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July 08, 2007

何が起こったのか

魚拓

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全身麻酔で虫歯治療の女児、急性心不全で死亡…山梨
 山梨県は6日、県立あけぼの医療福祉センター(同県韮崎市、佐藤英貴所長)で5日、全身麻酔で虫歯の治療を受けていた同県甲斐市の女児(9)が心停止状態となり、約6時間後に死亡したと発表した。

 死因は急性心不全で韮崎署が司法解剖を行い、詳しく調べている。

 同センターによると、治療は、5日午前10時15分に全身麻酔を施された後、同50分から始まった。午後2時ごろ、突然、女児の容体が急変、心停止状態になった。一時、心拍が再開し、甲府市内の病院に搬送されたが、同7時50分過ぎに死亡が確認された。

 治療は、県歯科医師会から派遣された男性歯科医、麻酔科の女性医師ら7人が行った。女児は重度の知的障害を持ち、手術中に動いてけがをする恐れがあったため、全身麻酔を施したという。同センターは「適切な方法で治療は終盤まで順調に行われていた。どうしてこうなったか全くわからない」としている。

 同センターでは2006年度に、全身麻酔による歯の治療を16件行っている。同センターは、児童福祉法に基づいて重度の障害を持つ子どもたちの入所、通園を受け入れる施設で、県内で唯一、障害者専門の歯科を設けている。

(2007年7月6日21時42分 読売新聞)

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亡くなられた児童の冥福を祈るとともに,ご遺族にはこころよりお悔やみ申し上げます。


本来は亜酸化窒素と書くべきだろうが,ここでは笑気とする。

上の記事では児の死亡した理由がさっぱりわからない。

歯科治療の鎮痛のために笑気を使用している開業歯科医も多いと聞いている。そのようなクリニックでは患者に治療前の絶食を指示してあるのだろうか。私は虫歯の治療前に絶食というのは聞いたことがない。歯科治療の後はしばらく食べられないので直前にたらふく食べてくる患者も多いと思う。

いくつかの歯科クリニックのHPを見てみると,笑気は30%程度の低濃度で使用しているようだ。気になるのは「笑気で嘔吐反射を抑制できる」などと書いてあること。低濃度の笑気にそんな作用があるとは知らなかった。しかし嘔吐反射が抑制されるなら,喉頭蓋の機能も低下しそうだ。そうなると,嘔吐した場合に誤嚥する可能性が高くなる。つまり「嘔吐反射は抑制できるが,万一嘔吐すると非常に危険」ということになるだろう。それに,そもそも笑気はPONVのリスクファクターではなかったか。

また,急変時に備えて静脈ルートを確保しているのか疑問だ。そんなものの必要がないくらい,低濃度の笑気吸入は安全なのだろうか。

とにかく,歯科クリニックでの笑気使用は危険だと前々から思っていた。そんなことを言い出すと,「局所麻酔薬の歯肉への局注でもアナフィラキシーや局麻中毒の危険性はある。万一に備えて全例に静脈ルートを確保しろとでも言うのか」と反論されそうだ。

普通の歯科治療に静脈ルートは不要だと思うが,私が患者なら虫歯の治療に笑気吸入を勧められても断る。

さて,上の記事の山梨県立あけぼの医療福祉センターは個人の歯科クリニックではなく,立派な施設なようだし麻酔科医が麻酔を担当しているので,歯科外来での「静脈路無しフルストマック無挿管笑気麻酔」などではなく,救急薬品の揃った手術室で,術前ちゃんと絶食し静脈路も確保して気管挿管もしたはずと信じたい。

しかし,ここのHPを見てみると手術室はなさそうだ。


麻酔科医も常勤はおらず,麻酔科の女性医師は非常勤だったようだが,それは関係ない。マスコミなら「非常勤=質が低い」でストーリーを作るかもしれないが。

歯科外来のあのイスで全身麻酔を行ったのか。ある程度フラット近くにはなるだろうが,私はあまりやりたくない。アンギオ室を上回るアウェーだ。そんなところでは実力を充分発揮できない。

