院内発生の妊婦心肺停止症例に対応するための体制整備(System development and simulation training for management of in–hospital maternal cardiac arrest)

要旨 【目的】妊婦が心肺停止に至ったときに，母体救命のため 死戦期帝王切開PMCD（perimortem cesarean delivery）を行うことが考慮される。当院は院外症例の受け入れ体制は整っていたが，院内症例の体制整備はされておらず，心停止から5分以内にPMCDを実施することが可能な体制をつくることとした。【対象】産科病棟で発生したと想定し，問題点の抽出をした。実施場所に関して，手術室で行うには手術申込みや入室認証が必要であったため，少しでも時間を短縮させるため分娩室とした。実施までのフローシート，連絡経路も事前に作成した。PMCDの適応や効果に関して教育を行い，PMCD器材と，新生児蘇生器材とに分けて準備し，シミュレーションを行った。【結果】第1回目のシミュレーションは救急科医の到着を待って，分娩室に移動しPMCDを実施したが，実施までに14分かかった。2回目は，心肺停止を覚知後すぐに患者を分娩室に移動させPMCDを実施し，4分で行うことができた。除細動の適応波形の場合にはどうするべきか，などの新たな問題点が抽出された。【結語】院内発生の妊婦心肺停止症例では，心停止から医療従事者接触までの時間が短く救命できる可能性が高い反面，短時間でPMCD実施の決断や実行が求められるため，シミュレーショントレーニングは重要と考えられる。 ABSTRACT Aims: Perimortem cesarean delivery (PMCD) is performed as a maternal lifesaving measure in cases of cardiopulmonary arrest during pregnancy. While our hospital has a system for receiving pregnant patients with cardiopulmonary arrest from other facilities, it lacks a system for responding to cardiopulmonary arrest in pregnant inpatients. Thus, a system for performing PMCD within five minutes of maternal cardiopulmonary arrest is now being planned. Methods: To address our training needs and identify current problems, we performed PMCD simulations in the obstetrics department instead of the operation room to circumvent time–consuming application procedures for room use. The main concerns were to determine the place of implementation and establish a pathway and flowchart to deal with possible emergencies. The participants familiarized themselves with the PMCD indications and procedure beforehand, and equipment needed for PMCD and neonatal cardiopulmonary resuscitation was assembled. Results: The first simulation required 14 minutes to begin due to moving the patient to the delivery room after the emergency physician’s arrival before performing PMCD. In the second trial, upon cardiopulmonary arrest onset, the patient was moved to the delivery room and PMCD was performed in four minutes. Problems potentially emerging during treatment, such as defibrillation waveform, were anticipated, and countermeasures were considered. Conclusion: Although the time from cardiac arrest in pregnant inpatients to intervention by healthcare workers is brief, and the probability of saving the patient’s life is high, repeated simulations are crucial to ensure the performance of PMCD under severe time constraints.