Sudden cardiac arrest during percutaneous nephrolithotomy once again demonstrated the anesthesiology department's ability to provide protection

For a long time, everyone thought that the anesthesia department was only responsible for administering anesthesia. Even the surgeons and nurses who worked with the anesthesia department every day more or less believed this. Because most surgeries were completed without any ripples under the careful care of the anesthesia department, and there were very few times when the anesthesia department was needed. As for rescue, it would not happen for a long time.

Not long ago, a percutaneous nephrolithotomy really made everyone nervous. This operation was nothing special, and we had to do several operations like this every day. The patient's physical examination was fine, so the operation was carried out in a relaxed manner.

However, when the operation was more than halfway through, the anesthesiologist discovered something unusual: the patient's blood oxygen level was getting lower and lower, and the rate of decline was very fast. While the anesthesiologist was troubleshooting the anesthesia machine, the pipeline, and the monitor, the blood oxygen level had dropped to around 50%.

At the same time, the sharp drop in blood pressure and heart rate reminded the anesthesiologist: this patient is in critical condition!

Therefore, the anesthesiologist immediately ordered the termination of the operation and placed the patient in a supine position.

Even though the surgeons are usually very capable, at this moment the patient has a problem and they have no choice but to cooperate.

As the anesthesiologist gave instructions for chest compressions, the chief surgeon forgot to instruct the young surgeon to do so and instead went up to do the compressions himself. They knew what it would mean if the patient could not leave the operating room.

On the anesthesiologist's side, adrenaline has already entered the patient's body as soon as the patient lies flat. Although the anesthesiologist does not know why the patient has such an emergency, cardiopulmonary resuscitation is the necessary first step in the event of cardiac arrest.

After the first injection of epinephrine, the anesthesiologist observed the patient's vital signs and performed blood gas analysis and other operations. He needed more clues to analyze what was happening to the patient.

What puzzled and excited him was that soon after the patient lay down, his blood pressure began to rise, followed by his heart rate and blood oxygen gradually returning to normal.

Normally, if cardiac arrest occurs, some vasoactive drugs should be continued. However, this patient obviously no longer needs them. The surgeon who had been pressing there was ready to press for half an hour.

The surgeon thought he had misheard the anesthesiologist's words "stop chest compressions" and asked in confusion: "Stop compressions?"

Yes, the patient is back. As the anesthesiologist pointed to the monitor, the surgeon said excitedly, "Good! Good! Good! Great!"

At this time, only a few minutes had passed since the patient was turned over. The nurse who ran in with the defibrillator didn't know what had happened and was about to defibrillate the patient. The anesthesiologist said: No need, the patient is back.

"Are you back?" the nurse asked in disbelief.

This situation is indeed rare. The anesthesiologist stared at the data on the monitor and wondered what happened. If the cause is not found, it is very likely to happen again. The next time it happens, maybe we won't be so lucky.

The anesthesiologist noticed that the patient had some special manifestations before the cardiac arrest: the patient's head and neck, upper limbs and chest 3 to 4 cm below the nipples were cyanotic and congested, and the eyeballs were protruding.

If combined with the patient's low blood pressure, isn't this a manifestation of obstruction of superior vena cava return?

The factors that can lead to obstruction of superior vena cava return are nothing more than superior vena cava tumors, high pressure compression inside and outside the mediastinum, etc.

However, the patient's superior vena cava was normal in the X-ray taken before the operation, and there was no existing pathological change. Could it be that something happened to the patient during the operation?

What happens during the operation? The anesthesiologist will review all the steps of the operation step by step.

Suddenly, he thought of a situation: there was a flushing step before the event occurred.

According to experience, this operation is performed near the pleura, and there is a high possibility of pleural damage. If the pleura is damaged, the flushing fluid may enter the chest cavity. Once the flushing fluid enters the chest cavity, the effusion in the cavity causes the mediastinum to suddenly shift to the other side, the superior vena cava is compressed and blocked, blood reflux is obstructed, and acute hemodynamic disorder and cardiac arrest occur.

Now that we have a reasonable explanation, how do we verify it?

The anesthesiologist picked up the stethoscope and began to listen to the lungs. At the same time, he asked the nurse to get a mobile ultrasound.

When the stethoscope was placed on the patient's chest wall, everyone fell silent. At this moment, the anesthesiologist was no longer the doctor who only gave anesthetics, but the backbone of everyone.

When the anesthesiologist took away the stethoscope, he said with certainty: There is a problem in the chest cavity, most likely pleural effusion, and we will come for ultrasound to verify it later.

As a clear liquid level appeared on the ultrasound screen, the surgeon, who did not want to admit it, could only say: Please ask the thoracic department to come for a consultation.

Generally speaking, it is not easy to consult other departments in such a situation. Once other departments are consulted, it means that the matter can no longer be covered up. However, in a situation where human life is at stake, all other reasons cannot be used as excuses.

Soon, the thoracic department performed closed chest drainage on the patient, and the surgical department continued the operation, and the operation had to be completed.

At this time, his courage to perform the operation came from the support of the Department of Anesthesiology.

In the second half of the operation, the surgery department seemed a little relaxed and showed great admiration for the anesthesiology department. When the patient left the operating room, the surgery department's eyes were full of gratitude. However, this situation may not last long. In a few days, the anesthesiology department may become a department that only knows how to give anesthesia. However, if the patient can be safe every day, let them be.

Author: Dr. Luo from Beijing

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