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    Home > Active Ingredient News > Anesthesia Topics > [Crisis event] Sudden acute hemopneumothorax during perianesthesia

    [Crisis event] Sudden acute hemopneumothorax during perianesthesia

    • Last Update: 2022-05-01
    • Source: Internet
    • Author: User
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    Jingzhe · 24 solar terms, spring qi sprouting, nature has new vitality Chapter 26 Sudden acute hemopneumothorax in the peri-anesthesia period—, the occurrence and harm of sudden acute hemopneumothorax in the peri-anesthesia period 01 Sudden peri-anesthesia period Definition of acute hemopneumothorax Acute hemopneumothorax refers to the accumulation of blood and gas in the pleural cavity caused by chest trauma.
    It is a common complication of chest injury.
    Serious threat to the patient's life
    .

    Perioperative hemopneumothorax refers to the sudden onset of blood and gas in the pleural cavity during surgery, which is mostly caused by iatrogenic factors
    .

    If the hemopneumothorax in the perioperative period is not detected and treated in time, one or both lungs may be compressed and collapsed, the alveoli cannot be ventilated, and the lung ventilation/blood perfusion will be seriously imbalanced, and the patient will experience extreme breathing difficulties.
    Large amounts of unoxygenated blood are mixed with arterial blood, resulting in marked cyanosis and hypoxemia, as well as clinical manifestations of acute respiratory failure
    .

    Due to the high pressure in the thoracic cavity of the affected side, it is enough to push the mediastinum to the unaffected side, the heart is displaced, and the blood flow of the vena cava back to the heart is blocked, causing a significant decrease in cardiac output, severe hypotension, or shock
    .

    If acute hemopneumothorax is not treated in time, the patient may die due to respiratory and circulatory failure in a short period of time
    .

    The clinical manifestations show different clinical symptoms and signs according to the speed of gas entering the thoracic cavity, the amount of accumulated gas, the amount of bleeding, and the degree of lung tissue compression
    .

    Mild cases may be asymptomatic.
    If more than 1/5 of the lung tissue loses ventilation function, shortness of breath, difficulty in breathing, cyanosis, and tachycardia may occur
    .

    There may be no obvious changes in blood pressure at the beginning, and with the progression of the disease, such as mediastinal displacement, increased hypoxia, and increased blood loss, hypotension or even shock occurs
    .

    The first signs seen under general anesthesia may be tachycardia and hypotension that are not readily distinguishable from deep anesthesia or hypovolemia, but an increase in airway resistance is felt during rescue breaths due to decreased compliance of the compressed lung , need to increase airway pressure to maintain ventilation
    .

    There may also be subcutaneous emphysema
    .

    Contrasting bilateral chest percussion may show hyperresponsiveness on the affected side
    .

    Bilateral tension pneumothorax not only significantly weakened ventilation, but also showed stridor and excessive response to both chest percussion
    .

    Arterial blood gas analysis showed a significant decrease in PaO2 and an increase in PaCO2, and chest X-ray examination could confirm the diagnosis
    .

    02 Occurrence of sudden acute hemopneumothorax in the peri-anesthesia period Hemopneumothorax is a common complication in patients with multiple trauma.
    The incidence of hemopneumothorax in patients with blunt trauma is about 20%, and the incidence in patients with penetrating injury is as high as 40%
    .

    The incidence of hemopneumothorax in patients with chest trauma is as high as 60% to 70%, and hemopneumothorax causes blood volume reduction and lung compression and collapse.
    In severe cases, it can cause difficulty in breathing and even threaten the patient's life
    .

    Although the incidence of acute hemopneumothorax in the perioperative period is relatively low (currently 0.
    1 to 0.
    2/10,000 in China), it seriously threatens the life safety of patients, and it is not easy to detect during anesthesia
    .

    Therefore, once this case is diagnosed, it should be dealt with immediately to remove the cause, maintain smooth breathing, maintain the stability of hemodynamics, and prevent damage to organ function
    .

    03 Symptoms of sudden acute hemopneumothorax during the peri-anesthesia period (1) Chest pain: acute hemopneumothorax is often accompanied by severe chest pain.
    However, chest pain is difficult to detect under anesthesia, mainly manifested as an unexplained increase in heart rate.
    Analgesics and sedatives cannot be relieved
    .

