Kuroda Masahiko, Kawamoto Masashi, Yuge Osafumi
Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
J Anesth. 2005;19(2):164-6. doi: 10.1007/s00540-004-0298-5.
We have encountered a case of cardiac arrest during anesthesia care in which an application of a new-generation pulse oximetry technology led to a misleading interpretation of the patient's true condition. Just after manipulation of the peritoneum, the heart rhythm suddenly became asystole, while the ECG showed a standstill and an arterial pressure wave was absent. However, the Datex-Ohmeda AS/3 Patient Monitor connected to the Masimo SatShare Waveform Generator feature continued to display a pulse wave with a reading of 99%. Because we assumed the reading to be reliable, we took no immediate action. However, the ECG standstill and flattened arterial wave lasted for about 10 s, with no pulse at the common carotid artery; thus, 0.5 mg atropine and 4 mg ephedrine were given and chest compression performed using ventilation with oxygen. About 20 s later, the heart rhythm reappeared, which was monitored by the ECG and arterial pulse wave. This incident demonstrates the importance of becoming familiar with a new technology; otherwise, we will fall into medical errors.
我们遇到了一例麻醉护理期间心脏骤停的病例，在该病例中，应用新一代脉搏血氧饱和度测定技术导致对患者真实状况的解读出现误导。就在对腹膜进行操作后，心律突然变为心搏停止，心电图显示停搏且无动脉压波。然而，连接到Masimo SatShare波形发生器功能的Datex-Ohmeda AS/3患者监护仪持续显示脉搏波，读数为99%。由于我们认为该读数可靠，所以未立即采取行动。然而，心电图停搏和平坦的动脉波持续了约10秒，颈总动脉处无脉搏；因此，给予了0.5毫克阿托品和4毫克麻黄碱，并使用氧气通气进行胸外按压。约20秒后，心律重新出现，通过心电图和动脉脉搏波进行监测。这一事件证明了熟悉新技术的重要性；否则，我们将陷入医疗差错。
