After a while, Chief Liu came back after finishing the preoperative instructions.
He asked Chief Miao for instructions, then washed his hands again and began to change the surgical method. He once again finished the unfinished surgery.
The surgery was very simple. It was just a destructive nephrectomy. Chief Liu's technique was exquisite. Even with the old chief standing behind him and watching, he still did not show any nervousness. In less than an hour, he completed the entire surgery.
When the skin was sutured, the song of good luck echoed in the operating theater. Chief Liu also seemed to be a little relaxed. He asked, "Chief, how do you think it came about?"
"There was no damage to the major blood vessels during the surgery. Renal vein? Lumbar vein? The right phrenic vein and the inferior vena cava are very good. We don't have to worry about the damage causing the gas to be quickly absorbed into the circulation. I think it should be when the gas was quickly inflated to establish the pneumoperitoneum, the carbon dioxide passed through the malformed blood vessels of the kidney tumor and then entered the circulation. "
"The patient's blood pressure did not drop quickly. I looked at the anesthesia record. You have about 11 minutes of resuscitation," Chief Miao said clearly with his hands behind his back. "Do you still remember that I scolded you once?"
"I remember." Chief Liu did not avoid this question. He said very calmly, "The last time I performed surgery, the Hem-o-lock was placed at the bifurcation of the renal vein. It did not completely clamp the renal vein."
"Yes, if that's the case, a large amount of carbon dioxide will enter the blood circulation along with the pressure difference," Chief Miao continued. "I reckon that's how the 50% mortality rate came about. The carbon dioxide in the pneumoperitoneum will enter the large blood vessels and lead to an irreversible death. In the situation you encountered, a small amount of gas entered the malformed blood vessels and could still be saved. "
"The carbon dioxide followed the pressure gradient through the open vein through the inferior vena cava into the right atrium? The right ventricle? The pulmonary artery formed an air embolus clamp at the pulmonary artery, causing a mechanical obstruction, preventing the blood flow from entering the left ventricle, causing the patient's circulatory failure? "
"The amount of gas that entered was not much. This is also because you did the surgery meticulously. There are some complications that cannot be prevented. You just need to remember how to resuscitate them. You have to be more careful before the surgery. It's fine to say a few more words. "
Chief Miao was still nagging like a chief.
"Chief, do you need to blow on the ventilator for a few days after the surgery?" Chief Liu asked.
"One to two days will do," Chief Miao said confidently. Chief Miao said confidently, "Go back and check the bedside echocardiography. Find someone with good skills to do it. If there is no residual gas in the heart, you can remove the tube in two days at most. "
After saying that, Chief Miao paused for a moment and said, "Remember to tell the ICU nurses to be more alert at night and suck sputum once an hour. If there is a large amount of sputum left in the lungs due to pulmonary edema, I'm afraid that there will be pulmonary atelectasis."
"Chief, I'll stay in the ICU to see the patient tonight," Chief Liu said naturally. "Don't worry."
"Yes." Chief Miao nodded. All of this seemed to be reasonable.
"Director, thanks to your experience, I was stunned at that time," Director Liu said frankly. "Liu Ao Zhang" He said. "You.
"While Liang", he said., he, he, he, he "Liu, Liang," You said. The incidence of gas embolism is very low, about 0.002% to 0.02%, but once it occurs, the fatality rate can be as high as 50%.
"In all these years, there have been a total of three cases in our department, including your case."
Indeed. "While.," Liu Chen "Xiao,", "Everyone,", "Fang," Sea, and all. Indeed. "Indeed..," Everyone, "
Indeed, whether it was in terms of surgical skills or other aspects, everyone was qualified. But that was under normal circumstances. Once something like this happened today, Chief Surgeon Liu deeply felt that having an elder at home was like having a treasure.
There were thousands of laparoscopic surgeries a year, but only three cases had occurred over the years. From Chief Miao's meaning and Chief Liu's understanding, there were two cases that happened when he did not come.
"Therefore, when you perform laparoscopic surgery, I have to remind you to pay attention to the patient's condition. Rapid diagnosis and timely and effective treatment are necessary for success because there is too little time left for rescue. "
"The goal of the management of the air embolism is to prevent the gas from further entering the circulation and to maintain hemodynamic stability. This is very important.
"Once an abnormal situation occurs, you should immediately stop inflating and lower the pneumoperitoneum pressure. Place the patient in the left decubitus position with the head low and the feet high so that the air bubbles that enter 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 defibrillation must be performed immediately to maintain circulation while allowing air to flow out of the pulmonary artery."
"He Junjin did a good job. He used the central venous catheter to suck out the gas as soon as possible."
"I looked at the anesthesia record. After He Junjin came, he increased the amount of fluid infusion. Let me ask you why?" Chief Miao's voice suddenly became cold, like a strict teacher asking a naughty student.
"Is it because a large amount of fluid was infused to increase the venous pressure to prevent carbon dioxide gas from further entering the venous system?" Chief Liu's basic knowledge was also quite solid, so he answered directly without thinking.
"Yes, that's it."
When Chief Miao saw that he had finished the last stitch, he turned around with his hands behind his back and was about to leave.
"Chief Miao, wait a moment!" Chief Liu's hand speed increased. After the last needle was threaded, he used the needle holder and the forceps in his hand to pat the patient's leg. He turned around and chased after Chief Miao.
"Huh?" Chief Miao hummed softly.
"Chief Miao, I went to see you a few days ago. Think about what I told you," Chief Liu said very seriously. Director Liu said very seriously, "Even if you're rehired, there won't be too much work. You just have to take us to check rooms once a week. The key is … The key is that you're not here. I'm not confident. "
"You're so promising." Chief Miao snorted coldly. "You'll have to leave sooner or later. Don't be afraid to take action just because of one or two accidents. Go back and flip through the books and ask He Junjin. I remember that three years ago, there was a gas embolism during a laparoscopic surgery in the gastrointestinal tract. He Junjin was the one who anesthetized that surgery. "
Seeing that Boss Zheng was about to leave, Lao He unplugged the USB drive and was busy talking. When he heard Chief Miao mention him, he chuckled.
Zheng Ren glanced at Lao He. It was really not easy for this guy to live to such an old age.
"Chief …"
"You guys work hard. My retirement is my retirement. I won't be rehired," Chief Miao said very firmly.
After saying that, he slowly left the operating theater with his hands behind his back.
Zheng Ren glanced at Chief Liu and then followed Chief Miao's footsteps. He knew the meaning of Chief Miao's last sentence. Chief Miao was still too kind.
..
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Note: The case was quoted from the Chinese Journal of Emergency Medicine, September 2014, Volume 23, Issue 9.
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