誤嚥の危険性はさておき,低濃度の笑気吸入で歯科治療を行えるのは,ある程度自分を抑制できる患者だと思う。重度の知的障害があれば,低濃度の笑気では体動を抑えられないはずだ。完全に意識を消失させたほうが安全に治療を行えるだろう。

このような患児にはやはり他の全麻手術に準じ,絶食した上で設備の整った手術室で挿管して歯科治療するべきだと思う。たかが数分で終わる虫歯の治療に大がかりだと思われるかもしれないが,斜視手術や鼠径ヘルニア修復術も数分で終わることもある。

あけぼの医療福祉センターでもちゃんとした全麻だったかもしれない(笑気だけでは気管挿管は無理か?)が,それならなおさら患児の死亡理由がわからなくなる。

先天性心疾患? 小児の心臓手術でもGOSでスロー導入することが多い。笑気単独で強い循環抑制が起こるとは考えにくい。

詳細がわからないので何とも言えないが,誤嚥を含む気道系のトラブルか,笑気単独の浅い麻酔のせいで迷走神経反射が起こったか。しかしECGをモニターしていれば徐脈や心停止にはすぐに気づくし,既に挿管され静脈ルートが確保されていればCPRも困難ではない。まさかECGをモニターしていなかったとか? そんなはずはない。麻酔科医の習性としてECGモニターのないところでは麻酔はしないはず。

MHやアナフィラキシーなら「どうしてこうなったかわからない」とはならないだろう。川崎病で心筋梗塞か。

とにかく,通常の全麻のセッティングで起こった悲劇なら他人事ではない。明日は我が身だ。

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Comments

はじめまして.
ベテランの先生の麻酔に関するさまざまな知見をいつも興味深く拝見しております.
しかし,管理人様のような経験の豊富な先生にしては,全身麻酔下の歯科治療について,ご存じないのではないかとおもわれます.
件の施設の麻酔がどのように行われたのか,報道では全く分かりません.
しかし,全国の歯科大学や,歯科医師会の施設において,通常の歯科治療が困難な
患者に対して,全身麻酔下の歯科治療は行われております.
施設によっても全く異なることは存じておりますが,通常の歯科用チェアーといっても
各種メーカーより完全フラットになるようなチェアーも販売されております.
このようなチェアーであれば全身麻酔に使用しても全く支障はございません.
また,重度の知的障害持つ患者であれば笑気単独の麻酔を,わざわざ医科の先生をお呼びして依頼することはないと思います.たとえ一本でも通常の挿管をおこなった全身麻酔での歯科処置になることもあります.ましてやこのような患児の場合,数分で終わるような処置にはなりません.多い子では十数本の処置が必要になる場合もあります.
この報道の症例の詳細が分からない以上,先生の経験のみでこのようなことをおっしゃられるのはいささか,配慮に欠けるのではないかと思います.
初めての投稿にもかかわらず,長文失礼致しました.またROMに戻ります.
障害児の全身麻酔経験のある歯科麻酔科医でした.ちなみに歯科医師です.

Posted by: myuki | July 12, 2007 at 03:55 PM

失礼しました。以後気をつけます。

Posted by: 管理人 | July 12, 2007 at 07:56 PM

歯科の一般開業医が使用する低濃度の笑気は、笑気吸入鎮静法と
いって、全身麻酔ではなくて、精神鎮静法の一種です。

笑気吸入鎮静法を勉強して、臨床の経験を積むとわかりますが、
全身麻酔とは、全く異なります。

今回の件は、全身麻酔であることが明白にもかかわらず、低濃度の笑気の
危険性を誇大視して、一般市民に誤解を与えるような記述のように感じられ、
真に残念でなりません。


