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醫療安全暨品質討論會 手術過程中病人皮膚完整性 台北醫學大學附設醫院 一般及消化外科 實證醫學中心 譚家偉 主任

醫療安全暨品質討論會 手術過程中病人皮膚完整性 台北醫學大學附設醫院 一般及消化外科 實證醫學中心 譚家偉 主任. Case 1. 個案進行臉部及腹部電波拉皮，過程採靜脈麻醉 (IVG) ，清醒後發現腹部燙傷產生水泡 。. Case 2. 病人因 進行 L5/S1 discectomy ， L3/4 laminectomy and Internal fixation 術式需要手術姿勢為俯臥。病人臉部、胸腹部、雙手、雙膝及小腿下皆有保護措施，但術後仍發現病人產生壓瘡：前胸兩邊肋骨處約 2x5cm 左右的水泡、手肘內側 ( 約 3x4cm) 及臉部破皮。. Case 3.

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醫療安全暨品質討論會 手術過程中病人皮膚完整性 台北醫學大學附設醫院 一般及消化外科 實證醫學中心 譚家偉 主任

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  1. 醫療安全暨品質討論會 手術過程中病人皮膚完整性 台北醫學大學附設醫院 一般及消化外科 實證醫學中心 譚家偉 主任

  2. Case 1 • 個案進行臉部及腹部電波拉皮，過程採靜脈麻醉(IVG)，清醒後發現腹部燙傷產生水泡。

  3. Case 2 • 病人因進行 L5/S1 discectomy，L3/4laminectomy and Internal fixation術式需要手術姿勢為俯臥。病人臉部、胸腹部、雙手、雙膝及小腿下皆有保護措施，但術後仍發現病人產生壓瘡：前胸兩邊肋骨處約2x5cm左右的水泡、手肘內側(約3x4cm)及臉部破皮。

  4. Case 3 • 病人因tonsillar tumor入手術室行Bilateral tonsillectomy ，術中刷手護理人員未與巡迴人員相互確認，將稀釋後的雙氧水當成局部麻醉藥給醫生使用，醫生使用後發現有組織燒灼傷現象，約2x2x0.1公分化學灼傷，向刷手與巡迴人員確認，巡迴人員表示無給予刷手人員局部麻醉藥物，才發現此異常。

  5. 台灣病人安全通報系統(TPR) 自2005年~2010年8月間通報事件中，與皮膚完整性受損相關事件共985件，其中燙傷事件共287件(約佔29%)。

  6. Tri-Service General Hospital Injury 1998 Jun;29(5):345-7 1 December 1996 - 28 February 1997 19 cases of skin injury from a total of 3657 operations (0.52%)

  7. Our experience

  8. 皮膚完整性受損 • 燙傷(化學性灼傷) • 電燒 • 雷射 • 手術壓瘡 • Other

  9. Surgical Fires • 100 fires each year in USA • 10-20 are serious Med Safety Alert. 2001;6(11):1

  10. Element of Fires • Heat or an ignition source • Fuel • An oxidizier

  11. The response of green towel and polyprolene drape to the fiberoptic cable and electrosurgical unit Green towel (cotton) Polypropylene drape No oxygen Oxygen No oxygen Oxygen • Fiberoptic cableResting - - - -Buried Yellow (2 min) Yellow (2 min) Hole (15 s) Hole (15 s) • Electrosurgical unit1 W - -10 W - -30 W - Skin burn American Journal of Otolaryngology 2008, 29(3):171-176

  12. Fire incidents involving fiberoptic light cables and electrosurgical devices reported to the FDA between 1998 and 2006 Fiberoptic Electrosurgical cable unit • Flash fire(head and neck procedure, O2 in use) 0 23  • Flash fire with drape fire 0 12  • Primary drape fire 2 18  • Fire under drape (accumulation of flammable gases) 0 7  • Primary device fire (spontaneous ignition of device) 0 1  • Preparatory solution related fire (alcohol-based preparatory solution) 0 4  • Staff gown fire 0 1  • Tracheostomy procedure fire (drapes involved) 0 6  • Total reported fire incidents 2 71 American Journal of Otolaryngology 2008, 29(3):171-176

  13. Burn incidents involving fiberoptic light cables and electrosurgical devices reported to the FDA between 1998 and 2006 Fiberoptic Electrosurgical cable unit • Drape burn without patient injury 4 –  • Drape burn with patient injury 3 –  • Direct patient burn 12 –  • Direct staff burn 3 –  • Equipment (camera damaged by fiberoptic cable) 1 –  • Total reported burn incidents 23 – American Journal of Otolaryngology 2008, 29(3):171-176

  14. Fire/burn risk with electrosurgical devices and endoscopy fiberoptic cables • Fiberoptic cables and electrosurgical generators represent a serious burn risk for surgical patients, with operating room drapes and towels affording only limited protection. Large hole in a polypropylene drape after exposure to a fiberoptic light cable connected to a 300-W xenon light source American Journal of Otolaryngology 2008, 29(3):171-176

  15. Fire safety in the operating room Current Opinion in Anaesthesiology 2008, 21:790-795

  16. Operation Room Fires: Optimizing Safety Plast. Reconstr. Surg. 120: 1701, 2007

  17. Surgical fires, a clear and present danger The surgeon 2010(8);87-92

  18. 手術壓瘡

  19. Incidence of pressure ulcers due to surgery (I) Journal of Clinical Nursing 2006; 15: 413-421

  20. Incidence of pressure ulcers due to surgery (I) Journal of Clinical Nursing 2006; 15: 413-421

  21. Incidence of pressure ulcers due to surgery (II) Journal of Clinical Nursing 2002; 11: 479-487

  22. Incidence of pressure ulcers due to surgery (II) • 44 patients (21.2%) developed 70 pressure ulcers in the first 2 post-op day • 52.9% on heels • 15.7% in sacral area • 12% were impaired by the lesions they developed Journal of Clinical Nursing 2002; 11: 479-487

  23. Intraoperative Pressure Sore Prevention: An Analysis of Bedding Materials Research in Nursing & Health 1994, 17, 333-339

  24. Surgical Positioning

  25. Fig. 5. 97% of the surgeons see a need for ergonomic improvement within the operating room. This improvement is not only important in a single area, but affects all aspects of the OR.

  26. Ann Surg. 2006 May; 243(5): 628–635

  27. World J Surg (2009) 33:1181-1187

  28. Preoperative Briefing in the Operating Room Chest (2010) 137(2):443-449

  29. Conclusion • Recognition • Alert • Improve equipment • Education and Training • Patient Safety Protocol • Full implementation

  30. Thanks for your attention

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