Chapter 2957: 2757 Don't Make This Mistake Again

When approximating the sternum, blood pressure fluctuated abnormally, with recurrent episodes of rapid ventricular arrhythmia, heart rate 170-180 beats per minute.

These values appeared even though the sternum was not fully approximated; if we forcibly closed the sternum, I'm afraid the patient wouldn't even be able to get off the operating table.

"Zheng Lao Ban, did you have a pre-op assessment?" Zhao Yunlong knew Zheng Ren's choice was correct, he asked softly.

"The echocardiogram shows the patient's heart is enlarged, but that's not the main reason; the basis for delaying sternal closure is prior treatment." Zheng Ren began preparations for delayed sternal closure, explaining as he did so.

"Zheng Lao Ban, ready to do the ultrasound now?" Lao He pushed the machine in and asked.

Okay.

Lao He didn't mind being hauled from home to the operating room early by Zheng Lao Ban just to do a transesophageal echocardiogram, doing whatever was asked, Lao He had no complaints.

Under general anesthesia with endotracheal intubation, successfully completing a transesophageal echocardiogram is also a skill—not everyone can do it.

"Just a moment." Lao He dashed to the computer, plugged in a USB drive, and the song "Good Luck Come" blared out.

"Nowadays, if you don't listen to this song, you can't do surgery." Lao He explained with a smile.

Although the surgery had reached its final step, Lao He still insisted on playing "Good Luck Come."

Moving to the beat of "Good Luck Come," Lao He felt his body lighten a bit, as if he had ascended to immortality.

The difficult operation became smooth in his hands; a few minutes later Lao He softly said, "Zheng Lao Ban, the SAM sign is prominent."

The SAM sign is a finding in M-mode echocardiography.

It mainly refers to the anterosuperior motion of the anterior mitral valve leaflet during systole; in obstructive hypertrophic cardiomyopathy, the CD segment of systole is not a slow upward plateau but shows an upward, i. e., septally directed, abnormal waveform—this phenomenon is called systolic anterior motion, abbreviated SAM.

"Give a small amount of beta-blocker and quickly replenish plasma." Zheng Ren issued the order, then began the steps for delayed sternal closure.

"Adjust the levosimendan dose to 0.5 mg/kg/min." Zheng Ren said, while Xie Yiren had already handed over the pediatric sternal retractor.

Zheng Ren swapped the adult sternal retractor for the pediatric size, then simultaneously monitored blood pressure, central venous pressure, heart rate and rhythm, cardiac contractility, and oxygen saturation.

He gradually adjusted the sternal retractor spread, seeking the position most favorable for blood pressure stability, heart rate not slowing or markedly increasing, no ventricular arrhythmia, CVP decreasing, strong myocardial contraction, no cardiac distension, and rising oxygen saturation.

"Boss, you're being too precise." Su Yun said, "There's no need to measure surgery in millimeters; thoracic surgery calls for boldness."

Zheng Ren smiled; Su Yun's notion of boldness probably differs from what others understand.

"A more accurate position will speed up postoperative recovery. If there are no complications, the swelling should gradually subside in 2–3 days, and Old Zhao should be able to close the sternum in about five days." Zheng Ren said.

Zhao Yunlong lowered his head, staring intently at Zheng Lao Ban's manipulation of the pediatric sternal retractor.

Every angle, every distance, every movement has its rationale, but Zhao Yunlong knows this is an instinct formed from rich surgical experience—perhaps even Zheng Lao Ban himself couldn't explain it clearly.

Better to observe carefully, go back and think it over; if there's a next chance, I could try it myself, Zhao Yunlong thought.

Place pericardial and mediastinal drainage tubes, then seal the incision and retractor with sterile transparent surgical film.

"Send him to the ICU." Zheng Ren stepped down from the platform, then turned back and asked, "Old Zhao, do you guys often perform delayed sternal closure?"

"We do it occasionally, rarely. But the ICU doctors and nurses have experience, Zheng Lao Ban, rest assured." Zhao Yunlong knew what Zheng Ren meant by that question, and he immediately replied.

"Alright, then let's do that."

Even with delayed sternal closure, the surgery's completeness reached 101%; Zheng Ren expressed great satisfaction with that.

The patient should be fine.

"Zheng Lao Ban, thank you." Director Lang bowed deeply on the side and whispered.

"You're welcome." Zheng Ren said, "IABP shouldn't be used; this time we have experience, so next time we won't make this mistake."

"Next time..." Director Lang murmured.

"Hmm?" Zheng Ren sensed there was more in Director Lang's words, gave him a questioning look.

But Director Lang didn't continue; instead he asked, "Zheng Lao Ban, isn't IABP quite appropriate? Whenever I encounter a similar situation I use IABP to resolve it."

"Don't be too dogmatic." Zheng Ren said, "After noticing multiple early signs of cardiac tamponade, one should immediately perform pericardiocentesis drainage and other emergency measures to relieve it. At this point your management is fine; you did a great job."

Seeing Director Lang's mood off, Zheng Ren didn't overstimulate him but instead offered rare praise.

"During our intraoperative exploration we didn't see the usual hemopericardium from coronary artery perforation causing tamponade; logically, even with pericardiocentesis drainage there would be at least a little—this situation is too rare."

"Zheng Lao Ban, is it due to a small branch rupture?" Director Zhang asked.

"Probably, and we can also consider a small branch rupture that has self-healed as intrapericardial pressure rose." Zheng Ren said, "Indeed our luck was a bit off; actually, if this patient had done nothing at all, he might have been better off."

……

Director Lang was speechless; Zheng Lao Ban's words made him feel absurd.

The absurd black-comedy style and nonsensical talk are unsuitable for the operating room; Director Lang indicated he couldn't accept it.

"But I think it's more likely due to the patient's older age; the main cause of his tamponade is marked myocardial congestive edema, not intra-pericardial blood." Zheng Ren explained, "I believe it occurred during your PCI procedure, because extensive myocardial infarction caused cardiac edema."

"In early myocardial infarction, myocardial edema is severe, and with left coronary dominance and a large infarct area, this particular change results."

"In other words, it's not hemopericardium from coronary artery rupture causing tamponade, but tamponade from acute necrosis and exudation."

"In such a rare situation, all the maneuvers you performed afterward, Director Lang, were wrong." Zheng Ren finally stated the factual truth.

"Although the IABP measure reduced the patient's ventricular afterload, it failed to promptly relieve the pericardial pressure on the heart itself, so symptoms worsened."

……

Director Lang listened as Zheng Ren explained the patient's condition in detail; his own assessment of the patient's condition was not the small coronary artery branch bleed that Director Zhang had mentioned, but another complication.

In an instant, Director Lang felt a bit dazed.