Nineteenth Century Medical Guide

Chapter 128 125. End of Surgery
Women's pregnancy to childbirth is like riding a roller coaster. The previous pregnancy in October was an uphill slowly accumulating atmosphere, and when it comes to childbirth, it is a downhill release of adrenaline from top to bottom.If it is said that natural childbirth is a progressive process for the gap, then cesarean section is to pull this stimulation to the extreme and compress it to detonate in just half an hour.

Compared with a normal delivery that takes more than ten hours, the cesarean section is really fast. From the time the skin is cut to the time the baby leaves the mother's body, it usually takes no more than 10 minutes, and it can come out in as fast as one or two minutes.

What was originally a relatively mild change was suddenly accelerated, avoiding common problems in childbirth such as episiotomy and pelvic floor dysfunction [1], and will definitely bring other new problems.

The most important of these is hemodynamics. 【2】

The enlarged uterus suddenly shrunk and was pulled out of the abdominal cavity by Kaviti, causing the originally compressed inferior vena cava to rebound, and a large amount of blood from the lower body began to flow back into the heart.Coupled with the changing position of the operating table, this reflux should become more intense.

In modern times, it is the responsibility of the anesthesiologist to ensure that the pregnant woman survives the operation smoothly.

But now, the only person on stage who can judge Brenda's physical condition is Carvey himself.

Whether it is excessive blood loss or increased blood return to the heart will cause the heart rate to rise [3].However, if we only use "elevated heart rate" to reversely judge whether Brenda has lost too much blood or has heart failure with increased return of blood, then we need to add another variable as a basis for judgment.

Because the treatment of the two is completely different, if it is really just a transient increase in blood return to the heart, immediately increasing the fluid replacement at this time will only further increase the load on the heart, causing Brenda to die on the operating table.

So even though the bleeding volume has reached nearly 1000ml, without the help of a sphygmomanometer[4], Carvey managed to stabilize himself. While watching them prepare to add medicine to the blood basin, he checked Brenda’s Body.

His breathing is okay, his pulse is a little weak, and his face is pale.

Looking at the still bleeding uterus, Carvey made a decision: "Take a jar from my box, cover the mouth of the jar with gauze to make it look like a funnel, and pour the medicated blood into the jar. "

This is the anticoagulant-sodium citrate, also known as sodium citrate, which Carvey obtained after going back and forth between the University of Vienna Medical School and the chemical plant.

Compared with the common modern heparin, the preparation of sodium citrate is much simpler, and the most important raw material is citric acid, which is citric acid. 【5】

Since it is a new drug different from oxytocin, it is necessary for Carvey to explain: "Italy, my second hometown, is the world's best producer of citric acid. Once my father made a mistake in his experiment and put Citric acid and sodium hydroxide get mixed together, which leads us to this new thing, sodium citrate.

It's effective at relieving blood clotting and is used at a dose of 2.5g per liter of blood, as they are doing now. "

Since he used a basin to collect blood, many people in the audience thought it was weird. Now after listening to him describe the effect of sodium citrate, many people have realized what Carvey will do next: "You Want to reinfuse the blood that left Brenda's body?"

"Yes, I am doing autologous reinfusion."【6】

Another brand-new concept, a brand-new idea of ​​rescue, and some people in the audience could not help but start discussing the feasibility of this approach.But for other viewers, this step-by-step operation is crushing their common sense and ravaging their brains.

Once the train of thought can't keep up, after seeing these dazzling things, they are only left with admiration.

As for applause, let's take it out after Carvey completely completes the operation.

The blood was filtered through eight layers of gauze, slowly flowed into the jar, and then poured into the infusion bottle, and returned to Brenda's blood vessel through the rubber tube.The non-washing autologous reinfusion has a very high collection rate. 1L of blood can leave 600-700ml after anticoagulation and filtration, which is enough to maintain Brenda's life.

"The bleeding hasn't stopped yet. When the basin is empty, take it over and keep it for blood collection."

Carvey cleaned the uterine cavity again, Herman kept rubbing the fundus of the uterus with both hands, and Bergett helped hold the incisions on both sides of the uterus, and the bleeding in the implanted area continued: "The uterine cavity has been cleaned, I still choose to do it before Spiral sutures are used to suture the separated surface of the placenta to achieve hemostasis."

