96: Chapter 96 Puncture? Needles to be inserted into the heart?
Lu Chen moved the probe to the apex of the heart.
Then to the left sternal border.
And finally, below the right costal margin.
With each cross-section, he carefully observed the distribution of the adhesion bands and the concentrated areas of the effusion.
The Master Level Ultrasound-Guided Puncture was proving its worth at this moment.
Although the progress was at zero, the image-reading ability and judgment granted by the skill itself were far superior to those of an ordinary physician.
He quickly constructed a three-dimensional structure of the entire pericardial cavity in his mind.
The effusion was mainly concentrated in the posterior-inferior and left regions, while the effusion in the anterior region was partitioned into several small cavities due to adhesions.
"Director Li, I've finished my assessment."
"Speak."
"The subxiphoid approach is indeed obstructed by adhesions, but if we shift slightly to the left, entering the needle about two centimeters to the left of the xiphoid process, and angle it about thirty degrees towards the left shoulder, we can avoid the main anterior adhesion bands and enter the largest effusion cavity in the posterior-inferior region."
Director Li Sen stared at the screen for a few seconds.
Then he turned to look at Lu Chen.
"Are you sure?"
"Looking at the ultrasound image, there is a window of about two to three centimeters without adhesions at that position, which is enough for the needle to pass through."
Director Li Sen looked at the screen again.
He was a veteran of the Emergency Department and had performed Pericardiocentesis more than ten times, but cases with adhesions were indeed rare.
After examining the Puncture path Lu Chen described, he felt it made sense.
"Alright, we'll follow the path you described. I'll perform the Puncture, and you'll be responsible for real-time ultrasound guidance."
"No problem."
At this moment, the patient's wife standing nearby could barely hold herself up.
"Director Li, what exactly is wrong with my husband?"
Director Li Sen turned to face the family member.
"Ms. Zhou, your husband's heart is wrapped in a membrane called the pericardium. Right now, a large amount of fluid has accumulated between this membrane and the heart. The fluid is compressing the heart, preventing it from beating normally. That is the reason for his chest tightness and shortness of breath."
"Then, what should we do?"
"We need to perform a Pericardiocentesis for drainage. Simply put, we use a needle to draw out the fluid to relieve the pressure on the heart."
"Puncture? You mean you're going to stick a needle into his heart?"
"Not into the heart itself, but into the membrane surrounding the heart. However, this procedure carries certain risks and requires precise positioning under ultrasound guidance. I will perform it under constant monitoring."
"Is the risk high?"
"Any invasive procedure carries risks, but the risk of not performing the Pericardiocentesis right now is even greater. Your husband's blood pressure is already very low. If we don't decompress it as soon as possible, his heart could stop beating at any moment."
The woman's face turned pale instantly.
"Then, then hurry up and do it!"
"I need you to sign the informed consent form."
Zhao Yaqin handed over a document.
The woman's hand trembled so much she could barely hold the pen, but eventually, she signed it.
...
After signing, Zhao Yaqin guided her to the waiting area outside.
The door closed.
In the Resuscitation Room, only the medical staff remained.
Director Li Sen, Lu Chen, Zhao Yaqin, Shen Xiaoning, and a Nurse on duty.
"Start the preparations." Director Li Sen's tone changed, shifting from the gentleness used when communicating with family members to the decisiveness of the operating table.
Lu Chen assisted Director Li Sen in putting on the sterile surgical gown and gloves.
Shen Xiaoning coordinated by disinfecting and draping the Puncture site.
The patient was still conscious, but his breathing was becoming increasingly labored.
"Mr. Zhou, can you hear me?" Director Li Sen leaned over and asked.
"Yes, I can hear you..." The patient's voice was very weak.
"I am going to give you a local anesthetic in your chest now, and then perform the Puncture to draw out the fluid. You must keep still during the process. Can you do that?"
"Yes..."
Director Li Sen glanced at Lu Chen.
"Ultrasound positioning."
Lu Chen placed the ultrasound probe on the left edge of the xiphoid process again.
He adjusted the angle, locking onto the adhesion-free window he had identified earlier.
On the screen, that two-to-three-centimeter safe passage was clearly visible.
