Li Fengmin's condition changed. Although the words "mild pulmonary embolism" were still very faint, almost only a faint outline, the status bar did remind Sun Lien that there was something wrong with Li Fengmin's blood.
To be honest, this change was not beyond Sun Lien's expectation. In other words, if Li Fengmin did not have this symptom, Sun Lien would still feel a little strange, and at the same time feel a little lucky that it is a miracle that such heavy bleeding did not cause blood problems.
There are two reasons that may cause pulmonary embolism. The first is venous thrombosis. Li Fengmin's external iliac vein was torn. Although the external patch was re-patched, the bleeding was successfully stopped. However, because the operation was too urgent, it was not trimmed and reconnected and it ruptured.
The blood vessels of the lower limbs have been damaged, and the tourniquets of the lower limbs actually hinder the venous blood return of the lower limbs. These factors are likely to cause thrombosis. When these thrombi move upward with the reopened blood vessels and enter the pulmonary veins, they will directly block them.
Block the pulmonary veins, leading to pulmonary embolism.
The second reason is even more troublesome. If it were not for pulmonary embolism caused by venous thrombosis, Li Fengmin might have fallen into the symptoms of DIC (disseminated intravascular coagulation).
As the final path of many blood diseases, the pathogenesis of DIC has been studied over and over for a long time. When the human body consumes too many coagulation factors due to various reasons, the human body may spontaneously develop coagulation disorders. Coagulation fibrin
Blood is deposited in small blood vessels, resulting in coagulation, while other parts may have a tendency to spontaneously bleed due to lack of coagulation substances. However, the specific circumstances under which the body will develop DIAC are still unclear.
Mystery.
Although there is no clear answer, scientists and doctors have summarized a set of high-risk factors for DIAC. Unfortunately, Li Fengmin met two of them: massive blood loss and major surgery.
Speaking of which, in fact, the term "major surgery" is a bit wishful thinking. In the medical field, it is generally rare to say "large and small". Instead, it is judged by risk. The greater the risk, the closer it is to what people generally understand as "major surgery".
.The external iliac veins on the left and right sides serve as the main connection to the inferior vena cava and are also hidden deep in the abdominal cavity. Even if the operation is performed in a hospital with complete facilities, there is considerable risk. And emergency hemostasis in the conference room
The risks of surgery can be imagined.
Although the cause has not yet been determined, no matter what the cause is, the embolism must be treated immediately. Otherwise, Li Fengmin will never be able to get off the operating table.
"Didi, didi!" Just when Sun Lien opened his mouth to speak, the cardiopulmonary monitor suddenly shouted. Everyone in the operating room immediately stopped their preparations and looked in the direction of the anesthesiologist.
past.
"The blood oxygen saturation dropped to 90%!" The anesthesiologist suddenly stood up from the stool. He turned around and walked quickly to Li Fengmin. He checked the trachea and breathing tube still inserted in Li Fengmin's throat as quickly as possible.
Machine settings, "The ventilator settings are OK. Did any of you just meet the patient?"
"I'm disinfecting." The instrument nurse raised the iodophor cotton in her hand, "I just completed the first disinfection."
"It has nothing to do with this." The anesthesiologist continued to check according to the prescribed procedures. "There is no nail polish and no bright light. Let me try another probe." He quickly ran to the heart and lung monitor and took out a blood tube that had not yet been opened.
The oxygen saturation monitoring probe was unpacked and replaced.
"The blood oxygen saturation is 89%, it's not a malfunction." The anesthesiologist frowned and walked quickly to the operating table, "It can't be DIC, right?"
It is not the anesthesiologist's responsibility to use heparin on patients, but he is responsible for stabilizing the patient's vital signs. "I will increase the respiratory flow and try changing to pure oxygen breathing." He looked at Lin Hua and said, "Dr. Lin,
Let’s do a B-ultrasound to check the blood flow in the lungs.”
Generally speaking, to diagnose whether a patient has pulmonary infarction, the gold standard is pulmonary contrast imaging. But Li Fengmin had a venous rupture, which is a contraindication for contrast imaging. Even if imaging is required, a patient with an open belly should be transferred to the interventional room.
It’s also unrealistic. If you can judge the situation immediately, you can only rely on B-ultrasound imaging.
"B-ultrasound of the lungs... call Director Guo from the Ultrasound Department." Lin Hua immediately made a decision. It is not a simple task to use B-ultrasound to determine the blood flow of the lungs. Although the Sanya Branch of the Military General Hospital
B-ultrasound machines are advanced enough, but the pulmonary artery is hidden just below the sternum. This physiological structure determines that it is extremely difficult to detect it with an ultrasound probe. Only doctors with extremely high skills can complete this task.
