Small surgery, almost fatal.

Introductiona large number of flushing fluid is very easy to cause acidosis, electrolyte disorders, hypothermia and other serious complications, should be done before surgerypreventionmeasuresgraduated from the current hospital work, a few years ofclinicalfirst-line grinding, think has grown into a little experienceof residentbut a case that happened to me in the middle of last year is still a matter of great fearBecause a patient of his own age to do uterine surgery (most people think of small surgery), the operation experienced three crises, nearly lost his life, and finally transferred to the ICU to continue treatment!Today I try my best to tell the whole story, I hope you join me as a warning! It was a friday with little surgery, and there was little left of the operation around noon, and as soon as I finished my meal, I was told I needed to take over a coscinal surgeryto know that this "small surgery" is usually done in the clinic can be done, I think to do do not intubate full hemp or joint anesthesia can be done; However, the surgeon informed me that the patient's placental implants and uterine adhesion were severe, and that the co-
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laparoscopic surgeryintrauterine residue removal, the operation time was 1-2 hours ; So I changed the way I anesthetized for the intubation whole hemp, and in hindsight it was the most correct thing I did very soon, I and the second line on the implementation of the whole hemp, everything started very smoothly 13:00, the operation begins, first in the B super guided by the coprinal probe, in half an hour to remove a large amount of placental tissue ; 14:05, it was observed that the surgeon's operation was not smooth, intravenous urine 10 mg, at this time the amount of urine is unknown; 14:15, observed the patient face edema, the body temperature is very low, the lower eyelid mucous membrane pale, quickly punctured the left artery blood gas, 3 minutes later the return is as follows: patients have a severe chloric acidosis, severe hypothermia, while severe anemia !" The operation is suspended! Calculate the inlet! Open the liquid all the way, the re-temperature blanket and the temperature meter at the same time!" I said nervously at the same time limit the liquid into, head shake 30 degrees high, catch up with accelerated urine 20 mg, potassium chloride 1g static droplets, calcium gluconate 1g slow injection, 5% sodium bicarbonate 200ml very soon, the results of the in-entry came out, surgery to this 1 hour or so to flush physiological saline intake 13000ml, flush out the amount of 9000 ml, while the infusion Ringer fluid 500ml, Wanwen 500ml, urine volume of 900ml, bleeding volume can not be calculated the result of the is a net intake of 4000ml per hour, the blood severely diluted! At this time I am more nervous, second-line doctor arrived in time, under his guidance to supplement calcium 3g, prevention give hydrogenated pine 75mg, and then add 10mg of diuretic, while entering 20% glycol injection 250ml, blood RBC4u plus plasma 400ml after the rescue, the patient's internal environment improved significantly, just when I was relieved, the patient's airway pressure increased significantly for a short time, from 15cmH2O after intubation to 32cmH2O, hearing double lung and obvious wet tone, the patient had acute pulmonary edema?
After reviewing the blood gas, add 5% sodium bicarbonate 100ml and urine 10mg; after communicating with the surgeon, decided to end the operation considering that the patient's symptoms improved, the whole rescue process had stable vital signs, and when the patient's body temperature rose back to 35.7 degrees Celsius, we decided to try to wake up, but a more terrible danger was approaching us As I expected, the patient quickly woke up and successfully removed the catheter, asking for no special discomfort Ready to lift the patient to the transfer bed, at this time, the patient suddenly a large number of jet vomit, large and colorless odorless liquid, about 400 ml, quickly head low side lying, fortunately did not vomit again because of concerns that the patient may have other complications, then transferred to the ICU observation, before the room to review the blood gas summary analysis (1) Because the patient temporarily transferred from the clinic to the operating room, flushing with physiological saline unheated for direct use in the uterine chamber examination, while the placental implant removal surgery caused by a large number of open, a large number of cold physiological saline directly into the blood vessels , dilution blood at the same time caused a significant drop in body temperature, inhibit the activity of clotting enzymes, causing clotting dysfunction, causing more saline into the body (2) a short period of time a large amount of salt water diluted blood will cause severe chlorpyrifos poisoning, strong ion difference SID sid 144 s 2.6-126 s 20.6, SID significantly reduced causing serious acidosis ; At the same time, the effects of chlorpyrifos on the body include metabolic acidosis caused by inhibition of myocardial contraction, reduced tissue perfusion, increase the incidence of nausea and vomiting after surgery, etc , and high chlorine can also slow down the blood flow of the kidneys and reduce the rate of glomerular filtration, resulting in reduced urine formation (3) Severe