    (2) Shock: acute blood loss in patients with severe hemopneumothorax results in a sharp decrease in effective circulating blood volume
    .

    Hypovolemic shock can result when acute blood loss exceeds 20% of systemic blood volume
    .

    During the peri-anesthesia period, patients are under anesthesia, which is mainly manifested as a sudden increase in heart rate, a decrease in blood pressure, a weak pulse, a sharp decrease in SpO2, and a decrease in hemoglobin and red blood cells, which seriously threatens the life safety of the patient
    .

    (3) Dyspnea: When hemopneumothorax occurs, patients have different degrees of dyspnea, and the severity is related to the attack process, the degree of lung compression and the original lung function state
    .

    The main manifestations in the peri-anesthesia period are the decrease of SpO2, the increase of airway pressure, the weakening of respiratory movement, and the weakening or disappearance of breath sounds on auscultation
    .

    (4) Traumatic hyperglycemia response: Disturbance of glucose metabolism is an important change in the post-traumatic metabolic response, often manifested as increased blood sugar and lactic acidemia, and increased blood sugar concentration after the occurrence of hemopneumothorax in the peri-anesthesia period
    .

    (5) Systemic inflammatory response syndrome: Inflammatory response is a physiological response of the host to injury or infection.
    After severe trauma, the body may have a systemic inflammatory response, manifested as fever (body temperature greater than 38°C) and increased heart rate.
    (greater than 90 beats/min), increased white blood cell count (white blood cell count greater than 12X107L).
    Increased capillary permeability, negative nitrogen balance, increased plasma corticosteroid concentration, increased liver acute phase protein and cytokine synthesis
    .

    Severe hemopneumothorax in the peri-anesthesia period can cause a systemic inflammatory response
    .

    (6) Perioperative hemopneumothorax is sometimes accompanied by some special manifestations, making it difficult to detect and diagnose hemopneumothorax
    .

    Such as: intraoperative pneumothorax manifested as abdominal distention
    .

    (7) Hemo-pneumothorax caused by iatrogenic injury can lead to respiratory and circulatory disorders, and in severe cases can endanger the patient's life
    .

    04 Harm of sudden acute hemopneumothorax during peri-anesthesia period Acute hemopneumothorax during peri-anesthesia period destroys the patient's respiratory, circulatory and hemodynamic stability, leading to ischemia and hypoxia, and in severe cases, shock to the patient, and can also induce pulmonary infection, blood gas The chest can even cause abdominal infection, systemic inflammatory response, respiratory and circulatory failure, and damage to systemic organs and endanger the life of patients
    .

    How to predict and prevent the occurrence of acute hemopneumothorax in the peri-anesthesia period is a common problem faced by all anesthesiologists and surgeons
    .

    2.
    Analysis of the causes of sudden acute hemopneumothorax during the peri-anesthesia period 1.
    Patient factors (1) The patient himself suffers from lung, tracheobronchial diseases, such as emphysema, bronchiectasis, bullae, chronic obstructive pulmonary disease, etc.
    And congenital diseases, such as: congenital bronchial atresia, rupture of alveoli and trachea causing gas or blood to enter the pleural cavity
    .

    (2) The patient suffers from cardiovascular disease, such as hypertension, arteritis, aneurysm, etc.
    , as well as hemorrhagic vascular disease.
    During the peri-anesthesia period, blood vessels in the lungs and chest are ruptured and hemorrhage due to blood pressure fluctuations or surgical trauma, which infiltrate into the pleural cavity.
    Blood pneumothorax
    .

    2.
    Surgical factors (1) When performing invasive central venous monitoring (internal jugular vein or supraclavicular and inferior venous puncture), since the puncture point is close to the pleura and lungs, the puncture operation often punctures the pleura and induces a hemopneumothorax
    .

    (2) Injuries caused by surgical operations, when performing tracheostomy, thyroidectomy, and neck tumor operations, the visceral or parietal pleura and blood vessels are often damaged during the surgical operation, resulting in acute hemopneumothorax
    .

    (3) Surgery that leads to increased airway pressure.
    For example, during laparoscopic surgery, pneumoperitoneum needs to be established for the convenience of operation, and a large amount of CO2 is injected into the abdominal cavity, which increases the abdominal pressure, which leads to the increase of airway pressure, which is easy to cause pulmonary bullae.
    In patients with bronchiectasis and bronchiectasis, airway rupture can cause hemopneumothorax, or excessive CO2 absorption into the pleural cavity has become a risk factor for inducing pneumothorax
    .

