super anesthesiologist

Chapter 9 Internal Iliac Artery Embolization

9 Internal iliac artery embolization

"Take a deep breath, take a deep breath." Lin Xiaobei quickly comforted, the only effective thing at this time is spiritual encouragement.

At the same time, capacity expansion and voltage boosting are also needed.No matter what, we must first find a way to maintain her vital signs.

The most urgent thing at this time is that the blood source is not coming.

The pieces of gauze that Li Xiumei pressed into Li Mengxia's abdomen quickly turned red, one piece after another, as if they had been fished out of a dye vat.

"Quickly call the blood transfusion department!"

"Already called."

At this time, Li Mengxia's vital signs deteriorated sharply, her blood pressure dropped to 85/42mmHg, and her heart rate jumped to 140 beats per minute.

Shocked!
"Director Li, I'm going to switch to general anesthesia." Lin Xiaobei said to Li Xiumei, no matter how effective the spinal anesthesia is, there is no way to continue to support the patient's breathing.

"Okay, okay, hurry up, do whatever you think works." Li Xiumei nodded.

Catkins quickly pumped up the general anesthetic and put it aside, and prepared a set of tracheal intubation: laryngoscope, tracheal tube (reinforced, with built-in steel wire to prevent collapse under pressure), pressure pad, catheter core, Tape.

Started to give oxygen to the patient with a mask. Li Mengxia was too fat, and Liu Xu's small hands couldn't support her thick jaw at all.

Such a huge jaw is an excellent exercise opportunity for every newcomer.Lin Xiaobei didn't have time to teach Liuxu the tricks, so he just asked her to push the medicine.

Considering that Li Mengxia is in shock, intravenous drugs that affect the circulatory system must be used with caution during the induction of general anesthesia, such as Propaminophen (Pro, an intravenous sedative) cannot be used at this time.

Lin Xiaobei asked catkins to infuse 15ug SF (narcotic analgesic) and 15mg of ethoxylate intravenously, and then gave roxamine 50mg (muscle relaxant) for rapid intubation.

After general anesthesia, Li Mengxia's vital signs did not drop very badly, her BP was 79/41mmHg, HR was 142 beats/min, and SPO2 was 99%.

"Prepare the heparin, I'll insert the central vein." Lin Xiaobei continued to direct Liuxu.

The simple peripheral venous infusion channel has been difficult to maintain, and the rapid infusion channel must be re-established, and the internal jugular vein is the first choice.

The development of human beings is really strange, as if it was preordained in the dark.Most of us are right-handed, and the fine motor skills of the right hand are much higher than those of the left hand.

The beauty of the internal jugular vein lies in its direction. It extends from the left and right sides of the skull base to the neck, and is covered by muscles (sternocleidomastoid muscle) throughout.The right internal jugular vein is thicker, almost in line with the brachiocephalic vein and the superior vena cava.And the right pleura is lower than the left, and there is no thoracic duct on the right.

These special anatomies make the puncture and cannulation of the internal jugular vein preferentially performed on the right side.

Just in line with the right hand movement of most people.

It is not necessary to position the patient in the standard head-down supine position (Trendelenburg position) with the right shoulder padded and the head thrown back.

There is also no need to feel the pulse of the artery first, then locate the anatomy, and then choose the anterior, middle, and posterior puncture method according to personal habits.

Lin Xiaobei didn't have time to be picky.

Li Mengxia was very obese, with thick subcutaneous fat and a thick and short neck. It was very difficult to locate her, and she couldn't feel the carotid pulse at all.

But these are nothing to the current Lin Xiaobei, he can feel the position of Li Mengxia's transverse process of the fourth cervical vertebra and thyroid cartilage with a light touch.

He took the intersection point of the patient's external jugular vein and the lateral edge of the sternocleidomastoid muscle, and then connected with the transverse process of the fourth cervical vertebra, and the horizontal position of the midpoint was just aligned with the thyroid cartilage.

After such a seemingly rough but very precise positioning, he tried it on, punctured the internal jugular vein, introduced the guide wire, broke the skin, and inserted the tube. The whole process was done in one go.

After the withdrawal was unobstructed, Lin Xiaobei said to Liu Xu who was standing stunned at the side: "You fix it, you are sure, the depth I left is 13cm."

These are all finishing operations, but for a novice like Liu Xu, this is a rare opportunity.A complex operation cannot be mastered in one step. It is first easy and then difficult, first simple and then complex, and from easy to deep.

She does not interfere with central venous fluids while she is sutured.

Lin Xiaobei checked his blood gas, and the result showed that the patient's hemoglobin (hemoglobin, Hbg) was only 7.2g/L, while the latest blood test result in the medical record was 12.8g/L.

This proved that there was too much blood loss suddenly during the operation. No wonder the patient's blood pressure collapsed so badly and his heart rate remained high.

典型的失血性休克，中心静脉压显示2cmH2O，血容量明显不足（正常值5——12cmH2O）。

The bad thing is that her abdominal cavity has been heavily polluted by amniotic fluid and meconium, and the lost blood cannot be recovered.

"Li Qiong, quickly draw blood, check blood coagulation function, thromboelastogram!" Lin Xiaobei almost ordered.

He highly suspected that the patient would develop "disseminated intravascular coagulation (DIC)".

Six units of red blood cells from the blood transfusion department finally arrived, but this drop in the bucket was far from solving the problem.The patient's bleeding continued.

"Apply for 10 more units."

Li Mengxia's uterine contraction was weak, and the blood from the wound continued to flow out like a leak from the gap in the wall of the sink. The gauze block had been replaced with a gauze pad.

