The blood pressure fluctuated abnormally when the sternum was closed, and rapid ventricular arrhythmias occurred repeatedly, with a heart rate of 170-180 beats/min.
This is the value that occurs when the sternum is not completely closed. If the sternum is forcibly closed, the patient may not be able to get off the operating table.
"Boss Zheng, did you make a judgment before the operation?" Zhao Yunlong asked softly, knowing that Zheng Ren's choice was right.
"Echocardiography showed that the patient's heart was enlarged, but this was not the main reason. The basis for delaying chest closure was the previous treatment." Zheng Ren explained as he began to prepare for delayed chest closure.
"Boss Zheng, are you ready to do ultrasound now?" Lao He asked as he pushed the machine in.
"good."
Lao He didn't mind that he was taken from home to the operating room by Boss Zheng early in the morning just for a transesophageal ultrasound examination. He did whatever he was told, and Lao He didn't complain.
To successfully complete a transesophageal echocardiography examination under general anesthesia and with ventilator intubation is also a skill that not everyone can master.
"Wait a moment." Lao He rushed to the computer, plugged in the USB flash drive, and the song of good luck came out.
"Now I won't know how to perform surgery if I don't listen to this song." Lao He explained with a smile.
Although the operation has reached the final step, Lao He still insists on playing Good Luck.
Stepping on the rhythm of good luck, Lao He felt that his body was a little lighter, as if he had become an immortal.
The difficult operation became smooth in his hands. After a few minutes, Lao He said softly: "Boss Zheng, SAM symptoms are obvious."
The SAM sign is a sign in M-mode ultrasound diagnosis.
It mainly refers to the forward movement of the anterior mitral valve leaflet during systole. In obstructive hypertrophic cardiomyopathy, the CD segment is not a slow rising platform during systole, but an abnormal waveform appears upward, that is, toward the interventricular septum. This kind of The phenomenon is called systolic forward motion, or SAM sign for short.
"Give a small amount of beta-blocker and quickly replenish plasma." Zheng Ren gave the doctor's order and then started the procedure of delayed chest closure.
"Adjust the dose of levosimendan to 0.5μg?kg/1?min." Zheng Ren said, and Xie Yiren had already handed over the child-type sternum expander.
Zheng Ren replaced the adult sternal expander with a smaller one for children, and then simultaneously observed blood pressure, central venous pressure, heart rate and rhythm, cardiac contraction strength, and pulse oxygen saturation.
His hands slowly changed the distance between the sternum, looking for the most favorable position for stable blood pressure, no slowing down or significant increase in heart rate, no ventricular arrhythmia, decrease in CVP, strong myocardial contraction, no heart expansion, and increase in oxygen saturation. s position.
"Boss, you are too precise." Su Yundao said, "You don't have to do surgery in millimeters. Cardiothoracic surgery requires roughness!"
Zheng Ren smiled. The roughness Su Yun said was probably different from what others understood.
"A more accurate position will help you recover faster after surgery. If there are no accidents, the edema will gradually subside in 2-3 days, and Lao Zhao can close his chest in about 5 days." Zheng Rendao.
Zhao Yunlong lowered his head and stared intently at the way Boss Zheng moved the child-type sternum expander.
Every angle, every distance, and every movement has its explanation, but Zhao Yunlong knows that this is an instinct formed by his rich surgical experience, and he is afraid that even Boss Zheng himself cannot explain it clearly.
It's better to look carefully and think about it when you go back. If you have another chance, you can try it, Zhao Yunlong thought to himself.
Pericardial and mediastinal drains were placed, and the incision and spreader were sealed with sterile transparent surgical film.
"Send to the ICU." Zheng Ren turned around and stepped down, then turned around and asked, "Old Zhao, do you often perform delayed chest closure surgery?"
"I do it occasionally, rarely. But the doctors and nurses in the ICU are experienced, so Boss Zheng can rest assured." Zhao Yunlong knew what Zheng Ren meant by asking, and he immediately answered.
"Okay, that's it."
Even if the chest closure was delayed, the completion rate of the operation reached 101%, and Zheng Ren said he was very satisfied with it.
The patient should be fine.
"Boss Zheng, thank you." Director Lang bowed deeply and said softly.
"You're welcome." Zheng Ren said, "IABP shouldn't be used. Now that I have experience, I won't make this mistake next time."
"Next time..." Director Lang murmured.
"Huh?" Zheng Ren heard something in Director Lang's words and gave him a confused look.
But Director Lang did not continue, but asked, "Boss Zheng, isn't IABP very symptomatic? I use IABP to solve similar situations every time."
"Don't be too dogmatic." Zheng Rendao, "After clinically judging that there are many early symptoms of cardiac tamponade, emergency measures such as pericardiocentesis and drainage should be carried out immediately to alleviate it. Your handling at this point is no problem and you have done a great job."
Seeing that Director Lang was not in the right mood, Zheng Ren did not overly stimulate him, but gave him a rare compliment.
"Our intraoperative exploration did not see the common situation of cardiac tamponade caused by blood accumulation caused by coronary artery perforation. Ordinarily, even if there is pericardiocentesis and drainage, it will be more or less. This situation is too rare."
"Boss Zheng, is it caused by the rupture of the small branch?" Director Zhang Lin asked.
"It should be, or it can be considered that the small branch has ruptured. As the pressure in the pericardial cavity increases, the damaged point has healed itself." Zheng Rendao, "It is indeed a bit unlucky. In fact, this patient might be better off if he did nothing. Some."
“…”
Director Lang was speechless. Boss Zheng's words made him feel ridiculous.
The absurd black comedy style and nonsensical words are not suitable for the operating room, and Director Lang said he could not accept it.
"But I think it's more likely because the patient is older, and the main cause of his cardiac tamponade is the highly congestive swelling of the myocardium, rather than intrapericardial hemorrhage." Zheng Ren explained, "In my analysis, it should be before you Cardiac edema caused by extensive myocardial infarction during PCI."
"Myocardial edema is severe in the early stage of myocardial infarction, and its left coronary advantage leads to a larger extent of myocardial infarction, which leads to this special change."
"In other words, it is not cardiac tamponade caused by coronary artery rupture and bleeding, but cardiac tamponade caused by acute necrosis and exudation."
"In this rare case, everything you do after that, Director Lang, is wrong." Zheng Ren finally told the truth.
"Although the IABP measures adopted reduced the afterload of the patient's ventricle, it failed to relieve the pressure of the pericardium on itself in time, so the symptoms became more and more severe."
“…”
Director Lang listened to Boss Zheng's explanation of the patient's condition, and his judgment of the patient's condition was not the small coronary artery branch rupture and bleeding that Director Zhang Lin had said before, but another complication.
For a moment, Director Lang was in a daze.