    3.
    Anesthesia factors (1) The airway pressure is too high.
    During anesthesia, applying high pressure to the patient to assist or control breathing can cause pulmonary bullae, bronchiectasis and other patients with alveolar rupture and induce hemopneumothorax
    .

    (2) Anesthesia damages the throat wall during laryngoscope or tracheal intubation, as well as damage to the pleura, lung tissue and blood vessels during brachial plexus block, intercostal nerve, paravertebral nerve block, and thoracic sympathetic nerve block The passage of gas or blood into the pleural space results in an acute haemopneumothorax
    .

    3.
    Coping strategies for sudden acute hemopneumothorax during peri-anesthesia period (3) Patients with acute hemopneumothorax are often accompanied by chest pain, dyspnea, hypotension, increased heart rate, decreased breath sounds on auscultation, and in severe cases, shock and respiratory and circulatory failure; ④ When hemopneumothorax is highly suspected X X-ray examination to confirm the diagnosis, chest X-ray shows pleural effusion or gas, X-ray is not obvious, CT-assisted and thoracentesis can be further confirmed
    .

    2.
    Monitoring (1) Pay attention to observe the patient's breathing, breathing frequency, breathing motion, skin color of lips and extremities, as well as the patient's thoracic undulation and intercostal space
    .

    (2) Auscultate the strength of breath sounds in the patient's lungs and the symmetry of the breath sounds on both sides
    .

    (3) Monitor the patient's pulse, blood pressure, heart rate, electrocardiogram, SpO2, and airway pressure during anesthesia
    .

    3.
    Treat a small amount of hemopneumothorax without obvious symptoms
    .

    Among them, mild cases such as simple small closed pneumothorax with lung collapse of 20% to 25% can be observed and absorbed by themselves
    .

    Severe haemopneumothorax with profuse bleeding or high-pressure gas is one of the leading causes of death from chest injuries and must be treated urgently
    .

    Acute hemopneumothorax, like other types of serious chest injuries, must be diagnosed and treated simultaneously
    .

    Give timely and effective treatment, so that patients can turn the corner, otherwise they may die due to not timely rescue
    .

    For patients with hemopneumothorax, the following 10 questions should be judged early: ① whether there is hypovolemia; ② whether there is respiratory insufficiency; ③ whether there is tension pneumothorax; ④ whether there is cardiac tamponade; ⑤ whether there is multiple rib fractures ( Paradoxical breathing); ⑥ with or without severe hemothorax, pneumothorax or hemopneumothorax; ⑦ with or without mediastinal injury; ⑧ with or without diaphragm rupture; ⑨ with or without rupture of the aorta or its main branches
    ;
    If the wounded has one of the above 10 items, his life can be in danger at any time
    .

    Diagnosis and treatment must sometimes be made before X-rays are done to save lives
    .

    The main treatment measures for acute hemopneumothorax in the perioperative period are as follows: (1) Early closed drainage of acute hemopneumothorax: The advantages of closed drainage in the early stage of acute hemopneumothorax are: ① Quickly relieve the compression of the hemopneumothorax on the lung and mediastinum, improve breathing , cycle function
    .

    ② can prevent or reduce the incidence of empyema and coagulation hemothorax
    .

    ③ Observe the amount of blood through drainage to determine whether there is active bleeding and whether emergency thoracotomy is needed
    .

    Clinically, the vast majority of patients develop hemopneumothorax immediately after injury.
    Except for bleeding from large blood vessels, most of the intrathoracic hemorrhage stops within a few hours and up to 12 hours.
    Generally, fibrin is precipitated in the blood within 2 to 5 hours, and the thoracic blood loses its coagulability.

    .

    However, some patients with thoracic trauma have no hemopneumothorax or a moderate amount (500-1000ml) or a large amount (above 1000ml) of hemopneumothorax occurs after admission
    .

    The incidence of this delayed haemopneumothorax is about 10%
    .

    The delay time is 5 hours for the shorter and 15 hours for the older
    .

    1/3 occurs within 24 hours after injury, especially within 6 hours after initial examination
    .

    Therefore, every wounded person with chest injury needs to be closely observed, or he is instructed to come to the doctor at any time when there is a change in the hospital
    .

