢者はそれまでの人生でいろいろな薬を経験しており,アレルギーを起こす人なら既知のことが多い(もちろん例外もある)。小児ではほとんどの薬が初体験。使用する薬剤は少ないほうが無難だ。マスキュラックスを使用しなければワゴスチグミンも使用しなくてすむ。導入時の心拍数が充分なら硫アトも不要かもしれない。マスク麻酔の欠点は前述のとおり両手がふさがることと,誤嚥を防げないこと。

気管挿管の利点と欠点はマスク麻酔の裏返し。利点としては誤嚥の危険性は低く,人工呼吸器に乗せてしまえば麻酔科医の両手は自由になる。欠点は(もちろん筋弛緩無しでも挿管は可能だが)マスキュラやワゴスなどが必要になることと,挿管に伴う合併症の危険性があること。

麻酔の導入に関しても迷うことがある。静脈ルートが確保されていない場合は迷うことなくスローインダクションだが,病棟で既にルート確保されていた場合に迷う。何のためらいもなくプロポフォールで急速導入している施設も多いだろうが,添付文書では「低出生体重児、新生児、乳児、幼児または小児に対する安全性は確立していない( 使用経験がない)」とされている。それに静注時の血管痛の問題もある。バルビツレートやドルミカムという手もあるが,維持をGOSとするならセボフルレンも笑気もどうせ維持に使うのだから,これらを導入にも使えば静脈麻酔薬によるアナフィラキシーは回避できる。

例えば,プロポフォールで急速導入しアナフィラキシーショックが起こったとする。そして心停止となって不幸な結果となった場合,警察・司法・マスコミがどういう態度と行動をとるか想像に難くない。
「小児には使用が認められていない薬剤を用いた」
そして,マスコミが用意する麻酔科医の発言は「私なら小児の鼠径ヘルニアならマスク麻酔のみで行うので,プロポフォールは絶対使用しない。挿管やラリマだからプロポフォールを使用することになる。最近の麻酔科医は短時間の手術でもすぐ人工呼吸器に乗せて楽をしたがるからこのようなことが起こるのだ」

一方,GOSでスロー導入してそのままGOSのマスク麻酔をしている最中に胃内容が逆流した場合はどうなるか。通常は禁飲食なので誤嚥の危険性は低いはずである。しかし理解の悪い親族が密かに食べさせるケースもある。麻酔前に乳児に「今日何か食べた?」と尋ねても答えてくれない。誤嚥性肺炎となり不幸な転帰をたどった場合の警察・司法・マスコミも予想がつく。
「未熟な麻酔科医による医療ミス」
「小児の顎は小さく脆弱なため,マスクを保持するには高度な技術を要する。また,成人に比べ口腔内に占める舌の容積比が大きくなるため,気道の開通が困難でマスク換気では酸素は肺ではなく胃に流れやすい。その結果,胃が膨満して嘔吐しやすくなる。担当麻酔科は自分の技術を過信し,誤嚥を防げる気管挿管を行わなかった」
「気管挿管していれば誤嚥など起こらなかった」
親族がNPOを守らせなかったこととか,挿管を選択しても導入中に誤嚥する可能性のあることは表にでない。

医療において不幸な結果が生じた場合,決断の分岐点までさかのぼり他の選択肢を採用した場合の利点のみを強調すれば,医師を犯罪者にするのは簡単だ。

医療行為の選択肢が多いというのは患者と医師の双方にとって幸福なことだと思っていたが,医師にとってはそうでもないようだ。

ところで小児の鼠径ヘルニアと言えば

-------------------------------------------引用開始------------------------------------
乳児ぼうこう切除、ヘルニア手術で初歩的ミス…大阪

 大阪府枚方市の星ケ丘厚生年金病院で昨年2月、ヘルニア手術を受けた1歳の乳児が、誤ってぼうこうの大半を切除されていたことが、わかった。

 当時、小児外科の専門医がおらず、同病院は「小児手術の経験が少ない執刀医による初歩的ミス」と認め、両親に謝罪した。

 28日会見した吉矢生人院長(67)らによると、ミスがあったのは、腸の一部などが足の付け根部分で皮膚の下に出てくるヘルニアの手術。主治医の男性外科医(30)が、腸を覆っている腹膜を取り出そうとして、誤ってぼうこうを取り出し、そのまま4分の3を切除した。別の男性外科医(38)が指導役として立ち会っていたが、気付かなかったという。
(読売新聞)

-------------------------------------------引用終了------------------------------------

小児の鼠径ヘルニアの手術は切開創が小さく,難しそうだなとは思っていたが…。

これはまずい。

最近の医療トラブルの新聞報道を見ていると,教科書にもよく載っているような合併症や不可避の有害事象でも“医療ミス”とされることが多く,記者の無知と悪意に憤懣やるかたないが,今回は紛れもなく過誤だろう。

我々医療従事者は,言いがかり的な“医療ミス”呼ばわりは断固として否定するべきだが,上のようなミスはミスとして認めることも大事だと思う。

それにしても,若い外科医がもっと若い外科医に教えながら小児鼠径ヘルニアの手術をしているのを何回か経験したが,あれは実は怖いことだったのか。

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