Posted by: 森 広 | July 15, 2007 at 08:34 PM

失礼しました。以後気をつけます。

Posted by: 管理人 | July 16, 2007 at 09:08 PM

はじめまして 障害者歯科をしているものです。
自分は医科麻酔科医とも歯科麻酔科医とも仕事をしていますし自分も麻酔を行いますので先生の疑問よくわかります。まず笑気吸入前の絶飲食は 一般的な開業医では行っている所は少ないようですが濃度を高くすればする程嘔吐しやすくなります。また、30%吸入鎮静法でも嘔吐する人は嘔吐します。なので絶飲食をしたほうがいいと考えます。吸入麻酔薬を低濃度とはいえ吸入するわけで 行ったほうが良いと僕は考えています。ルートを取るのかという事ですが 一般的にはとらないことが多いですが正直言えば先生のおっしゃるようにとるべきだと思います。自分では吸入鎮静法は静脈内鎮静法と併用することがほとんどなので静脈内貯留針で静脈確保(なんか表現が硬いですね^-^)を行っています。笑気は先生の仰るとおりPONVのリスクファクターです。
さて今回の全身麻酔ですが 当院では体動が激しい場合にはセボフルレンで緩徐導入を行います ルートが取れる場合はアルチバorフェンタニル ディプリバン マスキュラックス 挿管して笑気 ディプリバンで維持することが多いです。またラリンゲルマスクフレキシブルなども使うことが多いです 先生の仰るとおりオペ室で行う施設も多いです。しかし他科がオペをしない病院などでは外来で行う事が多いです。歯科用ユニットは通常のものではフルフラットにならないので当院ではオペ用のフルフラットになるユニットにバックボードを置いて救急カートの中にエホチールやらボスミンやらペルジピンやらネオフェリンなど使用すると考えられる薬品を詰め込んでいます。外来にはパイピングもされており除細動器 気管切開セット ブロンコファイバーなど使用されると考えられるものが用意されています。多分今回の場合も同様に行っていたと思いますが 何でこのような転機を迎えてしまったのか 本当に怖いなーと思います。
自分も明日はわが身だといつも思いながら行っているのが現状です。
特に障害者でも自分の所で行っている患者さんをみていると解剖学的に通常の患者さんと違うんじゃないかと考えられる患者さんや立つことが少ない患者さんが多く 妙に気道がご近所だったり呼吸中枢やばいんでないかと思ったり^-^嚥下機能低下等いろいろ思うことも少なくなく結構実は色々あったりします。ここでやっている方法は自分や他の病院のやり方をミックスしたオリジナルなので全国的に行われているかといえば少し不安ですが このように行っていますよーという紹介でした。本来麻酔科医はオペ室以外での全身麻酔なんて絶対やりたくないのが現状だと思います。自分も医科の麻酔科医と始めた当初は同じように言われましたし 同様の感想を持つのが普通の麻酔科医だと思います^-^。なので実は歯科の外来で行う為には結局手術室に見劣りしないようにいろいろ工夫されているのが現状だったりします。実は僕も山梨の報道直後すぐに施設のホームページでどういうところでやっていたのかなーと気になって見てみました。歯科は抜歯を始めファジーにしてきた所が僕はいっぱいあると思っています。ファジーにできる事はいいと思いますが あんまりにもファジーになりすぎてしまいすぎだなと思っています。今後も為になる記事楽しみにお待ちしています。

Posted by: ren | August 02, 2007 at 02:22 AM

renさん,こんにちは。コメントをありがとうございます。

>当院ではオペ用のフルフラットになるユニットにバックボードを置いて救急カートの中にエホチールやらボスミンやらペルジピンやらネオフェリンなど使用すると考えられる薬品を詰め込んでいます。外来にはパイピングもされており除細動器 気管切開セット ブロンコファイバーなど使用されると考えられるものが用意されています。

先生のように備え万全でされているところは大丈夫ですね。
私などまだまだ修行が足りず,勝手が違うアウェー,例えばアンギオ室などでは警戒モード全開で,非常に疲れます。歯科外来のセッティングは私にとってはアウェーですが,歯科麻酔の先生にとってはそこがホームですね。