At the end of the passage was the largest effusion cavity in the posterior-inferior region.
"Position confirmed. The window is about 1.5 centimeters to the left of the probe. The safe passage is approximately 2.3 centimeters in diameter, and the effusion cavity can be reached at a depth of about 4 centimeters."
Director Li Sen nodded.
He picked up the local anesthetic syringe and injected lidocaine around the entry point marked by Lu Chen.
The patient winced slightly from the pain.
"Bear with it, it will be quick."
After the local anesthesia took effect, Director Li Sen picked up the Pericardiocentesis needle.
An 18G long needle.
He glanced at the image on the ultrasound screen.
Then, he aimed the needle tip at the entry point.
"I'm inserting the needle. You provide real-time guidance."
"Received."
Lu Chen stared intently at the ultrasound screen, holding the probe steady with one hand to ensure the image did not shift.
Director Li Sen's technique was very steady.
He was truly a veteran director who had worked in the Emergency Department for over twenty years.
The needle tip pierced the skin and passed through the subcutaneous tissue.
On the ultrasound screen, Lu Chen could see a bright spot moving forward slowly.
That was the tip of the needle.
"Direction is correct. Continue, depth is two centimeters."
The needle tip continued to advance.
"2.5 centimeters. Watch out for an adhesion band on the right, about 8 millimeters away. Maintain the current angle and don't deviate."
Director Li Sen made a slight adjustment with his wrist.
"Three centimeters."
"3.5 centimeters. About to enter the effusion cavity."
Director Li Sen connected the syringe, aspirating as he advanced the needle.
When the needle tip advanced to four centimeters.
Pale yellow fluid appeared in the syringe.
"Fluid aspirated." Director Li Sen said.
Lu Chen confirmed on the ultrasound screen.
"Needle tip position is correct. It has entered the effusion cavity and has not touched the myocardial wall."
"Good."
Director Li Sen began to draw fluid slowly.
The first syringe, 20 milliliters.
The second syringe, another 20 milliliters.
The color of the fluid was pale yellow, slightly turbid, not bright red blood.
This was a good sign.
It indicated that it was not hemorrhagic effusion caused by acute cardiac rupture, but more likely an exudate caused by inflammation or other reasons.
"Keep drawing."
Director Li Sen switched to a larger syringe and began drawing with a 50-milliliter one.
The first 50 milliliters were drawn.
The patient's breathing became slightly smoother.
The heart rate dropped from 126 to 118.
Blood pressure rose slightly to 86/58.
"It's working." Zhao Yaqin said while looking at the data on the monitor.
"Continue."
A second 50 milliliters.
A third.
A fourth.
A total of approximately 250 milliliters of fluid was drawn out.
The patient's condition improved significantly.
His breathing was no longer so rapid, and his complexion had turned from grayish-white to a faint pink.
But Lu Chen, staring at the ultrasound screen, frowned slightly.
Because he saw a problem.
Although the main effusion cavity in the posterior-inferior region was shrinking, there was an independent effusion cavity on the left side partitioned by an adhesion band, and the fluid inside had not decreased.
The position of that partitioned cavity was very specific, right against the left ventricular wall.
And the amount of effusion in that cavity was not small.
The information from the Eye of Truth was also updating in sync.
[Eye of Truth Alert: The left partitioned effusion cavity is approximately 280ml, not connected to the main effusion cavity. The current Puncture needle cannot drain this area. The effusion in this partitioned cavity is still continuously compressing the left ventricular wall.]
Lu Chen's heart skipped a beat.
The fluid in the main effusion cavity had been drained, and the pressure had been released.
But the fluid in the partitioned cavity remained.
And that partitioned cavity was right against the left ventricle.
If only the main cavity was drained while the partitioned cavity was ignored, the patient might improve in the short term, but the pressure in that partitioned cavity would remain, potentially leading to... at any moment.
He was just about to open his mouth to warn Director Li Sen.
The monitor suddenly rang.
An urgent alarm sounded.
Everyone's eyes turned to the screen simultaneously.
The heart rate jumped from 118 to 142.
Then to 155.
Blood pressure plummeted from 86/58.
78/50.
72/46.
65/42.