liquid load caused a significant increase in the amount of fluid inside and outside the cell, driving the average effective fluid static pressure of the of the blood vessels significantly increased ; At the same time, the osmotic pressure of the blood vessels decreases, which causes the liquid to enter the tissue fluid and cells, causing tissue and cell edema, the most serious is the cerebral cell edema, can cause the cerebral palsy; too much liquid will enter the third gap, such as the stomach intestinal cavity ; (4) The placenta implantist is serious, the blood sinus open during the scraping process can not calculate the amount of bleeding, infusion of RBC and plasma, the patient's whole process hemodynamic stability, infusion RBC can improve the ability to carry oxygen to increase tissue oxygen supply; but infusion plasma harm sorceration is more than good, plasma is mainly can improve blood clotting, increase colloidal osmotic pressure, but only 30% of the blood coagulation factor can maintain normal coagulation function, and the main measures to deal with blood dilution is to reduce blood capacity, maintain plasma osmosis pressure application of glycol may be better (5) surgery in 2 hours only applied 50 mg of rapid urine, resulting in urination too slowly too little, consult the psilocybose instructions: "usage" treatment of acute left heart failure exhausted, the initial dose of 40 mg intravenous injection, if necessary, an additional 80 mg per hour, until satisfactory efficacy, the total daily dose does not exceed 1 g , different from diuretics, there is a significant dose-effect relationship with diuretics such as furanemi, with the increase of the dose of diuretic effect significantly enhanced, and the drug dose range is large ; At the same time, the prostagres can inhibit the activity of the prostaglandin decomposition enzyme, so that the level of prostaglandin E increases, so as to dilate blood vessels, increase the blood flow of the kidneys; can also expand the lung capacity veins, reduce the pulmonary capillary blood vessel permeability, coupled with its diuretic effect, so that the amount of backheart work is reduced, left ventricular diastorate pressure is reduced, helping to the treatment of acute left heart failure all of the above shows that the furasemiis is the main treatment drug, and the safety is high, the effect is good, should be as soon as possible full additional Therefore, should be vigilant against such surgery, a large number of flushing fluid is very easy to cause acidosis, electrolyte disorders, hypothermia and other serious complications, should do a good job of preventive measures before surgery: 1, always pay attention to the amount of surgical flushing fluid, irrigation pressure is less than 60cmH2O ; 2, flushing fluid temperature; 3, timely urine to the psimili TURP syndrome: in uterine surgery, due to the combined action of the pressure of the puffin and the perfusion medium, the body absorbs a large number of perfusion media, significantly changes the balance of water electrolyte in the body fluid, the liquid overload absorption, causing a series of changes in the body possible mechanisms of absorption of water poisoning perfusion media: (1) direct access to open blood vessels during surgical excision; water poisoning hazard: can cause body fluid overload and dilution of hyposodium emis, and cause the corresponding changes in heart, brain, lung and other important organs, clinical show slow heart rate and elevated blood pressure, followed by lower blood pressure, nausea, vomiting, headache, blurred vision, anxiety, insanity and drowsiness, if diagnosis and treatment is not timely, convulsions, heart failure, and even death high-risk factors of water poisoning: surgery time is too long, the pressure of the uterus is too high and the blood sinuses are open, the small artery is cut off, the endometriosis or the removal of the endometrial is open to the blood vessels on the surface of the uterus, the uterine perforation and cervical fractures the principles of treatment of water poisoning: oxygen absorption, diuretic, treatment of hyponatremia, correction of electrolyte disorders and water poisoning, treatment of acute left heart failure, prevention of lung and cerebral edema Emergency measures for water poisoning: (1) improve the symptoms of hypoxia, in the event of water poisoning, should be terminated as soon as possible to ensure oxygen supply, combined pulmonary edema can be used 3 to 5cm H2OPEEP ventilation; Edema can be treated with glycol dehydration; (3) correct hyponatremia, sodium supplementation speed should not be too fast, according to the concentration of blood to adjust the drop rate; (4) control blood sugar; (5) if congestive heart failure, can use artichokes, (6) if necessary, antibiotics treatment, to prevent infection water poisoning prevention: (1) cervical and endometrial pretreatment helps reduce the absorption of irrigation fluid; (2) maintainuterine cavity pressure of 100mmHg or average arterial pressure; (3) control irrigation fluid difference in 1000 to 2000ml; (4) Shorten the surgical time to avoid too much damage to the uterine muscle wall, (5) dynamic monitoring of changes in hemodynamics, electrolytes and urine volume during surgery, and (6) close monitoring during surgery, always alert to the occurrence of body fluid overload Jiang Jianfeng Source: Anaesthetic Logic