未戴口罩导致产妇分娩后脑膜炎死亡—美国的一起麻醉相关医疗事故（有视频）

xiaoxiaoma

　　美国Ohio（俄亥俄州）的Mary Rutan Hospital医院近期发生里一起离奇的医疗事故，看看大家能够从中吸取些什么经验么？看个这个事故报道，你肯定再不会认为美国是天堂了，至少是麻醉医学。
　　3月21日，Mary Rutan Hospital医院的两名孕妇准备分娩，在之前，她们分别被送到一个专门的房间里接受床旁腰麻（bedside intrathecal injection），第二天，也就是3月22日，这两个孕妇都出现了症状，并且进行性加重，随后被送入ICU，再被送到哥伦比亚Riverside Methodist Hospital 医院，第二天被检查出患了脑膜炎（meningitis），其中一位孕妇于当晚死亡。
　　Mary Rutan Hospital迅速把事故汇报给了美国疾病控制中心（CDC），CDC抽取了两个孕妇脑脊液、血液，分娩时的医疗器械和医护人员（包括麻醉医师）的口腔标本进行培养，结果发现导致两个孕妇发生脑膜炎的病菌是Streptococcus salivarius（唾液链球菌），这是一种寄生于人类口腔中的正常细菌，不幸的是在所有的医疗物品中都没有发现这种细菌，但是在同时为这两个孕妇做床旁腰麻的麻醉科医生口腔内发现了这种导致孕妇脑膜炎发作的细菌。CDC的检查是分别在美国三所著名的医院内独立完成的，所以病因已经非常清楚，也就是麻醉医师把自己口腔里的唾液链球菌传播到孕妇的蛛网膜下腔里了，并且导致她们出现分娩后急性脑膜炎的出现。目前这名麻醉医师已经停止了工作，Mary Rutan Hospital医院麻醉科的床边腰麻工作也暂时被停止。
麻醉医师为什么会把自己口腔里的细菌带到患者体内的呢？
　　这是因为美国麻醉医师的传统历史和现状，也就是在美国很多州，麻醉医师在实施床边腰麻的时候，都是不戴口罩的，可能是当时麻醉医师在实施腰麻的时候有咳嗽或者是喷嚏的发作，导致了这两个孕妇的不幸。
　　这件事情发生后Mary Rutan Hospital医院已经要求麻醉医生在操作过程中需要戴好口罩，但是这个传统在美国其他地方还是没有改变，从历史到现在，这种被美国麻醉医师习惯行为可能还需要通过制定政策来强制实施。不论如何，由于麻醉医师当时没有佩戴口罩是符合历史和现实常规的，至于如何处理这个没有佩戴口罩的不幸的麻醉医师，Mary Rutan Hospital还需要成立一个专家委员会来继续调查。
　　相关视频报道：http://www.whiotv.com/news/19792580/detail.html

