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 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。

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%) 。

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

Our experience

皮膚完整性受損 燙傷 ( 化學性灼傷 ) 電燒 雷射 手術壓瘡 Other

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

Element of Fires Heat or an ignition source Fuel An oxidizier

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 cable Resting Buried Yellow (2 min) Yellow (2 min) Hole (15 s) Hole (15 s) Electrosurgical unit 1 W W W - Skin burn American Journal of Otolaryngology 2008, 29(3):

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):

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):

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):

Fire safety in the operating room Current Opinion in Anaesthesiology 2008, 21:

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

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

手術壓瘡

Journal of Clinical Nursing 2006; 15: Incidence of pressure ulcers due to surgery (I)

Journal of Clinical Nursing 2006; 15: Incidence of pressure ulcers due to surgery (I)

Journal of Clinical Nursing 2002; 11: 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:

Intraoperative Pressure Sore Prevention: An Analysis of Bedding Materials Research in Nursing & Health 1994, 17,

Surgical Positioning

Fig % 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.

Ann Surg May; 243(5): 628–635

World J Surg (2009) 33:

Chest (2010) 137(2): Preoperative Briefing in the Operating Room

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

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