エントリーでは障害者歯科のことをよく知らず,出過ぎたことを書きましたが,お叱りもなく,暖かいお言葉ありがとうございます。

今後ともよろしくお願いいたします。

Posted by: 管理人 | August 03, 2007 at 12:07 AM

誤解のないように追加いたします。

笑気吸入鎮静法を応用して嘔吐反射を抑制させる場合の嘔吐反射を誤解のないように
狭義の意味で異常絞扼反射という言葉を使用します。

そこで、笑気吸入鎮静法時=①と、全身麻酔時=②とについて考えてみますと、

  ① 精神的要因+歯科治療的要因 ⇒ 異常絞扼反射

  ② 笑気(高濃度)+ 他の要因(全身麻酔etc.) ⇒ PONV(術後の悪心・嘔吐)

①の笑気吸入鎮静法の20-30%の笑気は、精神的要因を変化させて、異常絞扼反射を間接的に
抑制することが目的であり、それにより、最大の目的である歯科治療を遂行させることにあります。

鎮静法などの応用のない治療は、程度の差こそあれ、異常絞扼反射が発現する確率はほぼ100%
です。もちろん、20-30%の笑気は奏効しない場合もありますが、異常絞扼反射を間接的に抑制
できる患者さんも少なからずおられます。

②の全身麻酔時のPONV(術後の悪心・嘔吐)の発現のリスクはご存知のように20-30%であり、
笑気を使用することによるリスクの上昇は明確ではないようですが、リスクは
少し(10%位?)上昇するとの報告が多いようですね。ただ、条件がいろいろありますし、
10%位のリスク上昇では笑気のみが原因とは言えないと思います。

対して、①の術中、術後の異常絞扼反射の発現については、笑気のスクファクターがあることは
否定できませんが、特に術中の場合は、発現し易さから考えて、症状(嘔吐反射の情景)から
考えて、むしろ、異常絞扼反射によるものと推察するのが妥当であるように思われます。

以上、笑気吸入鎮静法については、笑気による副作用、合併症としての悪心・嘔吐のエビデンス
は、術中に嘔気があれば過剰鎮静か?というくらいのもので、もし悪心・嘔吐が起こっても
意識があり呼吸も咳反射も保たれているので問題とはならないと思います。

これは、もし一般の歯科治療後にPONVが起こったとしても、歯科治療+20-30%の笑気が、全身
麻酔下での手術に比べ、侵襲性が低いことも十分推測できますので、そのPONVは比較的に問題
とはなりにくいことにもよるでしょう。

まとめますと、笑気吸入鎮静法時は笑気を原因とする悪心・嘔吐は問題とはならず、治療を遂行
させるための笑気の有効性の方がはるかに高いと考えられます。

これは、治療に役立つという麻酔の真骨頂でもあるところです。

ただ、freeanesthe先生がご心配される歯科医の麻酔の実力についてはごもっともなところですね。

Posted by: 森 広 | August 07, 2007 at 02:42 PM

10%のリスク上昇は、100人中20-30人の発生が22-23人に上昇する、
という意味ですので、誤解ないようにお願い致します。

Posted by: 森 広 | August 07, 2007 at 03:14 PM

すみません。訂正します。

10%のリスク上昇は、100人中20-30人の発生が22-33人に上昇する、
という意味ですので、誤解ないようにお願い致します。

Posted by: 森 広 | August 07, 2007 at 03:17 PM

森 広さま,詳細な解説をありがとうございます。

まとめレスで失礼いたします。

笑気は私もまだ有用だと思いますし,今もどこの手術室でも使えますが,さすがにハロセンの気化器は私の周りでは最近見かけません。

小児ではセボフルランの切れの良さがかえって使いにくいと感じるときがあります。セボフルランやイソフルランが出始めた時,「エンフルランは退場するだろうが,ハロセンは残るだろう」と仲間と話していましたが,私の医療圏ではハロセンの気化器は絶滅した模様です。田舎の病院でたまにエンフルランを見かけることはあります。

Posted by: 管理人 | August 08, 2007 at 12:12 AM

ハロセンもいつ消えるか? ということですね。
ハセロンと笑気によるスロー導入は、second gas effect の効果を感じられて、スローと言いながらも結構速やかな導入で、なかなかいいですよね。

昔、カッパーケトルにエトレンを入れて使用していましたけど、使わなくなって、消えていくのを淋しく思いました。

Posted by: 森 広 | August 11, 2007 at 12:16 PM

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