Chapter 2723 The Last Lesson

After a while, Director Liu explained before the operation and came back.

He asked Director Miao for instructions, then washed his hands again, and began to change the operation method to finish the unfinished operation again.

The operation is very simple, just a destructive nephrectomy. Director Liu's technique is exquisite. Even with the old director standing behind him, he still didn't show any nervousness. It took less than an hour to complete it. The whole process of surgery.

The skin was sewed, and the sound of good luck singing echoed in the operating room. Director Liu seemed to be a little more relaxed. He asked, "Director, how do you think you got here?"

"There was no damage to the large blood vessels during the operation, and the renal vein, lumbar vein, right phrenic vein, and inferior vena cava were all intact, regardless of the damage that caused the rapid absorption of gas into the circulation. I think it should be due to the rapid gas inflation to establish the pneumoperitoneum when carbon dioxide passes through the kidney tumor. Malformed blood vessels, and then enter the circulation."

"The patient's blood pressure drops uncomfortably. I read the anesthesia record, and you have about 11 points for rescue." Director Miao said clearly, with his hands behind his back, "Do you still remember that I scolded you once?"

"Remember." Director Liu did not evade this question, and said calmly, "I had an operation once, and the Hem-o-lock was placed at the bifurcation of the renal vein, and the renal vein could not be completely clamped."

"Well, if that's the case, a large amount of carbon dioxide will enter the blood circulation along with the pressure difference." Director Miao continued, "I guess the 50% mortality rate comes from this way. Irreparable death. And in this situation you have, a small amount of gas enters the malformed blood vessel, and there is salvation."

"Carbon dioxide enters the right atrium, right ventricle, and pulmonary artery through the open vein through the inferior vena cava along the pressure gradient, forming an air embolism clip at the pulmonary artery, causing mechanical obstruction, preventing blood flow from entering the left ventricle, and causing circulatory failure in the patient"

"The amount of gas entering is not much, which is also due to the fineness of your surgery. There are some complications that cannot be prevented, as long as you remember how to rescue them. You should be more careful in explaining before the operation, and it's okay to say a few more words."

Director Miao was still nagging like a big director.

"Director, you will need a ventilator for a few days after surgery." Director Liu asked.

"1-2 days." Director Miao said confidently: "After going back, check the bedside echocardiogram, and find someone with good skills to do it. If there is no residual gas in the heart, it can be pulled out in at most 2 days. Tube."

After finishing speaking, Director Miao paused, and then said: "Remember to tell the nurses in the ICU to stay alert at night and suck the sputum once an hour. If there is a lot of sputum left in the lungs due to pulmonary edema, it may cause atelectasis. "

"Director, I will stay in the ICU to see patients at night." Director Liu said naturally, "Don't worry."

"En." Director Miao nodded, all of this seemed to be taken for granted.

"Director, thanks to your experience, I was dumbfounded at the time." Director Liu said calmly. He didn't hide his lack of experience, and said it directly and frankly.

"It's good to have experienced it once." Director Miao said, "With the establishment of pneumoperitoneum, the risk of gas embolism is inevitable. The incidence rate of gas embolism is very low, about 0.002%~0.02%. Once it occurs, the fatality rate can be as high as 50%. %"

"For so many years, there have been three cases in our department, including your case."

Director Liu was a little bit emotional. The Department of Urology of 912 is very strong. Otherwise, it would be impossible for all the professors leading the group to feel that they could compete for the position of director.

Indeed, no matter in terms of surgical level or other aspects, everyone has this qualification. But that's a normal situation. Once something like this happened today, Director Liu deeply felt the correctness of the saying that a family has an old man like a treasure.

Thousands of laparoscopic surgeries are performed every year, but only 3 cases have occurred over the years. According to Director Miao's meaning and Director Liu's understanding, 2 cases happened when I didn't come.

"So when you perform laparoscopic surgery, I have to remind you to pay attention to the patient's state. Rapid diagnosis and timely and effective treatment are necessary conditions for success, because there is too little time left for rescue of air embolism."

"The goal of air embolism management is to prevent further gas from entering the circulation and to maintain hemodynamic stability, which is critical."

"Once an abnormal situation occurs, the inflation should be stopped immediately and the pneumoperitoneum pressure should be reduced. The patient should be placed in the left lying position with the head down and the feet high, so that the air bubbles entering the right ventricle will gather at the apex of the heart and prevent them from entering the pulmonary artery."

"CPR and defibrillation are required in a sudden cardiac arrest to maintain circulation while moving air out of the pulmonary artery."

"He Junjin did a good job. He used the central venous catheter to suck out the gas in the fastest time."

"I read the anesthesia record sheet. After He Junjin came, he increased the amount of fluid input. Let me ask you why?" Director Miao's voice suddenly became serious, like a stern teacher questioning a mischievous student.

"It's because a large amount of fluid was injected to increase the venous pressure, thereby preventing carbon dioxide gas from further entering the venous system." Director Liu also had a solid foundation in basic knowledge, and he replied directly without thinking.

"Well, that's right."

Seeing that the last stitch was finished, Director Miao turned around with his hands behind his back to leave.

"Director, wait a moment!" Director Liu speeded up his hand, and the last needle was inserted. He patted the needle holder and the tweezers in his hand on the patient's leg, and turned to catch up with Director Miao.

"Huh?" Director Miao hummed lightly.

"Director, I went to see you a few days ago, and you should think about what I told you." Director Liu said seriously, "There is nothing too heavy to do when you return to employment. Just take us to check the house for one day a week. The key is ...The key is that you are not here, so I have no idea."

"Promise." Director Miao snorted coldly, "Sooner or later, you have to leave. Don't be afraid to do it because of one or two accidents. Go back and read the book carefully, and ask He Junjin. I remember three years ago. Gas embolism occurred in a case of laparoscopic surgery, which was anesthetized by He Junjin."

Seeing that Boss Zheng was about to leave, Lao He unplugged the USB flash drive and was busy chattering. When Director Miao mentioned him, he smiled.

Zheng Ren glanced at Lao He, it was really not easy for this guy to live so big.

"director……"

"You guys work hard. When I retire, I will retire, and I won't re-employ." Director Miao said firmly.

After finishing speaking, he slowly left the operating room with his hands behind his back.

Zheng Ren glanced at Director Liu, then followed Director Miao's footsteps. He knew the meaning of Director Miao's last words, and Director Miao was still too kind.

...

...

Note: The case is quoted from "Chinese Journal of Emergency Medicine", Volume 23, Issue 9, September 2014.