I can see the status bar

Chapter 1075 Proposal to reject
Viral hepatitis causes persistent damage to the liver, and the result of this damage is cirrhosis.The fibrous tissue hyperplasia and nodular regeneration of liver cells after diffuse degeneration and necrosis of liver cells occur repeatedly, eventually leading to the gradual disorder and diversion of the hepatic lobular structure and blood circulation pathways, promoting liver deformation and leading to liver cirrhosis.

This description is relatively short and general, but this general description is relatively accurate in nature.This is a complex and lengthy damage process. With the current level of research, it is almost impossible to fully understand the cause of its formation.

But Sun Lien has extracted one of the key points - the disorder of blood circulation.

The interstitial pneumonia caused by the new coronavirus infection, the hypoxemia caused by the interstitial pneumonia, and even the subsequent respiratory distress syndrome are essentially severe tests on the circulatory system and the oxygen content of the blood. .

When cirrhosis occurs, the perfusion circulation inside the liver will become poor.At this time, hypoxemia reappears, which will make the liver worse.

Maybe it's more appropriate to say "iceberg on top of snow".

The combination of hypoxemia and weakened perfusion circulation makes it impossible for the cells in the liver to get enough oxygen.And when the hypoxemia continues, there may be only one result.

Extensive acute liver injury.

Sudden hyperkalemia occurs in the human body. When the rate of potassium excretion and potassium intake of the patient has not changed significantly, the potassium that suddenly appears in the blood can only come from dead cells.

This kind of stubborn, large amount of potassium excretion, and Mrs. Lu has not yet experienced acute renal failure caused by myoglobin.Then a large number of dead cells should not be muscle cells——by continuing to study this logic, it is not difficult to find that the source of Mrs. Lu's persistent and stubborn hyperkalemia can only be liver cells.

At the same time, due to the swelling of liver cells caused by severe hepatitis, the patient's ability to synthesize glycogen and protein in the liver is impaired, and the patient's own ability to consume blood potassium also declines.The combination of the two led to the appearance of intractable hyperkalemia.

In other words, this is a case of refractory hyperkalemia caused by acute liver injury, and the patient also had pneumonia caused by a new coronavirus infection.

At the same time, the No.14 prompt on the status bar also made Sun Lien firm in his opinion.

"Extensive necrosis of the right anterior lobe of the liver 00.41.27"

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Although it is impossible to confirm 100% that Mrs. Lu's hyperkalemia is indeed caused by acute liver injury, such logic makes sense and is currently the most likely cause.To deal with such a situation, the persistent damage caused by acute liver injury must first be addressed.

"Do interventional embolization for her now?" After hearing what Sun Lien said, Yuan Ping'an was taken aback.It is indeed possible that liver injury can lead to hyperkalemia, which is mechanistically plausible.However, clinically, electrolyte disturbance mainly manifested by hypokalemia is common in patients with decompensated liver cirrhosis.Sun Lien's judgment cannot be said to be wrong, but Yuan Ping'an feels that the possibility does not seem to be that high.

The treatment method proposed by Sun Li'en is even more incredible. Interventional embolization is the mainstream method for treating liver tumors.

Interventional embolization for the treatment of liver tumors and intervention for coronary heart disease are two completely different directions.The purpose of interventional surgery for coronary heart disease is to dilate blood vessels, reopen the blocked coronary arteries and accept blood flow.The interventional embolization for tumor treatment is to make the tumor unable to continue to get blood and wither and die.

However, this treatment technique does not help at all in acute liver injury.Rather, with the completion of embolization, the part of acute liver injury may be further expanded.With less blood flow to the liver, more liver cells in the area die completely and release more potassium ions.

Not only will this not improve the patient's condition, but it will even lead to complete necrosis of her liver at a faster rate.

"Her liver is failing." Sun Lien insisted on his own judgment, "With so many potassium-lowering methods, her blood potassium still rose by 0.24mmol/L within half an hour. This is not just a simple acute liver injury. It can be done. You are on dialysis now, but her condition is still stable instead of improving, and the area of ​​liver damage is too large to be reversed by conventional means.”

"Then you can't just embolize the liver vein. Don't you want the liver?" Yuan Ping'an said anxiously, "In her current condition, what do you use to replace the function that is missing after the liver embolism is removed? The alternative treatment is only It can delay the time, but the liver itself cannot grow well by itself!"

"Using CT to judge the edema, the edema part of the liver can be left, but the part that has already manifested as necrosis, the entire lobules are embolized." Sun Lien said seriously, "Dialysis is non-stop, and liver replacement therapy is performed immediately after embolization is completed. Give up the liver that can no longer be saved, at least the blood potassium released by it can no longer kill people."

Sun Lien's treatment plan was very radical, to the point where Yuan Ping'an felt that he was a little insane.But at the same time, Yuan Ping'an had to admit that this is probably the most effective and fastest "rescue measure" at present.

