Chapter 2922: with translation of chapter title

After a while, Director Liu returned after finishing the preoperative briefing.

He consulted Director Miao, then washed his hands again, began to change the surgical approach, and finished the unfinished surgery once more.

The surgery was simple, just a destructive renal cancer resection; Director Liu's technique was meticulous, and even with a senior director standing behind watching, he showed no sign of tension, completing the entire procedure in less than 1 hour.

Suturing the skin, the song "Good Luck Come" echoed in the operating room; Director Liu also seemed a bit more relaxed, and he asked, "Director, what do you think caused it?"

During the surgery, no major blood vessel injury occurred; the renal vein, lumbar vein, right diaphragmatic vein, and inferior vena cava were all intact, so we don't consider injury causing rapid gas absorption into circulation. I think it should be that during rapid insufflation to establish pneumoperitoneum, carbon dioxide passed through the malformed vessels of the renal tumor and then entered the circulation.

The patient's blood pressure didn't drop quickly; I looked at the anesthesia record, you guys had about 11 minutes of resuscitation." Director Miao said with his hands behind his back, speaking clearly, "Do you still remember me scolding you once?"

Remembered." Director Liu did not avoid the question, speaking frankly, "During one surgery, I placed a Hem-o-lock at the bifurcation of the renal vein but failed to completely occlude the renal vein."

Well, if that's the case, a large amount of carbon dioxide would enter the blood circulation due to the pressure difference." Director Miao continued, "I estimate the 50% mortality rate comes from this: carbon dioxide from pneumoperitoneum entering a major vessel leads to irreversible death. In your situation, however, a small amount of gas entering the malformed vessels still allows survival."

Carbon dioxide, following the pressure gradient, passes through an open vein into the inferior vena cava, then into the right atrium? right ventricle? pulmonary artery, where it forms a gas embolus clamp at the pulmonary artery, causing mechanical obstruction that prevents blood from entering the left ventricle, leading to patient circulatory collapse?

The amount of gas that entered is not large, which also reflects the finesse of your surgery. Some complications cannot be prevented; as long as you remember how to resuscitate, that's enough. Pay a bit more attention to the preoperative briefing, and saying a few extra words is no problem.

Director Miao continued to nag like a senior director.

"Director, how many days should the patient be on the ventilator after surgery?" Director Liu asked.

"One to two days will be fine." Director Miao said confidently, "After returning, do a bedside echocardiogram to check, find someone skilled to perform it. If there's no residual gas in the heart, the tube can be removed in at most two days."

After speaking, Director Miao paused, then said, "Remember to instruct the ICU nurses to stay alert at night, suction secretions every hour; if a large amount of phlegm remains in the lungs with pulmonary edema, atelectasis may occur."

"Director, I'll stay in the ICU tonight to watch the patient." Director Liu said naturally, "You can rest assured."

"Hmm." Director Miao nodded; all of this seemed like a matter of course.

"Director, thanks to your experience, I was confused at the time." Director Liu spoke frankly. He did not hide his lack of experience, speaking directly and honestly.

"Just experiencing it once is enough." Director Miao said, "Establishing pneumoperitoneum inevitably carries the risk of gas embolism; the incidence of gas embolism is very low, about 0.002%~0.02%, but once it occurs, the mortality rate can be as high as 50%."

"Over these years, our department has had a total of three such cases, plus yours."

Director Liu felt somewhat moved; the strength of the 912 Urology Department is strong, otherwise it would be impossible for all team-leading professors to think they could compete for the director's position.

"Indeed, whether from surgical skill or other aspects, everyone has that qualification. But that's under normal circumstances; once encountering today's situation, Director Liu deeply felt the truth of the saying 'having an elder in the family is like having a treasure.'"

"Several thousand laparoscopic surgeries are performed each year, yet over these years only three cases have occurred. According to Director Miao's meaning and Director Liu's understanding, two of them happened when he was not present."

"So when you perform laparoscopic surgery, I always want to remind you to monitor the patient's condition. Rapid diagnosis and timely, effective treatment are necessary conditions for success, because the time left for rescue from an air embolism is too short."

"The goal of managing gas embolism is to prevent further gas from entering the circulation and to maintain hemodynamic stability; this is crucial."

"If an abnormality occurs, one should immediately stop insufflation, lower the pneumoperitoneum pressure. Place the patient in a head-down, left lateral position so that bubbles entering the right ventricle collect at the apex, preventing them from entering the pulmonary artery."

"In case of cardiac arrest, promptly perform CPR and defibrillation; while maintaining circulation, this also helps expel air from the pulmonary artery outflow tract."

"What He Jun Jin did was good; he used a central venous catheter to aspirate the gas as quickly as possible."

"I looked at the anesthesia record; after He Jun Jin arrived, he increased the fluid infusion rate, and I asked him why." Director Miao's voice suddenly turned stern, like a strict teacher questioning a mischievous student.

"It's because infusing a large amount of fluid raises venous pressure, thereby preventing further CO2 gas from entering the venous system?" Director Liu's basic knowledge is also quite solid; he answered directly without thinking.

"Hmm, that's right."

"Seeing that the skin had been sutured, Director Miao, with his hands behind his back, turned to leave."

"Director, wait a moment!" Director Liu sped up his hand movements; the last suture was pulled through, he slapped the needle holder and forceps in his hand onto the patient's leg, then turned and chased after Director Miao.

"Hmm?" Director Miao gave a soft hum.

"Director, a few days ago I came to see you and mentioned the matter; please consider it." Director Liu said seriously, "If I return on a rehire basis, there won't be too much work—just leading us to check the wards once a week. The key is… the key is that without you, I lack confidence."

"Promising." Director Miao snorted coldly, "You'll have to leave sooner or later; don't let one or two accidental incidents make you afraid to operate. Go back, study hard, and ask He Jun Jin. I remember that three years ago, the gastroenterology department had a laparoscopic surgery case with gas embolism, and that operation was anesthetized by He Jun Jin."

"Old He saw Zheng Lao Ban about to leave, pulled out the USB drive, was busy chattering, and upon hearing Director Miao mention himself, he hehehed and laughed."

"Zheng Ren glanced at Lao He; this guy managing to live this long is truly not easy."

"Director…"

"Work well, I'm retiring and will not be rehired." Director Miao said firmly.

After saying that, he walked out of the operating room with his hands behind his back.

"Zheng Ren glanced at Director Liu, then followed Director Miao's steps. He understood the meaning of Director Miao's last words; Director Miao is still too kind-hearted."

……

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