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October 31, 2009

点滴失敗で腕が腫れたら業務上過失傷害?


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カテーテル誤挿入で死亡 大阪の国立病院、人工心肺取り付け時

産経新聞 10月16日14時32分
医療事故のあった大阪医療センター=大阪市中央区

 大阪市中央区の国立病院機構大阪医療センターで、入院中の男性患者(69)が人工心肺装置を取り付ける際、カテーテルの誤挿入で血管を損傷、その直後に容体が急変し死亡していたことが16日、病院関係者への取材で分かった。病院側は医療事故として大阪府警に通報。司法解剖の結果、死因は出血性ショックと判明した。府警は業務上過失致死の疑いもあるとみて関係者から事情を聴いている。

 病院側の説明などによると、男性は10月5日、大阪市東成区大今里南の洗剤工場で作業中に起きた火災でやけどや一酸化炭素中毒などの症状で救急搬送され入院。翌日から肺の機能が低下して意識不明となり、11日午後から20代の男性医師ら2人が人工心肺装置を取り付ける緊急手術を実施した。

 人工心肺装置は通常、太ももの静脈から直径数ミリの細長い管(カテーテル)を心臓まで通し、酸素不足となった血液を抜いて人工肺で血液に酸素を注入。ポンプで循環させ、一時的な血流維持などに使われるが、病院関係者などによると、医師が男性の左太ももからカテーテルを挿入した際、誤って静脈を損傷した可能性が高いという。

 男性はこの直後に容体が急変し、約1時間後に死亡が確認された。病院は「医療事故があった可能性がある」として府警に通報。遺族にも経緯を説明し、謝罪したという。

 病院側は当初、男性の症状が重篤で、死因が急性肺障害などに起因する呼吸不全の可能性が高いと説明。ところが、司法解剖の結果、直接死因が血管損傷による出血性ショックだったことが判明し、府警はカテーテルの誤挿入が死亡につながった疑いもあるとみている。

 同センター管理課の斉藤三則課長は「懸命な延命治療を行った中で、不幸な結果となり残念だ。何が原因だったのか、危険は予見できたのかなど今回の問題を院内でもきちんと検証し、再発防止を図りたい」と話している。

 同センターは、国立大阪病院として発足とし、平成16年4月に独立行政法人に移管され、現在の名称になった。

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PCPSのためのカテーテル挿入と内頸静脈からのCVカテーテル挿入とは全く異なる。しかし,生きるか死ぬかの段階でのカテーテル挿入失敗で業務上過失致死の疑いなら,healthy patientの予定手術でカテーテル挿入に失敗して結果が悪ければどんな仕打ちを受けるやら。


私の独断による,麻酔科医のCVカテーテル挿入ポリシーにおけるステージ分類

I期(修行期):外科医に頼まれるまでもなく,CVカテーテルを積極的に入れたがる。 
II期(円熟期:I期よりもカテーテル挿入の適用範囲が狭くなる。
III期(不動期):重症and/or大手術でもCVカテーテルは入れない,もしくは入れてもCVPは測定しない。
IV期(覚醒期):外科医にカテーテル挿入を依頼された場合,もしくは自分が麻酔中にカテコラミンルートを必要とする場合のみ挿入。
V期(反発期):自分が必要とするときのみ入れる。外科医が依頼してきても「先生らが必要とするなら先生らが術前に病棟で入れておいて下さい。こちらはCVカテーテルを必要としないのにリスクだけ背負わされるのはゴメンです」
VI期(保身期):麻酔管理上CVカテーテルがあればありがたいと思っても自分では入れず,外科医が術前に入れるのを期待する。V期のことがあるので「麻酔科が必要とするので病棟で入れといて」とは言えない。ここで我慢すれば外科医が術前にCVカテーテルを入れるのがルーチン化する。


私は現在,もちろんVI期。

来週の症例もCVカテーテルが入っていればやりやすいのだけど...ここは我慢。

そのうち「CVカテーテルを入れていたなら助かったはず」とかいうおバカ判決が出たならまた考え直すとしよう。

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Comments

熱傷で肺障害でPCPSとなれば、限りなく負け戦。敗戦処理投手が、ホームランを打たれて試合を壊したと言われたようなものです。
PCPSで下肢がネクッたりしても、注意義務がとか言う話になるでしょう。起死回生を狙った大ばくちはしないほうがお互いのためなのではないでしょうか?

Posted by: タカ派の麻酔科医 | November 02, 2009 at 11:00 AM

医師が放った起死回生の大ばくちが見事成功し,奇跡の生還を遂げた患者が数多くいたはずですが,そういうことがなくなるわけですね。世間が望んだことですから仕方ないですね。

Posted by: 管理人 | November 03, 2009 at 12:10 AM

異常死と届けたのは何故なんでしょうね。そこが気になります。
リスクの高い方に、リスクの高い治療をやっているのですから、何かしら起こっても不思議は無いと思うのですが・・・。
以前「注射を失敗ばかりされるし、漏れやすいし。あんたら患者の気持ちなってよ」と家族の方に怒鳴り散らされた事がありました。抗がん剤の投与と低栄養(浮腫)でボロボロかつ分かりにくい血管なんで漏れるやすいし、刺しにくいのですよと説明しても全く納得してくれなかった事を思い出しました。

Posted by: キケロ | November 05, 2009 at 10:31 AM

死因が出血性ショックと判明

解剖したら死因が出血性ショックて診断できるんですか?
そんな巨大な血腫でも作っていたのですか

Posted by: 私立病院外科医 | November 05, 2009 at 12:44 PM

循環動態から>熱傷ショック期とどう鑑別診断するんだろうか
血性腹水>熱傷のDICだと、きっと腹水もゼロじゃないでしょう
静脈損傷>そもそもPCPSは静脈にかなり大きな穴をあけないとカテーテルはいりません。
急死>PCPSつけようというわけだから、何もしなくても、死亡する可能性大だったと思いますが。

熱傷で皮膚はかちかち、輸液でぱんぱかりんになって動脈拍動も感じられなくなっている患者さんに、正確にPCPSをいれるのは、至難の技。
そして、PCPSのために抗凝固剤使用したら、もっと出血傾向になりそう。

経験のない人は、困難さを想像することもできないと思いますよ。

Posted by: 麻酔科医 | November 05, 2009 at 08:07 PM

救急とは一生無縁であることを願うばかりです。
医師としても,患者としても。

Posted by: 管理人 | November 06, 2009 at 09:26 AM

熱傷は特に悲惨です。

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