"You really found a difficult job for me." Director Guo of the Ultrasound Department walked in wearing a blue disposable hair cap. He muttered to Lin Hua, "Use B-ultrasound to see the pulmonary artery? Why not?
Enhance it?"
"The stomach is open, and even if there is a venous rupture, we can't do angiography." Lin Hua spread his hands and said that there was nothing he could do about it. "Please take a look quickly, we are trying to save lives."
Sun Lien watched helplessly as the condition above Li Fengmin's head changed from "mild pulmonary embolism" to "moderate pulmonary embolism." If Director Guo hadn't picked up a small probe and pressed it on Li Fengmin's chest, he would have really couldn't bear it.
Please be reminded that pulmonary embolism can be fatal.
But the conditions in the status bar are just a reminder after all. To obtain real medical decision-making basis, we still need to rely on detection methods. Fortunately, the cardiopulmonary monitor has been monitoring Li Fengmin's vital signs. Although the situation is getting worse, at least he is still there.
a little time.
"There is reflux, about one-third." In less than two minutes, Director Guo looked at the B-ultrasound image and made a judgment. "It may be at least a moderate pulmonary embolism, or it may be DIC, depending on the specific situation.
To make a judgment, let’s do the five coagulation tests and see the results.”
Lin Hua frowned. It seems that the operation can only be stopped for now. Pulmonary embolism that has already occurred must be intervened to remove the embolus. If it is a thrombus, anticoagulation treatment needs to be started as soon as possible like DI. But no matter which kind
As a result, there was a great risk for Li Fengmin who needed to redo the external iliac vein.
The operating room needed the results of the five coagulation tests, so the testing department certainly didn't dare to neglect. After getting the results as quickly as possible, Lin Hua frowned deeper. Li Fengmin's plasma prothrombin time was only 6 seconds, and his fibrinogen level
1.5g/l, and the d-dimer level is as high as 0.7mg/l. The three examination results all indicate DICIS symptoms and meet the DIDI diagnosis criteria.
"Add heparin sodium, intravenously inject 7,000 units, and add a bottle of 500 saline heparin sodium, 10,000 units, 30 ml per hour." Lin Hua has not dealt with DIC once or twice, and he can provide corresponding treatment methods.
It is said that he is familiar with it. But the real difficulty lies behind. After starting anticoagulation treatment, Li Fengmin's coagulation function will be suppressed. At this time, the operation of cutting off and re-anastomizing a major vein is started, and the risk of intraoperative bleeding is too great.
Chen Tianyang, who had been a bystander, also guessed what Lin Hua was worried about. He was about to speak, but suddenly turned around and asked Sun Lien, "Xiao Sun, do you think the operation can be continued now?"
Chen Tianyang estimated that a doctor like Sun Lien, who was more interested in emergency medicine and diagnosis, might object to higher-risk surgeries. He was going to remind Lin Hua by rebutting Sun Lien. But Chen Tianyang forgot that Sun Lien was the one who dared to suggest that in the conference room
A freak who had emergency laparotomy.
"Do it, and it must be done immediately." Sun Lien finally found an opportunity to express his opinion. He hurriedly said, "The hemostatic patch attached to the patient's external iliac vein will consume fibrin. I think it should be done after the patient's coagulation function is affected.
Perform surgery immediately before the suppression reaches an unacceptable level."
People will die if they don’t breathe, but people will die if there is no blood in their bodies. It makes no sense to discuss whether Li Fengmin should stop breathing or drain his blood. In the case where any one symptom can be fatal, then all possible fatal symptoms must be dealt with.
Symptoms. Sun Lien has been working in the emergency department for more than a year, and he has done many things to stop bleeding while clearing the respiratory tract of patients. In Sun Lien's opinion, Chen Tianyang's problem does not need to be considered. After the heparin sodium is injected and takes effect, he will stop the bleeding.
The patch is very likely to fail. If it is delayed until this time, the anastomotic blood vessels may still continue to bleed even if they are sutured.
But it is obviously unrealistic to ignore DIC. The main function of blood is to transport oxygen to various cells in the body, and at the same time transport carbon dioxide produced by metabolism. The blood vessels were sutured, but the patient's DIC caused the blood in the lungs to become
Blood tofu, how about transporting a shitty amount of oxygen?
