Changzhi News of the Yellow River News Network: Left nephrectomy 10 years ago, stenting for coronary heart disease diagnosed 5 years ago, and right coronary balloon dilation 1 year ago ......Recently, the Peace Hospital Affiliated to Changzhi Medical College has worked closely with multiple disciplines to successfully help a patient who has undergone multiple surgeries to overcome the two major difficulties of kidney failure and bypass.
Patient Che, 68 years old, underwent left nephrectomy in Beijing 10 years ago due to kidney tumor; 5 years ago, he was diagnosed with coronary heart disease in Heping Hospital and underwent stenting; One year ago, he suffered a seizure of chest tightness and was re-admitted to the Department of Cardiology of Heping Hospital, where he underwent right coronary PTCA balloon dilation. I thought that my body was getting better day by day, but in the past few days, Che's chest tightness has been frequent, and his family is worried, so Che was admitted to the hospital again for examination.
After admission, coronary angiography was performed, and the results showed that there were multiple coronary lesions, including 80% stenosis at the beginning of the anterior descending, almost complete occlusion of the circumflex, 70% stenosis again after right coronary stent placement, diffuse stenosis of the entire coronary artery, and the progression of coronary artery lesions was very fast, the risk of intervention was high and the effect was not good, and further coronary artery bypass surgery was required.
In the past year, the patient's right kidney has almost lost its function, the daily urine output is less than 50ml, and he has undergone hemodialysis 3 times in our hospital in the past week, and has been regularly dialysis for more than 10 months. With insufficient kidney function and a history of two heart surgeries, the patient's physical condition is not optimistic, but the disease cannot be left untreated! "In the face of great trials and challenges, the doctors did not flinch and responded positively.
After multidisciplinary consultation with the Department of Cardiovascular Medicine, Nephrology, Anesthesiology, Intensive Care Medicine and other departments, everyone finally reached a consensus that the patient had multiple coronary artery lesions and clear indications for coronary artery bypass grafting. Considering Che's special physical condition, the Department of Intensive Care Medicine and the Department of Nephrology formulated a detailed blood filtration plan in advance. After the surgical plan was determined, Niu Zhigao, director of the Department of Cardiac and Vascular Surgery, patiently explained the necessity of the operation and the postoperative diagnosis and treatment plan to the patients and their families. After many times of communication, Che finally agreed to undergo surgery**. On January 7, Che underwent "coronary artery bypass grafting".
According to the results of the patient's coronary angiography, non-cardiopulmonary bypass ("non-stopping") bypass was routinely performed on the operative day. During the operation, it was found that the patient's coronary artery stenosis and sclerosis were severe, coupled with the long course of the disease and poor cardiac function, when the heart was moved during the operation for circumflex branch anastomosis, multiple ventricular arrhythmias and ventricular fibrillation occurred, and the cardiopulmonary bypass was urgently wetted, and drugs were given to control the ventricular rhythm, vasoactive drugs to maintain blood pressure, and intrathoracic cardiac compressions.
Under the close supervision of medical staff, the patient's heart rhythm changed to sinus rhythm, and finally the vascular anastomosis was completed under off-pump bypass. However, because the patient has anuria, serum potassium is elevated for a time, and hypokalemia is given**. At the same time, it is indicated that bedside hemofiltration should be performed immediately after surgery, and femoral vein cannulation should be given during surgery.
Postoperatively, the patient is returned to the Cardiac Macrovascular Surgical Intensive Care Unit. However, at this time, Che's hemodynamics are unstable, blood pressure fluctuates greatly, and bedside hemofiltration may have a serious impact on hemodynamics, such as causing ischemia and hypoxia of various organs will be irreversible damage to the patient. Immediately, the cardiac and vascular surgeons quickly assessed and judged, adjusted the vasoactive drugs and rehydration regimen in time, and the hemodynamic forces gradually stabilized after one hour. After joint evaluation by the hemofiltration team of the Department of Intensive Care Medicine and the cardiovascular surgeon, he performed bedside continuous blood purification** (CRRT**) for Che in a timely manner
The hemofiltration lasted for four days, during which the medical staff dynamically adjusted the parameters of the hemofiltration machine according to various indicators and various cardiac specialty indicators. The patient was hemodynamically stable, with little fluctuation in blood pressure, and hemofiltration at the bedside was carried out smoothly for 24 hours. In order to reduce the complications caused by long-term bed rest, the nursing team effectively instructed patients to perform breathing exercises and postoperative** activities.
After the meticulous care and care of multidisciplinary medical care, Che's indicators returned to normal, hemodynamically stable, and he recovered well after surgery. At present, the patient has been transferred to the Department of Nephrology, undergoes hemodialysis regularly, and will be discharged from the hospital in a few days. (Niu Lili, Liang Xiaoyan, Li Xuan).