    (2) Anti-shock: The most acute contradiction in the early stage of patients with hemopneumothorax shock is hypovolemia, which is also the main cause of systemic physiological disorders
    .

    Correction of hypovolemia and maintenance of circulatory stability must be addressed concurrently with respiratory failure
    .

    Quickly and effectively restore circulation, ensure tissue oxygen supply, and prevent hypotension-induced cerebral hypoxia, cardiac arrest, and renal impairment are the basic goals of early post-traumatic shock resuscitation
    .

    ① Fluid resuscitation: Patients with hemopneumothorax are often accompanied by hypovolemia, and anesthetic drugs can exacerbate “functional” volume insufficiency
    .

    The first condition for fluid resuscitation is the establishment of venous access, in addition to the establishment of central venous access as far as possible
    .

    The tourniquet should not be released immediately when the patient has a tourniquet.
    It should be released as the situation requires after monitoring and fluid replacement have started
    .

    Fluid therapy for trauma patients should follow these three steps
    .

    The first thing that needs to be solved is to restore the patient's circulatory capacity.
    Most of the previously healthy trauma patients died of hypovolemic shock; the second is to restore the oxygen-carrying capacity of the patient's blood, that is, the transfusion of red blood cells; the last is to maintain the patient's coagulation function, which can be transfused.
    Inject platelets, fresh frozen plasma or other blood components
    .

    In the process of fluid resuscitation, the following points should be noted: a.
    The actual volume of blood lost is often underestimated; b.
    During surgical operations, the amount of tissue fluid lost per hour is 4~8ml/kg; c.
    If crystalloids are used for resuscitation, the dosage It should be 2 to 3 times the lost blood volume; d.
    Most anesthetics can increase the lumen of blood vessels, that is, expand the "functional" capacity; e.
    Hemoglobin should be maintained above 80g/L; f.
    A large number of crystalloids are used for resuscitation It can cause dilutional thrombocytopenia, and the platelet count should be maintained above 70X107L; g.
    Most trauma patients are in a low temperature state when they arrive at the hospital
    .

    When blood volume is deficient, colloid supplementation can achieve rapid resuscitation and increase cardiac output with only a small dose
    .

    Crystalloids often only restore blood pressure without increasing cardiac output
    .

    Hypertonic saline can restore blood pressure quickly, but the effect is short-lived and can be used with colloids
    .

    Hypertonic saline may be more appropriate for patients with traumatic brain injury
    .

    ②Blood transfusion: In the rescue of severe trauma, massive blood transfusion is very common, and attention should be paid to the various serious complications caused by it
    .

    Blood loss of more than 5000ml will lead to the loss of platelets and coagulation factors.
    When coagulation dysfunction occurs, blood components such as frozen plasma and platelets should be supplemented
    .

    Massive blood transfusion therapy can also cause electrolyte and acid-base imbalance, so blood gas and biochemical measurements should be routinely performed
    .

    During massive blood transfusion and rescue, serum potassium changes greatly, and monitoring must be strengthened
    .

    Due to the massive release of catecholamines during the stress response, hypokalemia is often accompanied on admission, but severe hyperkalemia can occur during massive blood transfusion.
    Only when the blood transfusion rate exceeds 100ml/min, can hypocalcemia and Rafter acid poisoning
    .

    In an emergency, patients with intra-abdominal hemorrhage can use their own blood for reinfusion to maintain hemodynamic stability and restore the pulse to the normal range, and the central venous pressure reaches 0.
    8 to 1.
    2 kPa
    .

    When the urine output reaches 1ml/kg per hour, it means that the infusion has been sufficient and the goal of restoring normal blood volume has been achieved
    .

    When the bleeding has stopped, the return of oxygen consumption to above normal levels is considered the best end point of resuscitation
    .

    Sufficient oxygen supply and increased oxygen consumption to repay the "oxygen debt" are beneficial to improve the survival rate of critically ill patients
    .

    ③ Vasoactive drugs: It is absolutely contraindicated to use vasoconstrictor drugs to replace blood volume in hypovolemic shock
    .

    When blood pressure is very low or undetectable, and a large amount of fluid cannot be replenished in a timely manner, in order to temporarily increase blood pressure, maintain cardiac and cerebral blood perfusion, and prevent cardiac arrest, a small amount of vasoactive drugs can be used
    .

