I can see the status bar

Chapter 1107
The case discussed at the discussion meeting was Sister Pan. As the doctor in charge of Sister Pan, Sun Lien did not speak directly on stage.He came a bit late, and coming to the stage now will definitely interrupt Yuan Pingan's host and case discussion.So, under the gaze of hundreds of pairs of eyes, Sun Li'en quietly and grandly sat in a corner under the stage.

Yuan Pingan glanced at Sun Li'en, and did not speak immediately, but continued to introduce his condition.

"First of all, the patient has type 1 diabetes and had placed a coronary stent in the circumflex branch, which is part of the underlying disease... The patient himself reported that he had come into contact with a patient with cough and fever symptoms on January 13. "Yuan Pingan clicked the computer, and the PPT behind him switched to the page of epidemic history investigation, "The patient was diagnosed with a new type of coronavirus infection on January 1 and was transferred to He'an Hospital for treatment. The patient in this case died on January 17. Symptoms of fever and cough, as well as symptoms of diarrhea and fatigue. CT examination showed large ground-glass shadows in both lungs, and the diagnosis was 'viral pneumonia?'."

"The central hospital took a nucleic acid sample for the patient on the 18th, and was diagnosed as a positive case on the 19th, and was transferred to the North Fifth District of Yunhe Infectious Disease Hospital on the same day for treatment." Yuan Ping'an continued to summarize the medical history, "On the 23rd, our team Taking over the North Fifth District, the patient was listed as 'highly concerned' on the same day. On January 1, the re-examination CT showed that the patient's lung lesions had shrunk. On January 26, the patient started to use tocilizumab, gamma globulin and CRRT. triple therapy."

"The triple therapy regimen used for this patient is tocilizumab 400mg Vi QD (400 mg, intravenous injection, once a day), gamma globulin 20g Vi QD." Yuan Pingan continued, "The patient's condition began to appear on the 28th. It got better, but there were intermittent recurrences. On January 1, the patient had a fever of 29 degrees Celsius, and then the fever subsided. On February 37.7, 2, and 5, he had fever again, with a maximum temperature of 6 degrees Celsius."

The four-day fever Sun Lien was not very impressed, especially the three-day fever in February - when he was fighting with his team members in the ICU.The fever was handed over to directors Lu Zhimin and Li Chengping.

"On February 2, the CT was rechecked, and the imaging examination showed that the patient's lung lesion area had progressed compared with before. On the 11th, the patient's finger pulse oxygen saturation dropped rapidly to 11%—during this period, the patient was receiving mechanical ventilation all the time." Yuan Ping'an Speaking of the important part, Sister Pan's situation began to deteriorate rapidly on the 92th.

"On the 12th, the oxygen saturation continued to drop rapidly. There was no room for further adjustment of the ventilator. Due to the low titer of IgG antibody in the patient's body checked on the 12th, considering that the patient's immune function was low, plasma exchange was performed on the same day, and a At the same time, the dose of intestinal microecological preparations has also been increased to 25 tablets BID." Yuan Pingan led everyone to quickly go through the case records, "Because the patient's blood lactic acid level is high, and D The levels of -2mer and C-reactive protein are very high, and it is suspected that there may be an inflammatory storm mediated by other inflammatory substances." Yuan Pingan suddenly changed the subject when he said this, "Plasma exchange proposed by Director Sun also reduced the blood pressure in the patient's body. The source of infection reduces the level of possible inflammatory mediators. The price is to reduce the IgG antibody level that is not very high in some patients. And this shortcoming is also weakened to the greatest extent under the coverage of the plasma of the recovered patients. "

Sun Lien blinked, feeling a little embarrassed by Yuan Ping'an's praise.

However, Sun Lien himself was quite proud of this plan.In particular, the idea of ​​checking a patient's IgG antibody titer levels -- it's a stroke of genius.Anyway, he thinks this kind of brainstorm is quite rare, and it's okay to be praised a few more times.

"But the treatment did not get a good effect, and the patient's condition deteriorated rapidly on the 13th. The levels of myocardial injury markers such as Ck-mb and hs-cTnl increased, and the ejection fraction decreased, suggesting that the patient had myocardial injury and Acute left heart failure—According to the analysis, we currently tend to believe that the heart failure is caused by acute viral myocarditis. The patient's vital signs were unstable. According to the treatment principle of moving the gate forward, VA Ecmo support therapy was performed on the 13th. "Yuan Ping'an finished introducing his illness, then sat on the stage and said to Sun Li'en, "Director Sun, can you come up and add something?"