This suture itself is also a product of experience.

Although suturing can stop the bleeding, it is also a traumatic intervention in itself, so the quality of the suture is determined by the operation: "Because the area of ​​​​placenta accreta has thinned, I chose to penetrate the uterus directly, increase the thickness of the suture and reduce the suture thread tearing of the stripped surface."

However, even if Carvey maximizes the operation, he is still limited by the weakness of the material.

The catgut couldn't bear the force of the ligation, so it was broken three times in a row, and the wound was not stitched up until it was replaced with stronger silver thread.
But it was just sutured, and it didn't really stop the bleeding.

Brenda's uterus retracted weakly. Since the incision of the uterus, Sarsson has injected six injections into the uterine muscle, which has exceeded the dose Nora received.Now Carvey has encountered a second fork in the road, whether to continue injecting oxytocin or choose to stop.

Continuing to inject oxytocin would greatly increase Brenda's blood pressure, which may not be visible now, but will be different when the blood is reinfused.All kinds of changes in the body under various stress reactions will be gathered in her body, resulting in a situation where it is impossible to judge only by guessing.

The lack of a blood pressure monitor was definitely the biggest challenge for Carvey.

Looking at the stitched surface that was oozing blood, he didn't have much time to waste: "Keep beating."

"it is good."

Those who don't know are fearless. Sarson, who was taking oxytocin, Herman, who was doing uterine massage, Bergert, who was pulling the hook, and Melen, who was doing blood filtration, all felt that the operation had come to this point because of Carvey's calculations. They didn't know The risks behind every decision.

They were very excited, because the operation was considered a success at this stage. Previously reported cesarean deliveries with placenta previa all ended in the death of both mother and child.

As the witnesses of the operation, they feel sincere pride.

The audience on the stage was even more excited, because the operation was worth the fare. The new operating table, infusion, placenta implantation, rapid fetal retrieval, blood anticoagulation, autologous reinfusion, every detail is unique in the Austrian surgical theater. appeared for the first time.

The most typical one is none other than Varela, who knows a little bit about surgery and belongs to the audience.

He has always scoffed at the conservative Austrian surgery, and only praised Ignatz's operation speed.He has always hoped that his country's surgical operations can be innovative, so that he can stand among the ranks of surgical powers and at the same time make his job more stable.

Previously, Varela only regarded Carvey as a new surgical star with surgical experience, great luck, and not bad operation.

Expectations but not much confidence, especially after Carvey chose to use a cleaner and time-consuming amputation, he felt more and more that Carvey would ruin his job.Several negative reports in the daily were written by him, with the purpose of suppressing Carvey and further maintaining the appreciation of surgery.

Today, however, Carvey's series of arrangements completely shattered Varela's long-standing perception of "viewability".

The Kavey who is doing fine manipulation in the face of the surgical incision can also become rough enough, and the speed is not slow at all.At the same time, it also tells the world that the ornamental value of surgery is not limited to blood splatter and fast operation, but also the innovation that Varela hopes.

Only half an hour after the operation, the senior surgical reporter had mobilized all his brain cells to understand and digest everything he saw as much as possible.But even with 120% effort, he can only understand what Kavey said, and there is still a long way to go before he really understands it.

In fact, not to mention Varela, even surgical experts such as Ignatz, Watman, Olgi and Massimov sitting in the front row can only partially understand it.

They had no choice but to temporarily skip the many details that were mentioned in one stroke. After all, in the fast-paced cesarean section, keeping up with the rhythm is the most important thing.

"It's the 10th shot of oxytocin."

"Stop for a while."

"Heart rate?"

"108."

A large amount of oxytocin finally had some effect, the size of the uterus has begun to shrink, and the bleeding seems to have stopped.However, Carvey's face was still stern. He looked at Bergett beside him and said, "Loosen the blocking belt in the lower part of the uterus."

"it is good."

The blocking belt cuts off a lot of blood flow in the uterus. If there is still no active bleeding after it is released, it can prove that the hemostasis is successful.In fact, the stripped surface was still bleeding after suturing. This sense of powerlessness that all efforts could not change the situation made other people on the operating table think otherwise.

"Why don't you cut off the uterus."

"Well, cut off the obstructive uterus and there will be no bleeding."