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Cause Determined In Meningitis Cases
Posted: 4:14 pm EDT June 18, 2009Updated: 5:49 pm EDT June 18, 2009
BELLEFONTAINE, Ohio -- On the evening of Thursday, May 21, two pregnant patients delivered healthy babies at Mary Rutan Hospital. Prior to their deliveries, each woman, in a separate room, received a bedside intrathecal injection, a spinal anesthesia given to women in active labor
The anesthesiologist conducting the procedure did not wear a mask as it has historically been normal for anesthesiologists at many hospitals throughout the country not to wear masks during bedside spinal anesthesia procedures.
On Friday, May 22, the patients began to show some signs of illness that may be typical of the spinal anesthesia. When it became apparent that their conditions were worsening, the hospital acted quickly, initiating therapy and transferring both women to its intensive care unit and then to Riverside Methodist Hospital in Columbus. On the following day, it was confirmed that the patients had developed bacterial meningitis. Sadly, one of the patients passed away later that night.
Mary Rutan Hospital began an internal investigation immediately after determining that the two patients had contracted bacterial meningitis, and contacted the Centers for Disease Control and Prevention for guidance in its investigation. Mary Rutan Hospital has been working closely with the CDC, the Ohio Department of Health and the Logan County Health District to determine the cause
The CDC directed the hospital to provide it with the blood cultures from each of the two patients, the medication that was used in the procedures, and several unopened medications from the same lot numbers. In addition, the CDC directed the hospital to provide five different respiratory samples from the anesthesiologist only, as he was the only individual common to both women during the bedside anesthesia procedures.
Findings
Mary Rutan Hospital and the Ohio Department of Health have received information from the CDC relating to its investigation of the two bacterial meningitis cases. The CDC reports its tests reveal that the bacteria involved in both cases was Streptococcus salivarius, a bacteria commonly found in the mouths of the general population.
This confirms tests completed independently by Mary Rutan Hospital, the Mayo Clinic and Riverside Methodist Hospital. The CDC was then able to confirm, through highly specialized DNA testing processes, that the bacteria found in each patient was identical.
The CDC also reported that no Streptococcus salivarius bacteria was found in the medications, ruling that out as a source of the infection. The CDC has determined that two of the respiratory samples taken from the anesthesiologist show bacteria from the same biological group found in each of the two patients.
Conclusion
Although more test results may be available in the future, based on current discussions with the ODH, these findings indicate that it is likely that the anesthesiologist was the source of the bacteria, as he was the only individual common to both women during the bedside anesthesia procedures.
In addition, it is probable that the transmission of the bacteria occurred in the course of normal respiratory activity such as breathing and speaking, as the investigation has determined that nothing unusual (coughing, sneezing, etc.) occurred during the administration of the spinal anesthesia.
What is Mary Rutan Hospital doing to uphold safety in the birth center and throughout the hospital?
Patient care and safety is our top priority. Even though our infection rate is well below the national threshold, we are aggressively reviewing all of our infection control procedures and practices throughout the hospital, and have added additional layers of protection for our patients
In regards to the birth center, it is now mandatory for all persons within two arms lengths of a patient receiving a bedside anesthesia procedure to wear a mask. In addition, Mary Rutan Hospital has suspended intrathecal injections indefinitely until further review. The hospital is safe and we will continue to have a safe environment for all of our patients and our community
Should the anesthesiologist have worn a mask during the procedure?
It has historically been normal for many physicians throughout the country not to wear masks during spinal procedures, which are done bedside and not in the operating room. Many hospitals do not have specific standards in place for the requirement of masks during these procedures and there is not a clear nationwide “standard of care” in this area.
We have issued a policy to the medical staff regarding the use of masks and all of our physicians and anyone within two arms lengths of a patient are now wearing masks at bedside spinal procedures
Will the anesthesiologist continue to practice at Mary Rutan Hospital? The anesthesiologist has voluntarily stepped aside during this investigation. The Medical Staff and Board, with input from outside sources, must evaluate the current belief that the anesthesiologist was working within the standard of care for bedside spinal procedures. He will not provide services until this analysis has been completed.
What is Mary Rutan Hospital doing to increase awareness within the medical community?
While this type of bacteria is commonly found in the mouths of the general population, it is extremely rare to contract bacterial meningitis through spinal anesthesia. Because of the rare occurrence of this type of meningitis, a standard has not been established by the medical profession and practices vary widely.
Mary Rutan Hospital has been in contact with several hospitals regarding the lack of clear standards in this area, and will be participating in a task force to establish standards for the administration of bedside spinal anesthesia, which hopefully will be used throughout the region

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Streptococcus salivarius
Streptococcus salivarius is a species of spherical, Gram-positive bacteria which colonize the mouth and upper respiratory tract of humans a few hours after birth, making further exposure to the bacteria harmless. The bacteria is considered an opportunistic pathogen, rarely finding its way into the bloodstream, where it has been implicated in septicemia cases in people with neutropenia.
S. salivarius has distinct characteristics when exposed to different environmental nutrients. For example, in the laboratory, if a SYTA plate is used, then S. salivarius is able to use the sucrose in the SYTA plate to produce a capsule around itself. However, if grown on GYC plate, with no sucrose, instead only glucose, then S. salivarius is not able to make a capsule from glucose.
More importantly, in the laboratory, S. salivarius can show a distinct clearing on GYC plates. This is because S. salivarius can ferment the glucose yielding lactic acid. Next, the lactic acid actually reacts with the calcium carbonate in the GYC plate, resulting in zones of clearings on the plate. [1]
Agglutination of Streptococcus salivarius is often used in the diagnosis of atypical pneumonia caused by Haemophilus influenzae

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lzdb00

大千世界
无奇不有
喝开水都会呛死人
……口罩还是要戴的

李波

在美国还会出现这种情况？还是规范操作好

woodbine8

应该要注重无菌原则的

ydhc

难以想象在美国实施腰麻竟不用带口罩。

suannaiyu

惊！确实难以想象

小小人

不知道他们怎样看待手术室空气无菌，和空气消毒。

一农戏猪

汗啊`````````````````

langren

腰麻的时候
无菌观念还是强的好

genine

细节决定成败，无菌操作要严格遵守

胜飞

难以置信，无菌观念何在？

rxl

美国麻醉不是在手术室打吗？在手术室可以不带口罩？

我素我行

太恐怖了吧，一个不小心就万劫不复啊。