Sun Li'en thought for a while, nodded and stood up, then walked all the way to the stage.

"First of all, this patient is a colleague of ours." Sun Lien made it clear, and threw out the most important content first, "Before the city was closed, many of the local medical staff in Yunhe were infected due to inadequate protection and lack of understanding. - They have to face the huge work pressure in their usual jobs, and they also have to face the test of the virus. Unfortunately, they are infected, which is an honorable injury. Our comrades are injured, and our task is not only to receive defense, We must also take care of our wounded comrades.”

Speaking of this, Sun Li'en felt a little emotional, "Comrades, you can't let the heroes shed blood and tears. Isn't that why we came to Yunhe all the way?"

An important reason why the members of the National Emergency Medical Team of Song'an Province decided to sign up was the queuing pictures that were circulated on the Internet at that time.They are suffering too much, so many patients with fever whose cause is unknown, and so many patients anxiously waiting to see a doctor are queuing up... They can only fight to the end and never retreat.The outpatient clinic opened from the morning of the previous day to the morning of the next day, and I couldn't eat or drink water... This is a perfectly natural situation.

With so many people waiting to see a doctor, which doctor has the heart to leave his post to take even a bite of food?The medical system has been completely exhausted, and all the Yunhe doctors who are sticking to their posts are burning themselves-persevering for one more minute, maybe they can see one more patient.In this case, even letting patients know that they do not have viral pneumonia is very valuable.

They all hold a determination-even if they don't eat, drink or sleep, they must kill the virus.

But... the infectivity of the virus far exceeds everyone's expectations, and the situation of exhausted medical resources has not been improved.So the medical team came.

The purpose of the medical team's assistance to Yunhe is to relieve the run on medical resources and rescue colleagues who have been fighting alone for almost a month.

"Several colleagues have died in the line of duty. We don't want to see even one more person added to that heroic team." Sun Lien said very sincerely on stage, "I proposed the treatment plan of grabbing one bed, but I still It’s just an ordinary person. No matter how many times you make adjustments, there may still be deficiencies. This is the reason for listing 1 bed as a case discussion this time——I hope everyone can take a look and discuss it , I warmly welcome any treatment methods that may be useful to patients, and any suggestions that may improve or adjust the plan. As long as it can save people.”

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Sun Li'en really has nothing to do with Sister Pan.Under the existing conditions, he has used all the treatment options.But Sister Pan's condition is still very serious.

ECMO is a treatment measure, but it is not a long-term solution.In order for Big Sister Pan to go offline smoothly, there must be at least three prerequisites.

First of all, the new coronavirus she was infected with must be completely eliminated.This is the basic premise of everything - without cleaning up the damn virus, follow-up treatment is impossible to talk about.

Secondly, Sister Pan's heart function must be restored to the point where she can be taken offline.Acute heart failure caused by viral myocarditis is not so easy to cure.

In the end, the damage to Sister Pan's lungs—that is, interstitial pneumonia and pulmonary fibrosis—had to be restored to the point where the lungs could compensate.If the damage to the lungs prevents her from exchanging enough oxygen and carbon dioxide for her spontaneous breathing, all treatment will be in vain.

These three points are indispensable, and each one is terrible.Considering the damage to the inner wall of blood vessels in the whole body caused by type [-] diabetes and the myocardial damage implied by coronary artery stents, even if Ms. Pan passed the first step of eliminating the virus, the second and third points are still almost impossible. An insurmountable hurdle.

The doctors in the medical team mainly discussed the second and third points.

"We can't deal with the virus for the time being. This can only depend on the development progress of antiviral drugs and the supply of serum from recovered patients." Dr. Ma Yongfang frowned, "Active ACE1 receptors will increase the damage of vascular endothelial cells, and according to speculation, The new coronavirus mainly invades human cells through the ACE2 receptor, and the ACE2 receptor has an inhibitory effect on the ACE1 receptor... In other words, the expression of the ACE2 receptor in patients infected by the new coronavirus will inevitably decrease. This is This leads to a lack of inhibition of the ACE1 receptor, so we can reasonably speculate that the vascular injury of the first bed patient will continue to increase as the infection worsens."