    One of the most commonly used drugs is dopamine, which can enhance myocardial contractility, increase cardiac output, increase peripheral vascular resistance, and increase blood pressure
    .

    The general dose is 5~10ug/kg per minute
    .

    (3) Anesthesia treatment Strive for every second before anesthesia, create conditions and improve the state, is the most important link to ensure the safety of anesthesia and surgery
    .

    Based on a series of drastic changes in pathophysiology of acute hemopneumothorax, the disease is severe and severe, and life is mostly in a dying state, and sudden death may occur even after every minute delay.
    Various complex puzzles
    .

    Such as massive blood loss and fluid loss, hypoxia, severe pain, airway obstruction, infection, vomiting and reflux aspiration, acidosis, cardiac tamponade, shock, traumatic wet lung, paradoxical breathing, massive hemoptysis, renal failure, malignant heart rhythm Abnormalities, intra-abdominal bleeding, etc.
    , occur almost simultaneously or consecutively
    .

    The shock rate can be as high as 48.
    7%, and the tension hemopneumothorax is 15.
    3%.
    Therefore, within the extremely limited time window before anesthesia, the effective alveolar respiratory exchange volume can be restored and maintained to the greatest extent, blood gas can be improved, and acidosis can be corrected.
    Among them, the trauma can be corrected as soon as possible.
    Consequential anatomical defects (closed drainage, chest wall immobilization), maintaining airway patency (oropharyngeal airway, trachea, and intubation), adequate oxygenation (nasal cannula or mask oxygen, artificial respiration), antibiotic administration, intravenous access Replenishing blood volume, relieving severe pain, and strict monitoring are the main measures
    .

    Selection and treatment principles of anesthesia methods: All anesthesia needs to be completed under tracheal intubation anesthesia.
    For patients with tension pneumothorax, closed chest drainage must be performed before induction of general anesthesia, otherwise positive pressure ventilation will aggravate tension pneumothorax and cause mediastinal displacement.
    , and even sudden death
    .

    For those with cardiac tamponade, pericardiocentesis should be performed under local anesthesia for decompression and drainage
    .

    The principle of anesthesia treatment is light anesthesia supplemented with muscle relaxants, local anesthesia or intercostal nerve block can be added to control breathing and improve respiratory function
    .

    Strictly prevent vomiting and aspiration during anesthesia, ensure that the respiratory tract and digestive tract are isolated and maintained until fully awake for safety, strive to eliminate and reduce mediastinal swings, avoid the diffusion of substances in the lungs, maintain PaO2 and PaCO2 at basically normal levels, and maintain a balanced volume and body.
    At the same time, it is necessary to pay attention to the characteristics of prolonged action time of anesthetics and extremely poor tolerance of anesthetics.
    It is advisable to use a small amount and light anesthesia
    .

    (4) Prevention of infection After the occurrence of hemopneumothorax, it is easy to cause infection of the patient's lungs, pleura, and even abdomen.
    Therefore, appropriate and timely prophylactic use of antibiotics after the occurrence of hemopneumothorax can reduce the infection of the patient
    .

    (5) Thoracotomy For acute severe hemopneumothorax and progressive hemopneumothorax, when the symptoms cannot be relieved by general treatment, thoracotomy can be performed
    .

    With the development of minimally invasive techniques, video-assisted thoracoscopic surgery for hemopneumothorax has also been developed, and has the advantages of less trauma, faster recovery, and fewer complications
    .

    4.
    Thoughts on sudden acute hemopneumothorax in the peri-anesthesia period 1.
    Adequate preoperative doctor-patient communication Doctor-patient communication is a basic skill that medical staff in modern hospitals must have, especially in the current "biological-psychological-social" medical model environment Doctors are also required to have good doctor-patient communication skills
    .

    In medical activities, if medical staff discuss the effects of the upcoming medical behavior, possible complications, limitations of medical measures, disease outcomes and possible risks, etc.
    , with patients or family members before implementing medical behaviors Communicate, let them know the correct medical information before making medical decisions related to treatment effectiveness and risk avoidance
    .

    Doctor-patient communication helps patients and their families to prepare psychologically, and to understand and treat them correctly when unsatisfactory results occur in the future
    .

    The high risk of anesthesia requires every anesthesiologist to have better communication skills between doctors and patients.
    Before anesthesia, fully explain possible complications, limitations of medical measures and possible risks to patients or their families, so as to create a harmonious medical environment.

    .