Li Xiumei's hands seemed to be soaked in a pool of blood, and she was still able to force herself to be calm. Liu Lu, who was opposite her, was completely pale and terrified.

"No, something will happen if this goes on (dead person), Li Qiong, go and call her husband, and I will tell him that his wife's uterus needs to be removed."

This is the most helpless choice after cesarean section bleeding.

The absence of a uterus means that the woman will never be able to conceive a child again.Although maybe she doesn't need to get pregnant again in the future, at least she has that ability.

Just like you have the ability to buy a house in the imperial capital but are unwilling to do so, and you cannot afford to buy a house in the imperial capital at all. The two feelings are completely different.

What's more, the health status of Li Mengxia's two babies is still unknown.

"Director Li, I have a solution, is it feasible?" Lin Xiaobei asked.

"Say it!" Li Xiumei seemed to see hope, and she was full of anticipation, and she was unwilling to make a bad move unless it was absolutely necessary.

"Can you try embolization of the internal iliac artery?"

"What?" Li Xiumei was taken aback, thinking that she had a hearing problem.

"Internal iliac artery embolism." Lin Xiaobei repeated.

"Doctor Lin, you---" she closed her mouth in time in disappointment, she was really not in the mood to say the word "just kidding".

Internal iliac artery embolization is a new method proposed in recent years to treat postpartum hemorrhage. Spring coils or gelatin sponge particles are sent into the appropriate position of the internal iliac artery through a catheter to block the blood flow of the aorta (because there are abundant collaterals in the lower abdomen) The circulation blood supply has little impact and will not cause ischemia and hypoxia in the lower abdominal organs and tissues).

This method has a definite curative effect, but it has high technical requirements for the operator and high requirements for the equipment.

It is a bit of a fantasy to mention this kind of treatment now in such an urgent time, and it is still in the operating room.

In Li Mengxia's state, it is difficult to transport her to the intervention room even with a helicopter.

Embolization of the internal iliac artery was new and unfamiliar to the others at the scene, so when Lin Xiaobei spoke, they all looked confused and didn't know what to say.

"I think you can try it, your hysterectomy will cause more bleeding." Lin Xiaobei said sincerely.He is not threatening, and now there are only 6 units of red blood cells. According to the current trend, it will not last long.

Li Xiumei was lost in thought, and after thinking for a while, she said to him: "Please turn on my mobile phone and call the intervention department."

She is not compromising, interventional doctors will 100% refuse, doing so just shows that they have fulfilled their responsibilities.

"That's not necessary, let me try." Lin Xiaobei's voice was not loud, but his shocking words stunned everyone else in the operating room.

In China, it is generally done by full-time interventional personnel under the perspective of interventional science.

Doctor Lin Xiaobei...

"You---" Li Xiumei had always had a good impression of him, and now she felt embarrassed to ridicule and sarcasm, but felt that he was too rampant, and her words were so unreliable.

"Don't worry, Director Li. I won't delay you for a long time." Lin Xiaobei has already started to prepare.

"Li Qiong, please open another changing bag, and bring me an ESD (digestive endoscopy) guide wire."

In fact, the best way is to use plastic interventional catheters, but there are none in the operating room, and it is too late to borrow from the interventional department at this moment.

Lin Xiaobei asked Hu Shuang on the stage to remove the instrument table first, and lifted Li Mengxia's lower body drape (upper body), exposing her right groin area (where the puncture point of the femoral artery is located).

Then quickly go out and wash your hands in the hand washing area (seven-step surgical hand washing method).

After the clothes were changed, the guide wire was delivered quickly and placed on a non-polluted instrument table.

"What else do you want, Dr. Lin?" Li Qiong asked.

"Gelfoam particles."

Lin Xiaobei put on gloves, and pierced the femoral artery where the pulse was most obvious.

His movements were very smooth. Although he couldn't see the specific situation of the guide wire in Li Mengxia's body clearly, it could be seen from the sliding movement of his hand that the guide wire moved smoothly and unobstructed in the blood vessel.

"Pass me the gelatin sponge particles." Lin Xiaobei roughly estimated the depth and stopped feeding the guide wire.

Li Xiumei began to worry, doubted for a while, then surprised, and finally a happy expression appeared on her face.She obviously felt that the bleeding on the right side of the uterus was much smaller, as if many springs were blocked.

After filling the right internal iliac artery, Lin Xiaobei withdrew the guide wire, pressed the puncture port with a gauze pad, and said to Liu Lu, "Please step down and help me press for a while."

The reason why he called her was also because he needed her to make way.

Embolization of the left internal iliac artery was also successful.

There is no need to press any more, the uterus is like a blocked dam at this time, no trace of blood seeps out.

Li Mengxia's blood pressure temporarily stabilized, her heart rate was still as high as 130 beats per minute, and her ischemia was still severe.

"Doctor Lin, you, when did you learn to intervene?" Li Xiumei asked in surprise and admiration.At this time, she looked relaxed, now there is no risk of continuing to bleed, and she only needs to wait for the source of blood to ensure Li Mengxia's safety.

She was secretly glad that today's anesthetist was Lin Xiaobei.

"I used to practice on pigs when I was a graduate student." Everyone who had seen Lin Xiaobei's technique asked this question, and he answered the same question.

"Oh!" Li Xiumei seemed to understand, but she was full of doubts. Why do you still work as an anesthesiologist when you have this technology?Intervention can be much higher than this income.

"Mr. Lin, the results of thromboelastometry and coagulation function are back." Liu Xu pointed to the latest test results from the computer and said.

Lin Xiaobei stared at the screen film carefully, with a stern expression, "Hurry up and deal with it according to DIC!"

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(End of this chapter)