After a while, Department Director Liu came back after he was done with the preoperative briefing.

He asked Department Director Miao for instructions, then washed his hands again and started to change the surgical method to finish the unfinished surgery.

The surgery was very simple. It was just a destructive kidney resection. Department Director Liu’s technique was delicate. Even with the old Department Director standing behind him watching, he did not show any signs of nervousness. The entire process of the surgery was completed in less than an hour.

As the skin was sutured, the song of “good luck” echoed in the operating theater. Department Director Liu seemed to have relaxed a little. He asked,”Department Director, how do you think they got here?”

“There was no damage to the major blood vessels during the operation. The kidney vein, lumbar vein, right diaphragm vein, and inferior vena cava are all in good condition. We don’t need to consider the rapid air absorption and circulation caused by damage. I think the carbon dioxide will pass through the abnormal blood vessels of the kidney tumor and enter the circulation system during the rapid inflation of the air pump to build the belly. “

“The patient’s blood pressure isn’t dropping too quickly. I’ve looked at the anesthesia record sheet. You guys have around 11 points for resuscitation.” Director Miao put his hands behind his back and said clearly,”do you still remember that I scolded you once?”

“I remember.” Department Director Liu did not avoid this question. He said very frankly,”in the first surgery I performed, the hemlock was placed at the junction of the kidney vein, so I couldn’t completely clamp off the kidney vein.”

“Yes. If that’s the case, a large amount of carbon dioxide will enter the blood circulation with the pressure difference.” Department Director Miao continued,”I guess that’s how the 50% mortality rate came about. The carbon dioxide from the pneumoperitoneum enters the large blood vessels, leading to an incurable death. However, in your case, if a small amount of gas enters the malformed blood vessels, you can still be saved. “

“The carbon dioxide flows along the pressure gradient through the open vein and enters the right atrium, right ventricle, and pulmonary artery through the inferior vena cava, forming an airlock clamp at the pulmonary artery, causing mechanical obstruction and preventing blood flow into the left chamber, resulting in circulatory failure.”

“You didn’t insert a lot of gas, which is also due to the precision of your surgery. There were some complications that could not be prevented, but it would be fine as long as he remembered how to save them. The preoperative instructions must be more detailed. It’s fine to say a few more words. “

Department Director Miao was still nagging like a Department Director.

“Department Director, you’ll need to blow the mechanical ventilator for a few days after the surgery.” Director Liu asked.

“One or two days will do.” Department Director Miao said with confidence,”when you go back, do a bedside ultrasound and find a skilled person to do it.” If there’s no residual gas in the heart, the catheter can be decaned in two days at most. “

After that, director Miao paused for a moment and continued,”Remember to tell the nurses at icu to be more alert at night and to inhale phlegm once an hour. If there is a large amount of phlegm in the lungs due to pulmonary edema, I’m afraid that the lungs will not expand.”

“Director, I’ll stay at the icu to see the patients tonight.” “Don’t worry,” director Liu said naturally.

“Yes.” Department Director Miao nodded. Everything seemed to be expected.

“Director, thanks to your experience, I was stunned.” Director Liu said very frankly. He didn’t hide his lack of experience and spoke frankly.

“It’s fine after experiencing it once. ” Department Director Miao said,”there is an inevitable risk of a gas block when we build a stillstomach. The occurrence rate of gas embolism is very low, about 0.002% to 0.02%. Once it happens, the death rate can be as high as 50%.”

“Over the years, there have been three cases in our Department, including your case.”

Department Director Liu felt a little emotional. The Department of Urology on the 912 emergency room was very powerful. Otherwise, it was impossible for all the leading professors to feel that they could fight for the position of Department Director.

Indeed, whether it was in terms of surgical skills or other aspects, everyone was qualified to do so. However, that was under normal circumstances. When it came to today’s incident, director Liu deeply felt that having an old man at home was like having a treasure.

There were thousands of cases of laparoscopy every year, but only three of them had happened over the years. Based on department Director Miao’s words and Department Director Liu’s understanding, two of the cases had happened before he arrived.

“That’s why I have to remind all of you to pay attention to the patient’s condition when you perform laparoscopy. A quick diagnosis and timely and effective treatment are the necessary conditions for success, because air embolism doesn’t give too much time for resuscitation. “

“The goal of the management of air clots is to prevent the air from entering the circulation further and to maintain the stability of the lifeblood. This is very important.”

“Once an abnormal situation occurs, you should immediately stop inflating and lower the abdominal pressure. Place the patient in a left prone position with his head low and his feet high so that the bubble that enters the right ventrum will gather at the tip of the heart to prevent it from entering the pulmonary artery. “

“When cardiac arrest occurs, CPR and electrocuting must be performed in time to maintain the circulation while also letting air out of the pulmonary artery.”

“He Junjin did a good job. He used a central venous catheter to suck out the gas in the shortest time possible.”

“I looked at the anesthesia record. He Junjin increased the fluid transfusion when he arrived. I’m asking you why he did that?” Director Miao’s voice suddenly became cold, like a strict teacher asking a naughty student a question.

“It’s because a large amount of liquid was administered to increase the vein pressure, which prevents carbon dioxide from entering the vein system. ” Department Director Liu’s basic knowledge was also quite solid, so he answered directly without thinking.

“Yes, it’s like this.”

When Department Director Miao saw that the last suture was done, he turned around and was about to leave with his hands behind his back.

“Director, please wait a moment!” Department Director Liu’s hand speed increased, and the last needle was inserted. He held the needle holder and the forceps in his hand and patted the patient’s leg. He then turned around and caught up with Department Director Miao.

“What?” Department Director Miao hummed in agreement.

“Director, I went to visit you a few days ago. Please consider the matter I told you.” Director Liu said very seriously,”we’re just rehired. There’s not much work to do. You just have to take us to check on the rooms one day a week. The point is … The point is that you’re not here, so I’m not confident. “

“Good for you.” Department Director Miao snorted coldly and said,”you’ll have to leave sooner or later. Don’t be so scared that you don’t dare to do anything just because of one or two accidents. I’ll go back and flip through the books and ask he Junjin. I remember that three years ago, there was a gas embolism when I performed a laparoscopic surgery on the stomach and intestines. He Junjin was the one who administered anesthesia for that surgery. “

When old he saw that boss Zheng was about to leave, he unplugged the USB. He was busy talking when he heard director Miao mention him and chuckled.

Zheng Ren glanced at old he. It was not easy for this guy to live to this age.

“Chief …”

“You guys do your best. My retirement is my retirement. I won’t rehire you.” Department Director Miao said firmly.

With that, he slowly left the operating room with his hands behind his back.

Zheng Ren glanced at director Liu, then followed director Miao. He knew what department Director Miao meant by his last sentence. Department Director Miao was still too kind.

……

……

[Note: the case was taken from [Chinese emergency medical Journal], September 2014, Volume 23, Issue 9.]

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