"Insightful." Chen Tianyang combed his thumbs in an inconspicuous manner, turned to Lin Hua and said, "Did you hear that?"
"I heard it." Lin Hua nodded, stopped talking, and said to the doctors on the surgical team, "Let's get to work and try to get it done within half an hour."
Suturing blood vessels sounds simple, but in fact, it is not ordinary. It is especially difficult for blood vessels such as the external iliac vein, which have a large flow rate, high pressure, and are hidden under many organs.
"Hemostatic forceps." Since he decided to complete the operation as soon as possible, Lin Hua could not waste time. Fortunately, Chen Tianyang's incision was perfect, which bought Lin Hua a lot of time. He quickly used the retractor instead of the bent one.
The fork separated the skin, the underlying muscle tissue, and the retroperitoneum. Lin Hua saw the hemostatic patch. And the moment he saw the blood vessels, he reached out and asked the nurse for a hemostatic forceps.
"I need to bend my head..." Hu Jia was leaning on Sun Lien and was distracted. After hearing this sentence, she subconsciously asked. After asking three words, she realized that the doctor was not asking her. Then she quickly covered her head.
He shut his mouth.
Sun Lien looked at Hu Jia, felt a little sad and hugged her shoulders, and gently touched her head with his free hand.
"Get another hemostatic forceps." Lin Hua ignored Sun Lien's voice. He concentrated on clamping the upper and lower ends of the damaged external iliac vein, letting go of the part wrapped by the hemostatic patch, and confirmed
After the hemostatic forceps are clamped well, the damaged vein is cut off with surgical scissors.
Lin Hua used tweezers to pull out the damaged vein that had fallen into the abdominal cavity, and then began to trim the two ends of the severed blood vessel. "Take the artificial blood vessel. It needs to be 11mm in diameter and two centimeters long."
After being tricked into praising Chen Tianyang several times, Yisuke quickly brought the prepackaged artificial blood vessel, cut out a suitable section, and handed it to Lin Hua.
"Vascular stapler." Chen Tianyang didn't say a single extra word. He didn't look like the usual chatterbox in the operating room. He needed to concentrate on completing the operation as quickly as possible, which originally took nearly two hours to complete. Any trace of energy
The dispersion may cause his hand to slow down.
If he were slower at this time, it might directly lead to Li Fengmin's death. Although Lin Hua didn't say anything else, the pressure on his shoulders now was unimaginable to outsiders.
It is not very common to use a vascular stapler to connect thicker veins. After all, blood vessels can also be sewn with a needle, and the suturing effect will not be much worse. But the biggest advantage of the stapler is now
Under these conditions, it is simply not suitable to use it to anastomose blood vessels, as it is really fast.
It takes a veteran like Zheng Guoyou about 20 minutes to sew a vein by ordinary hands. Lin Hua's own fastest record is 28 minutes. The eight-minute gap is that he and Zheng Guoyou have more than 20 years of medical and medical experience.
A concrete manifestation of the gap in surgical experience.
But if a vascular stapler is used, Lin Hua can complete the suturing within five minutes.
The eight-minute gap is approximately equivalent to twenty years of medical experience. However, the 23-minute improvement in vascular stapler improvement is simply impossible to make up for with personal skills.
Of course, artificial blood vessels are easier to sew than real blood vessels, but this means that it takes Lin Hua about ten minutes to sew the two ends of the two-centimeter-long artificial blood vessel to Li Fengmin's iliac
Go up the external vein.
time is life.
At 3 minutes and 51 seconds, Lin Hua connected the anastomosis between the artificial blood vessel and the distal external iliac vein. After checking that the anastomosis was good, he loosened the hemostat clamping the distal end, and the blood flowed out quickly.
There is no bleeding at the interface.
At eight minutes and twelve seconds, Lin Hua completed the anastomosis of the artificial blood vessel and the external iliac veins at both ends in a time short enough to show off. He picked up the stapler with tweezers, looked at it, and used a round hand commonly used in dentistry to
He looked at the connection effect below with a shaped observation mirror. After confirming that the stapler fit well and that the blood vessels were not obviously twisted or wrinkled, he loosened the hemostat at the proximal end. Then there was a suffocating silence.
"The blood vessels anastomosis are good and there is no leakage." After looking at the blood vessels for almost three minutes, Lin Hua announced that the operation was partially successful. "The abdominal cavity was lavaged and disinfected. After completion, prepare to close the abdomen."
This time, Li Fengmin finally didn't have to reveal his true feelings to others.