    2.
    Cooperate with the surgeon The operating room staff is a team.
    The smooth and smooth completion of the operation requires the mutual cooperation and appropriate work of the surgeon, nurses, and anesthesiologists.
    They have a common goal: "patient-centered, everything for patients"
    .

    The good cooperation between anesthesiologists and surgeons is very important to ensure the safety of patients' lives and reduce complications, so as to make patients comfortable and safe during the perioperative period
    .

    ① Discuss the condition, possible complications and risks with the surgeon before surgery, and inform the choice and risks of anesthesia methods; ② Closely monitor the vital signs during the operation, and explain the situation to the surgeon in time if there is any change, and the surgeon can be warned in special circumstances Suspend the operation and check carefully; ③ inform the surgeon about complications after anesthesia and nursing precautions after operation
    .

    3.
    Do a good job of prevention.
    Take precautions for everything.
    If you don't, you will fail.
    Take precautions in everything.
    Preventing troubles before they happen is the most sensible choice
    .

    Taking preventive measures to prevent the occurrence of diseases is undoubtedly the best treatment method
    .

    The prevention of hemopneumothorax in the perioperative period is an important responsibility of anesthesiologists, and it is also a fundamental means to safeguard the interests of patients
    .

    How to effectively prevent the occurrence of acute hemopneumothorax can be considered from the following aspects: ① Fully grasp the patient's condition before surgery, and consider whether there are risk factors for hemopneumothorax
    .

    ②Strict operation and caution during anesthesia and surgery to avoid damage to blood vessels and trachea, and do not puncture the pleura
    .

    ③ Intraoperative close monitoring, control of airway pressure, observation of respiratory movement, and auscultation of breath sounds
    .

    ④ Explain the precautions to patients and their families after surgery: do not do strenuous exercise, keep the stool unobstructed, pay attention to hygiene,
    etc.

    4.
    Reasonable resolution of medical disputes In the situation of asymmetric medical information between doctors and patients and the complex environment of doctor-patient relationship, the frequent occurrence of medical disputes is a social reality that is obvious to all
    .

    After a medical dispute occurs, both the patient and his family, the medical unit and the medical staff involved will be harmed
    .

    Reasonably resolving medical disputes and preventing their occurrence is an important part of building a harmonious medical environment
    .

    Sometimes complications are unavoidable.
    When acute hemopneumothorax occurs and medical disputes occur, both doctors and patients should understand each other, think in an empathy, and treat them rationally
    .

    The correct way to resolve disputes between doctors and patients is to fully negotiate through legal channels and with a peaceful and rational attitude
    .

    Both the doctor and the patient must be calm and understand each other, and do not confront each other, which will aggravate the disharmony between the doctor and the patient
    .

    V.
    Sharing of typical cases of sudden acute hemopneumothorax in the peri-anesthesia period Edema for 2 years, recurrence and aggravation for 1 week, and was admitted to the internal medicine department of our hospital.
    The diagnosis was: non-insulin-dependent diabetes mellitus; hypertension grade 3, very high risk; chronic cardiac insufficiency, cardiac function grade 3, coronary heart disease
    .

    After admission, CT showed a moderate amount of effusion in the right pleural cavity, thoracentesis was performed 3 times under B-ultrasound positioning, and 580ml, 320ml, and 200ml of pale yellow pleural fluid were taken out.
    After the third thoracic puncture, the patient felt chest tightness and increased shortness of breath.
    There was a large amount of pleural effusion on the right side.
    The non-coagulable fluid was extracted by thoracic puncture, and the hemoglobin was only 53g/L.
    Immediately closed thoracic drainage resulted in a total of 1100ml of bloody pleural effusion, and the chest tube was blocked by blood clots
    .

    After the discussion in the whole hospital, the thoracic surgeon underwent general anesthesia under video-assisted thoracoscopy to stop the bleeding, and performed thoracic blood clot excision
    .

    After general anesthesia, the patient was placed in the left recumbent position at 45°, and a skin incision of about 2 cm long was made in the fourth intercostal space of the right anterior axillary line.
    A 2cm-long skin incision was made in the seventh intercostal space of the right midaxillary line, and a thoracoscope was placed for exploration
    .

