After a while, Director Liu came back from the pre-operative instructions.
He asked Director Miao for instructions, then washed his hands again and began to change the surgical method to complete the unfinished surgery again.
The surgery was very simple. It was just a destructive kidney cancer resection. Director Liu's technique was delicate. Even with the old director standing behind him, he still didn't show any nervousness. It was completed in less than an hour. The whole process of surgery.
While the skin was being sutured, the singing of good luck echoed in the operating room. Director Liu seemed to feel a little more relaxed. He asked: "Director, how do you think you got here?"
"There was no damage to the great blood vessels during the operation. The renal vein, lumbar vein, right phrenic vein, and inferior vena cava were all intact. Regardless of the damage, gas was quickly absorbed into the circulation. I think it was because carbon dioxide passed through the kidneys when rapid inflation was established to establish pneumoperitoneum. The malformed blood vessels of the tumor then enter the circulation.”
"The patient's blood pressure didn't drop quickly. I looked at the anesthesia record sheet and it showed that you were rescued for about 11 minutes." Director Miao put his hands behind his back and said clearly, "Do you remember that I scolded you once?"
"Remember." Director Liu did not avoid the question and said calmly, "When I performed an operation, the Hem-o-lock was placed at the bifurcation of the renal vein and failed to completely clamp the renal vein."
"Well, if that's the case, a large amount of carbon dioxide will enter the blood circulation with the pressure difference." Director Miao continued, "I estimate that the 50% mortality rate comes from this. The carbon dioxide from pneumoperitoneum entering the large blood vessels will cause Death that cannot be saved. But in a situation like this, where a small amount of gas enters a malformed blood vessel, there is still hope."
"Carbon dioxide enters the right atrium, right ventricle, and pulmonary artery along the pressure gradient through the open veins through the inferior vena cava, forming an air embolus clamp at the pulmonary artery, causing mechanical obstruction, preventing blood flow from entering the left ventricle, leading to circulatory failure in the patient?" "
"The amount of air entering is not much, which is also due to the meticulousness of your surgery. There are some complications that cannot be prevented, just remember how to rescue them. You need to be more careful in your pre-operative explanations. It's okay to say a few more words."
Director Miao was still nagging like a big director.
"Director, will the ventilator be used for a few days after the operation?" Director Liu asked.
"It will take 1-2 days." Director Miao said with confidence: "Recheck the bedside echocardiography when we go back and find someone with good skills to do it. If there is no residual gas in the heart, it can be removed in 2 days at most. Tube."
After speaking, Director Miao paused and then said: "Remember to tell the nurses in the ICU to be alert at night and suction sputum once an hour. If there is a lot of sputum left in the lungs due to pulmonary edema, I am afraid there will be atelectasis. "
"Director, I will stay in the ICU to see patients in the evening." Director Liu said naturally, "Don't worry."
"Yeah." Director Miao nodded, everything seemed to be natural.
"Director, thanks to your experience, I was confused at the time." Director Liu said calmly. He did not hide his lack of experience and spoke frankly.
"It's good to have experienced it once." Director Miao said, "When establishing pneumoperitoneum, there is inevitably the risk of air embolism? The incidence of gas embolism is very low, about 0.002%~0.02%, but once it occurs, the fatality rate can be as high as 50%?”
"Over the years, there have been three incidents in our department, including your case."
Director Liu felt a little emotional, 912 Urology Department is very powerful, otherwise it would be impossible for all the leading professors to feel that they can compete for the position of director.
Indeed, no matter from the perspective of surgical level or other aspects, everyone has this qualification. But that's a normal situation. Once something like this happens, Director Liu deeply feels that the saying that every elder in a family is like a treasure is correct.
Thousands of laparoscopic surgeries are performed every year, but only three cases have occurred over the years. According to Director Miao's meaning and Director Liu's understanding, two cases occurred when he was not here.
"So when you perform laparoscopic surgery, I would like to remind you to pay attention to the patient's condition. Rapid diagnosis and timely and effective treatment are necessary conditions for success, because air embolism leaves too little time for rescue?"
“It is critical that the goals of management of air embolism are to prevent further entry of gas into the circulation and maintain hemodynamic stability.”
"Once an abnormality occurs, the inflation should be stopped immediately to reduce the pneumoperitoneum pressure. Place the patient in a left lateral position with the head down and the feet up, so that the air bubbles entering the right ventricle gather at the apex of the heart to prevent them from entering the pulmonary artery."
"In the event of cardiac arrest, cardiopulmonary resuscitation and electrical defibrillation must be performed promptly to maintain circulation while also allowing air to flow out of the pulmonary artery."
"He Junjin did a good job and used a central venous catheter to suck out the gas as quickly as possible."
"I looked at the anesthesia record sheet. He Junjin increased the amount of fluid input after he arrived. I ask you why?" Director Miao's voice suddenly became cold, like a stern teacher questioning a naughty student.
"Is it because infusing a large amount of fluid increases the venous pressure, thereby preventing carbon dioxide gas from further entering the venous system?" Director Liu also had a solid basic knowledge and answered directly without thinking.
"Well, that's right."
When Director Miao saw that the last stitch was done, he turned around to leave with his hands behind his back.
"Director, wait a moment!" Director Liu quickened his hand speed, inserted the last needle, patted the patient's leg with the needle and the tweezers in his hand, and turned around to catch up with Director Miao.
"Huh?" Director Miao hummed softly.
"Director, I went to see you a few days ago. Please think about what I told you." Director Liu said seriously, "When you return to the job, there won't be any heavy work. Just lead us to check the housing one day a week. The key is …The key is that without you, I don’t know what to do.”
"Promise." Director Miao snorted coldly, "Sooner or later, you have to leave. Don't be too scared to take action just because of one or two unexpected incidents. Go back and read the book carefully and ask He Junjin. I remember doing gastrointestinal surgery three years ago Gas embolism occurred in a case of laparoscopic surgery, and that surgery was anesthetized by He Junjin."
When Lao He saw that Boss Zheng was about to leave, he unplugged the USB flash drive and was busy talking. When he heard Director Miao mentioning himself, he smiled.
Zheng Ren glanced at Lao He, it was really not easy for this guy to live so long.
"director… "
"You guys work hard, I will retire when I retire, and I will not be re-employed." Director Miao said firmly.
After saying that, he slowly left the operating room with his hands behind his back.
Zheng Ren glanced at Director Liu, and then followed Director Miao's footsteps. He knew the meaning of Director Miao's last sentence, and Director Miao was still too kind-hearted.
…
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Note: The case is quoted from "Chinese Journal of Emergency Medicine", Volume 23, Issue 9, September 2014.