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March 20, 2008

ぶら下げタイプで禁静注


魚拓

-◆-◇-◆-◇-◆-◇-◆-◇-◆-◇-引用開始-◆-◇-◆-◇-◆-◇-◆-◇-◆-◇-
広島市立安佐市民病院で注射ミス、高1少年が死亡

 広島市立安佐市民病院(日高徹院長)は17日、入院していた山口県平生町の高校1年の少年(16)に、中枢神経抑制剤の筋肉注射を静脈に注射するミスがあり、少年が死亡したと発表した。病院は「ミスと死亡との因果関係は分からない」としているが、病院から届けを受けた安佐北署が司法解剖し、業務上過失致死の疑いで調べる。

 同病院によると、少年は原因不明の脳症で、2月26日に山口県岩国市内の病院から転院。今月16日午前、女性看護師(23)が、けいれん発作を抑えるために筋肉注射するフェノバルビタールを誤って静脈に注射。少年の心拍数は低下し、約5時間後に死亡した。看護師は処方せんをよく確認していなかったという。

 記者会見で日高院長は「あってはならない事故で、深くおわびする。薬剤投与の確認を徹底させる」と謝罪した。
(2008年3月18日 読売新聞)

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私の医療文化圏だけではないと思うが,麻酔科医は看護師に薬剤投与を任せることはない。もちろんペインクリニックやICUなどの例外はあるが,手術麻酔に関しては静注はおろか筋注・皮下注も看護師にさせることはまずない。任せるとしたら坐薬ぐらいだろう。かつては麻酔前投薬の指示を病棟で出していたが今はそれもほとんどなく,せいぜい常用薬を飲ませるかどうかを指示する程度。地域によっては麻酔に使用する薬剤(例えば筋弛緩薬や静脈麻酔薬)を看護師がシリンジに引いて準備してくれるらしいが,私はこれも誰かに任せることはない。

もちろん,私自身が薬剤の誤投与をするかもしれない。リバースを投与しようと手にしたシリンジをよく見るとマスキュラックスだったとか,バッキングしたので慌ててマスキュラックスを投与しようとしたらエホチールだったとか,誤投与のニアミスは今でもある。

しかし,自分で誤投与したならまだ諦めもつく。他人のせいにしたがる卑劣な自分を見なくて済む。

よほどの緊急事態でも起こらない限り麻酔中の薬剤投与は自分でするが,心配なことがひとつだけある。

それは,硬膜外に使用するアナペイン2mg/mL(0.2%)100mLの製剤。
容器には「禁静注」と大きく書かれているが,点滴台にぶら下げるため(?)の穴がついている。

02


私が持続硬膜外のセッティングをするためにアナペイン2mg/mL(0.2%)100mLを箱から取り出し,麻酔器のテーブルに置いてシリンジに引こうとする。そのとき急な用事(病棟での挿管依頼,緊急手術の打診etc)が入り手術室を出る。私がいない間に点滴が終了する。本来ならVeen Fなど同じ輸液製剤をつなげるはずが,看護師が“気を利かせ”,麻酔器の上に置いてあるアナペインを「麻酔科医が次の点滴に用意したもの」として点滴セットに接続する。アナペインを静注するとどうなるか経験がないので知らないが,おそらく数mLの投与で血圧は下がるだろう。私がいない時に血圧が下がったら,外科医がまず指示するのは点滴速度のアップ。
そして私が帰って来る頃には…。

「私がいない時に輸液製剤のボトルがカラになったら,同じものをつなぐこと」と言っておくしかない。

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Comments

麻酔科の実務離れて久しいですけど それはおっかないですね。

唯一の対抗策は "穴"ペインの "穴"は箱から出したらまず切ることかと思います。

Posted by: くらいふたーん | March 20, 2008 at 12:02 PM

くらいふたーん様,こんにちは。

>唯一の対抗策は "穴"ペインの "穴"は箱から出したらまず切ること

ありがとうございます。オヤジギャグ,大好きです。

下品な同僚は“アナルペイン”と呼んでいました。当然私は「何に使うんだよ」と突っ込みました。

Posted by: 管理人 | March 20, 2008 at 04:51 PM

初めましてこんにちは。アナペインの穴は仰るように点滴棒にぶら下げて、無痛分娩などに非ディスポーザブルタイプのPCAポンプに直線接続して使う事を想定していると思っています。シリンジェクターにアナペインがプレフィルドしてある製品があれば、誤投与防止に役立つと思っています(楽ですし)。
大野病院の求刑は禁固一年だそうです。いつから、痴漢強姦強盗殺人と診療中の不可抗力が同レベルになったのか呆れてしまいます。しかし、私はいまだ大学病院におりますし今まではこの手のハイリスク大量出血モノを受けざるを得ませんでしたが、医師をすぐに起訴出来るシステムが今年中には完成するそうですから今後は併せて断る正当性のある理由にしようかと考えています。追記:ptの状態にもよるでしょうが、アナペインはあのバッグの濃度だとかなり静中されても意外にバイタル不変なのかもしれません。点滴静中どころかボーラスでかましてるのを見たことがあります。勿論、眠気の中夜中にたたき起こされた外科系ローテーターの仕業ですが…。直ちにフルモニターされその後1日観察しましたが、そいつ(ローテーター)は悪運が死ぬほど強いのか?、何事も起きませんでした。
こちらのブログは

Posted by: 夢も希望もな医 | March 22, 2008 at 08:02 AM

夢も希望もな医さん,こんにちは。

本当に,0.2%アナペインのプレフィルドがあれば便利ですね。

>点滴静中どころかボーラスでかましてるのを見たことがあります。

硬膜外と間違えて三方活栓からワンショット静注してしまったのでしょうか。「麻酔科医が三方活栓を付けたままにしていたから誤投与した」などと責められることはないと思いますが,病棟では硬麻ラインから三方活栓ははずしておいたほうが無難かもしれませんね。

>医師をすぐに起訴出来るシステムが今年中には完成するそうですから今後は併せて断る正当性のある理由にしようかと考えています。

私も,MAPを4単位以上用意する手術は断りたくなってきました。もちろん一番恐いのは,予期しない出血ですが。

Posted by: 管理人 | March 22, 2008 at 11:47 PM

こんにちは。先生のご指摘は極めて的確で、それを契機にサンカツは付けないことになりました。流石に責められはしませんでしたが…
いつも、こちらのブログを励みにドサクサと働いてます。

Posted by: 夢も希望もな医 | March 23, 2008 at 03:36 PM

夢も希望もな医様,こんにちは。

私は三方活栓が好きですが,最近は三方活栓のついてない静脈ラインも増えてきて少々不便に感じています。

硬麻のワンショット用接続口は特殊形状(四角や三角)の注入口とし,それにしか接続できないプレフィルドシリンジの局麻があればと思っています。薬を薄めて使いたいときは不便ですが。

これからもよろしくお願いします。

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