The blood potassium of the patient Lu Xiuping continued to rise. Even after 10 minutes of dialysis machine treatment, her blood potassium level continued to rise slowly and remained at a level of 6.51mmol/L.

Two hours of dialysis can generally reduce the patient's blood potassium level by 2.0mmol/L, and if a low-potassium or potassium-free dialysate is used, the rate of decrease can be faster.Based on the dialysate with a potassium concentration of 3.0mmol/L, Lu Xiuping's blood potassium should also decrease by 0.33mmol/L instead of continuing to increase by 0.1mmol/L.Using the roughest method to estimate, the blood potassium in her body is rising at a rate close to 1.2mmol/L per hour, and may even be higher.

Steps must be taken to intervene immediately, otherwise the situation may get worse.Yuan Ping'an asked the nurses on the side to increase the dialysis rate again, and asked to actively supplement calcium.Later, he said to Sun Lien, "Your treatment plan is too risky, and the indication for the treatment of hepatic venous embolism is not refractory hyperkalemia. To treat the patient, we have to report to the higher authorities, at least Zhang Zhifu and The consent of the ethics committee is required, and the treatment plan must be communicated with the family."

"I'll do these things." Sun Li'en nodded. Since he proposed the treatment plan, he has been mentally prepared for these follow-up procedures. Go to the CT room for a plain abdominal scan."

Because the "rescue plan" proposed by Sun Lien is very radical and unconventional.In order to ensure that the relevant treatment will not cause harm to patients in ethical, moral and other fields, this treatment project must be reviewed by the ethics committee and medical committee of Yunhe Infectious Disease Hospital.However, due to the tight manpower during the epidemic, members of the ethics committee may not have time to attend such a review meeting, and Lu Xiuping's situation deteriorated too quickly. After obtaining the consent of the family members, Zhang Zhifu directly dragged Sun Lien into his office Ri participated in a higher-level ethics committee review.

The Ethics Committee of the National Aid Yunhe Medical Group held an emergency meeting online.

"I don't agree with this treatment method." After listening to Sun Lien's statement, experts from the Shanghai Stock Exchange first rejected Sun Lien's opinion, "If continuous dialysis can prevent blood potassium from continuing to rise, there is no need for patients to risk their lives. It is dangerous to accept such an operation whose feasibility exists only in theory. Percutaneous hepatic vein embolization itself requires contrast agent. She is now in a state of insufficient attention and metabolic acidosis. How can you ensure that the contrast agent will not let her The kidneys are also on strike?"

"I agree with Director Huang." The expert from Southwest nodded. "This treatment plan is too risky. Now there are other options. It is not ethically appropriate for patients to receive high-risk treatment."

"The patient's family has agreed to the treatment plan, and you have done a good job in compliance, Director Sun." The expert from Yangcheng said with a strange accent, "However, I agree with the opinions of Director Huang and Director Liu. Under normal circumstances, such a high-risk treatment plan may not be necessary—I see that if you take this treatment, and the residual liver volume is barely greater than 45%, will you have to do another operation to cut out the shrunken liver afterward?"

"My idea is very simple, which is to ensure the life of the patient first, and then consider the follow-up treatment plan." Several experts did not agree with Sun Lien's opinion, and Sun Lien tried to fight again for his proposal, "Potassium in cells The concentration is 30 times that of the cell fluid, and the liver cells are closely related and have a fine texture. The potassium released by other necrotic cells will not only enter the blood, but also further damage the surrounding normal cells. The damage and The rate of increase in blood potassium will be at the level of a chain reaction. Now we are still in a relatively early stage, and if it continues to drag on, no one knows whether the rate of increase in the patient's blood potassium concentration will exceed the upper limit of the clearance of the dialysis machine."

"There are 175 grams of potassium in the human body, which is 4.4 mol, and the liver accounts for about 2% of the total body weight. Even if this patient has liver hypertrophy, her liver accounts for 4% of the body weight, and the total potassium in her liver is only 176mmol, all of which are released into the blood, that is to say, in a theoretical state, her blood potassium can increase by another 44mmol/L." Expert Yunhe said suddenly after being silent for a long time, "Actually, the total amount of potassium in the liver It can’t be calculated like this, but let’s discount it in half, and calculate that it can increase the potassium content in the blood by another 22mmol/L. If you use potassium-free dialysate for hemodialysis, you can remove about 4mmol/L of blood potassium per hour. With this speed of dialysis, all the potassium ions can be replaced in five hours. If you feel that the speed is not enough, you can even connect another machine for dual-machine dialysis. In this case, the significance of interventional embolization of the patient’s liver Not too big."

"Three of the five objected, and the review rejected it." The expert who presided over the meeting nodded, "Director Sun, I can understand your feelings. But it is not yet the time to use such a high-risk treatment plan. If you think this Patients who cannot be treated here can be transferred to other hospitals for further treatment."

(End of this chapter)