This is indeed a good solution once and for all, not only confirming Brenda's life, but also allowing Carvey's operation to come to a successful conclusion.Such a dangerous cesarean section with placenta previa can achieve the safety of mother and child, which is already a pioneering work that can be shown around the world.

However, Carvey's thinking is completely different from theirs: "Don't think about these things."

"But the bleeding is too serious." As the second assistant and a friend of the same generation, Bergert still hopes that Kawei will stop the loss in time and keep this hard-won victory. "If you continue to let it bleed, maybe"

"Well, stop for a while." Kawei buried his head in checking the bleeding of the wound, and suddenly asked, "Who is the chief surgeon?"

Bergett immediately realized the change in his friend's attitude, swallowed, and replied, "...it's you."

"Then who has the final say on the operating table?"

"The main knife."

"So you are ordering the chief surgeon?"

"I just"

Bergett wanted to say something more, but felt that someone had kicked his calf, so he had to stop there.

The one who kicked him was Herman who stood aside and concentrated on doing uterine compressions.

He knew very well that Carvey, like Ignatz, was a kind of person who stood on the operating table and was the only one who would not listen to persuasion.Not to mention him, Bergett, even Hills, who has been working in the clinic for many years, was kicked out by Carvey.

"I'm sorry." Bergett immediately succumbed. Carvey's current ability is by no means something he can casually question.

Kavey gave him a blank look, used a large amount of gauze at hand to make intrauterine packing, and then introduced the current situation unhurriedly: "I have ligated the bilateral ascending arteries of the uterus after blocking the lower uterine segment, and now The hemostatic effect was not good, so I had to continue to ligate the descending uterine artery."

He had no room for hesitation. Continuing the operation would increase the risk of infection. He had to choose a more aggressive hemostasis strategy to end the operation as soon as possible.

The descending uterine artery is in the lower uterine segment. If you want to do suturing, you must do anatomical separation of the lower uterine segment, the most important of which is to separate the bladder【7】: "Don't worry about the blood supply, because the blood supply of the uterus is not only the arteries on both sides, but also the There are other small blood vessels.

We push down the bladder to fully expose the descending arteries of the lower uterine segment.Note that you must use a scalpel to cut and separate slowly, and you must not use your fingers, because it will cause irreparable damage to the bladder. After suturing and ligation, you need to see if there is any accidental injury in the rear, and finally check the bleeding inside the uterus.”

This is the last card that Carvey can play. If this method can't stop the bleeding, Carvey can only do a hysterectomy.

Fortunately, the upper and lower joint ligation worked well, and the wound in the uterus that had just been sutured finally stopped bleeding.

"Heart rate?"

"101."

"breathe?"

"It's still the same as before."

Carvey glanced at Brenda, who looked pretty good, and finally heaved a sigh of relief, and brought the audience the final result of the operation: "Because the bilateral uterine arteries were completely ligated, the bleeding has stopped now. The child survived, Brenda The lady survived and I declare the cesarean section a success."

This kind of "success" is only the result of compromise under the existing surgical cognition, and the real test lies in the postoperative care.

But for a broad audience, this success is enough to rewrite the obstetric ending.The two operations ended successfully. Carvey put the cesarean section on the operating table by himself, telling the world that mothers do not need to die when they encounter dystocia, and they have other options.

Many people in the field even ignored that the operation was still finishing, and they had already started cheering Kavey's name.

But the young chief surgeon didn't care about it. Cheering won't make Brenda recover completely, and she has to assign nursing tasks next.

"Bergett, put the remaining oxytocin into the saline, and use the infusion bottle to continue to infuse it slowly." Carvey handed the suture needle to Herman, "You suture the skin, make sure it is tight, and don't collapse the stitches." .”

"Ok, I know."

"Sarsen, go find a sandbag. Her uterine contraction is too bad, and there is no good way to continue to rely on oxytocin. It must be treated with pressure."

"it is good."

"The two midwives went back and told the nurses to perform abdominal compressions every once in a while to expel all the blood clots."

"it is good."

"Mellen, I'll give you the rest of the blood. After filtering, it will continue to be injected into her body as before."

"Ah."

Carvey bowed to the audience behind him: "The operation is over."

(End of this chapter)