    During the operation, a large amount of blood and blood clots were seen in the thoracic cavity.
    The thoracocentesis site of the right chest wall was swollen and oozing blood.
    Under the guidance of thoracoscope, the blood was completely removed and the blood clots were completely removed.
    , No bleeding was observed, and the chest was closed after the gauze and instruments were counted
    .

    A 32F chest tube was punctured in the right seventh intercostal space.
    A total of 1900ml of bloody pleural effusion and 200ml of blood clots were aspirated during the operation.
    The operation went smoothly and the postoperative recovery was good
    .

    2.
    1 case of pneumothorax caused by general anesthesia laparoscopic surgery, female, 50 years old, 60kg
    .

    Due to the diagnosis of gallstones, cholecystectomy under general anesthesia was planned
    .

    The general condition of the physical examination was normal, there were no other complications, and the electrocardiogram was generally normal
    .

    After the patient was admitted to the room, rapid induction general anesthesia was used for endotracheal intubation (ie, 2% lidocaine 40 mg, dexamethasone 10 mg, fentanyl 0.
    2 mg, propofol 120 mg, and rocuronium bromide 40 mg).
    Compound anesthesia was maintained
    .

    Before surgery, blood pressure was measured at 116/68mmHg, heart rate at 59 beats/min, SpO2 at 100%, PETCO2 at 37mmHg, and airway pressure at 13cmH2O.
    About 20 minutes after surgery, the patient experienced an increase in blood pressure (165/89mmHg) not caused by anesthesia.
    > Heart rate increased (105 beats/min), SpO2 gradually decreased to 86%, PETCO2 continued to increase to 53mmHg, and airway pressure was 40cmH2O
    .

    The patient had mild subcutaneous emphysema in the chest and neck, and there was obvious crepitus on palpation.
    The breath sounds of the right lung disappeared on auscultation.
    The initial diagnosis was diaphragm injury, and carbon dioxide gas entered the right thoracic cavity through the damaged area, resulting in the patient's tension pneumothorax
    .

    The operation was stopped, the abdominal gas was discharged, and the right thoracic closed drainage was performed immediately.
    The above abnormal symptoms of the patient were gradually improved, and the hemodynamics were normal and stable
    .

    Afterwards, the patient underwent laparotomy to remove the gallbladder and repair the diaphragm injury, and no postoperative complications occurred
    .

    3.
    1 case of massive hemopneumothorax caused by internal jugular vein puncture A 28-year-old female patient was admitted to hospital with "chest tightness and shortness of breath for more than 2 years after exercise"
    .

    Admission diagnosis: rheumatic heart disease, mitral valve insufficiency, secondary cardiac function
    .

    Prepare for mitral valve replacement under general anesthesia and cardiopulmonary bypass
    .

    To monitor the central venous pressure preoperatively, an ARROW7Fr2.
    4mm three-lumen central venous catheter was used to perform a midway puncture of the right internal jugular vein
    .

    When preparing to puncture again, the patient was found to be restless, which was considered to be caused by the shallow anesthesia and dealt with it.
    Later, it was found that the patient's blood pressure continued to drop, with a minimum of 38/35mmHg and a heart rate of 160 beats/min.
    80mmHg, the puncture was successful again
    .

    Surgery was started, blood heparinization was performed, and mitral valve replacement was performed under cardiopulmonary bypass
    .

    The operation went well and the heart automatically rebounded
    .

    During hemostasis, it was found that part of the pleura on the right protruded into the pericardial cavity and was dark purple, and hemopleural effusion was suspected.
    After exploration, it was found that there was a large amount of blood accumulation and blood clots in the right thoracic cavity totaling more than 1000ml.
    After cleaning, the pleura on the right subclavian artery was found A defect of about 0.
    2cm was bleeding with bright red blood, which was suspected to be caused by accidental injury to the subclavian artery during puncture of the internal jugular vein
    .

    After the cardiac function was stabilized, cardiopulmonary bypass was gradually stopped, and protamine was used to counteract heparin
    .

    Atelectasis of the right upper lobe was seen during lung expansion.
    Exploration showed that there was a 0.
    2cm damage on it.
    It was suspected that it was also an accidental puncture injury
    .

    He was sent to the intensive care unit, and the ventilator assisted breathing.
    The ventilator was stopped after the spontaneous breathing recovered on the 1st day after the operation.
    The chest X-ray on the 4th day showed: anhydrous pneumothorax, and he was discharged from the hospital after 15 days
    .

    A thunderclap begins with a light rain
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