"For the ACE1 receptor, you can consider using drugs including captopril or benazepril for inhibition - at least maintaining a relatively stable blood pressure is definitely beneficial to subsequent treatment." Dr. Ma Yongfang said, "But , the specific usage plan may still need to be determined by testing the drug to see the results."

"The patient's own triglyceride level is relatively high. In order to prevent the risk of coronary heart disease caused by vascular endothelial damage and high triglyceride level, I suggest adding blood lipid control drugs." Ma Yongfang continued to add her own opinion , "Consider adding fenofibrate treatment."

Fenofibrate is a common clinical drug used to control endogenous hypertriglyceridemia when diet control therapy is not ideal.And it can also increase the effect of anticoagulants, thereby further reducing the probability of coronary heart disease in patients.

"If the damage to the lungs has reached the point where it is difficult to control, maybe we can consider giving up the damage control to the lungs directly." Jiang Yanming, a thoracic surgeon who sat on the stage with Yuan Pingan, proposed a bolder treatment plan "Now that ECMO is used as life support, since the damage to the lungs is uncontrollable, we should simply give up the plan to control it. I suggest that the relevant immune indicators of the patient can be done first, and then listed on the waiting list for transplantation. As long as the coronary pneumonia can be dealt with If there is no virus, then double lung transplantation can be considered directly.”

Transplantation is generally the ultimate solution to organ lesions.When doctors face end-stage patients with single-organ lesions, this is often the only treatment plan that can be proposed.For physicians, advising a patient to transplant is basically tantamount to "surrender."This means that they have no way to deal with the patient's disease and can only rely on surgical intervention.

Ma Yongfang and Jiang Yanming's suggestions were carefully taken down by Sun Lien, and he couldn't help feeling emotional and blaming himself - if Sister Pan's case had been used as a discussion case earlier, maybe it wouldn't have been delayed to this point.

There are many other suggestions and plans, and Sun Lien thinks that the plans that may be useful include "increasing the frequency of interferon aerosol inhalation" and "using lopinavir/ritonavir combined with Liba Waring's suggestion.

There are only a few antiviral treatment options over and over again, especially at the current time point when "there is no confirmed effective antiviral treatment method", there are even fewer options for doctors to choose from.Among the current trial plans for diagnosis and treatment, there are only a few trial anti-viral plans recommended by the National Health and Medical Commission, so they can be used all at once. Fortunately, Sister Pan's liver function is not bad at the moment, as long as the frequency of relevant monitoring is increased, It shouldn't be too much of a problem.

Use everything that can be used, and resolutely don’t use what can’t be used.Sun Lien has repeatedly confirmed that Sister Pan currently has no status column prompts for bacterial infection, and the blood test does not support this judgment.Therefore, he did not agree to the suggestion of prophylactic antimicrobial treatment for Sister Pan.

"Is it possible to increase the treatment amount of C-ball?" Yuan Ping'an also put forward his own opinion, "Since the immune system is not enough to grab a bed, then a higher dose of C-ball may help her fight against the disease." Viral infection."

"Gamma globulin has been given to 400 grams per day." Sun Lien frowned and hesitated. According to the instructions, patients with fever should not use gamma globulin injection or use it with caution.The dosage given is already very large—twenty grams of gamma globulin per day, which is equivalent to eight bottles of intravenous human immunoglobulin with a total of 5ml administered daily.In order to prevent possible adverse reactions when injecting a large amount of gamma globulin, the Beiwu District is diluted with 1% glucose solution at a ratio of at least 1:[-] before instillation.

Although CRRT continues to filter out water, 800ml of fluid will still be a huge burden for Sister Pan who has already developed heart failure.

"Use it." Sun Lien thought about it and decided to give it a go.Sister Pan, who is currently using VA ECMO, does have heart failure, but with ECMO support, such heart failure will not be fatal immediately.At least not when ECMO is functioning properly.

And the sooner the viral infection is resolved, the sooner her condition can be stabilized.As long as Sister Pan can get rid of the virus, there is hope of recovery.Thinking of this, Sun Lien took out his phone and started calling for foreign aid.

"Old Pa, let me ask you something..." Sun Lien was on the phone on the stage, he quickly gave a general overview of Sister Pan's situation, and then asked, "Our main treatment now is to get rid of the virus infection as soon as possible The question - can I use an immune enhancer such as Thymopentin?"

(End of this chapter)