Chapter 2722

After a while, director Liu came back after the preoperative explanation.

He asked director Miao for instructions, then washed his hands again, began to change the operation, and finished the unfinished operation again.

The operation was very simple. It was just a destructive nephrectomy. Director Liu's technique was delicate. Even if the old director stood behind him, he still didn't show any tension. He completed the whole process of the operation in less than an hour.

After sewing the skin, the operating room echoed with the song of good luck. Director Liu seemed a little relaxed. He asked, "director, how do you think you came?"

"During the operation, the injury of large blood vessels did not occur. The renal vein, lumbar vein, right phrenic vein and inferior vena cava were intact. Regardless of the injury, the gas was quickly absorbed into the circulation. I think it should be rapid inflation. When establishing pneumoperitoneum, carbon dioxide passed through the abnormal blood vessels of renal tumors and then entered the circulation."

"The patient's blood pressure is not falling fast. I look at the anesthesia record sheet. You have about 11 points for rescue." Director Miao said with his hands on his back, "do you remember I scolded you once?"

"Remember." Director Liu did not avoid this problem and said frankly, "when I had an operation, Hem-O-lock was placed at the bifurcation of the renal vein and failed to completely clamp the renal vein."

"Well, in that case, a lot 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. Carbon dioxide from pneumoperitoneum enters large blood vessels, which will lead to irreparable death. In this case, a small amount of gas enters deformed blood vessels and can be saved."

"Carbon dioxide enters the right atrium? Right ventricle? Pulmonary artery through the open vein through the inferior vena cava along the pressure gradient, forming an air embolism clamp at the pulmonary artery, resulting in mechanical obstruction, making the blood flow unable to enter the left ventricle, resulting in circulatory failure?"

"The amount of gas entering is not much, which is also the delicacy of your operation. There are some complications that can't be prevented. Just remember how to rescue them. Be careful and say a few more words before operation."

Director Miao is still nagging like a senior director.

"Director, let's blow the ventilator for a few days after the operation." Director Liu asked.

"1-2 days." Director Miao said confidently, "after going back, recheck the bedside echocardiography and find someone with good technology. If there is no residual gas in the heart, the tube can be pulled out in two days at most."

With that, director Miao paused and said, "remember to tell the nurses in ICU to concentrate at night and suck sputum once an hour. If there is pulmonary edema and a large amount of sputum remains in the lungs, I'm afraid there will be atelectasis."

"Director, I stay in the ICU to see patients in the evening." Director Liu said naturally, "don't worry."

"Yes." Director Miao nodded. All this seemed to be taken for granted.

"Director, thanks to your experience, I was confused at that time." Director Liu said frankly. He didn't hide his lack of experience and said frankly.

"I wish I had experienced it once." Director Miao said, "to establish pneumoperitoneum, there is an inevitable risk of gas embolism? The incidence of gas embolism is very low, about 0.002% ~ 0.02%, but once it occurs, its mortality can be as high as 50%?"

"Over the years, there have been three cases in our department, plus you."

Director Liu sighed that the strength of 912 urology is very strong. Otherwise, it is impossible for all professors in the group to feel that they can compete for the position of director.

Indeed, no matter from the level of surgery or other aspects, everyone is qualified. But that's normal. Once you encounter such a thing today, director Liu deeply feels that there is an old man like a treasure at home.

There are thousands of endoscopic operations a year, but only 3 cases have occurred over the years. According to director Miao's meaning and director Liu's understanding, two cases occurred when he didn't come.

"So when you do endoscopic surgery, I should 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 due to air embolism?"

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

"In case of abnormal conditions, stop inflation immediately and reduce the abdominal pressure. Place the patient in the left lying position with head low and feet high, so that the bubbles entering the right ventricle gather at the apex of the heart to prevent them from entering the pulmonary artery."

"In case of cardiac arrest, cardiopulmonary resuscitation and defibrillation should be carried out in time to maintain circulation and flow air out of the pulmonary artery."

"He junjin did a good job. He used a central venous catheter to suck out the gas as soon as possible."

"I read the anesthesia record sheet. He junjin increased the liquid input after he junjin came. I ask you why?" Director Miao's voice suddenly became cold, like a strict teacher asking naughty students.

"Is it because a large amount of liquid is injected to increase the venous pressure, so as to prevent carbon dioxide gas from further entering the venous system?" Director Liu's basic knowledge is also quite solid. He answered directly without thinking.

"Well, that's right."

When director Miao saw that the last stitch had been sewn, he turned around with his back to go.

"Director, wait a minute!" Director Liu's hand speed accelerated, the last needle penetrated, took the needle holder and the forceps in his hand, patted the patient's leg, and turned to catch up with director Miao.

"Huh?" Director Miao gave a gentle hum.

"Director, I went to see you the other day and you should think about what I told you." Director Liu said seriously, "there's nothing too heavy to do when I come back from the reemployment. Just take us to check the room for one day a week. The key is... The key is that you're not here. I don't know."

"Promising." Director Miao humed coldly, "you have to leave sooner or later. Don't be afraid to do it because of one or two accidents. Go back and turn over the book and ask he junjin. I remember that gas embolism occurred in a endoscopic gastrointestinal operation three years ago, which was anesthetized by he junjin."

Seeing that boss Zheng was leaving, Lao he pulled out the USB flash drive and was busy talking. When director Miao mentioned himself, he smiled.

Zheng Ren took a look at Lao he. It's really not easy for the goods to live so big.

"Director..."

"You do a good job. I'll retire and won't be rehired." Director Miao said firmly.

With that, he left the operating room slowly with his hands on 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. Director Miao was still too kind.

……

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Note: the case is quoted from the Chinese Journal of emergency medicine, Volume 23, Issue 9, September 2014