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WeihuaQiu邱伟华PerioperativeManagementDepartmentofSurgeryRuiJinHospitalShanghaiJiaoTongUniversitySchoolofMedicinePerioperativePeriodDefinitiondependsonmultiplefactorsImportancedirectlyrelatedtotheoutcomeofsurgeryitselfCompositionpreoperativepreparation&postoperativemanagement
1.Electivesurgery2.Restrictivesurgery3.EmergentsurgeryPreoperativePreparationTheprincipleDifferentpreparationfordifferentproceduresTheclassificationofoperationsaccordingtothecharacteristicsofoperationsElectivesurgeryRestrictivesurgeryEmergentsurgeryElectiveSurgeryRestrictiveSurgeryEmergentSurgeryDr.EvilSays….$$$$????TheodorKocher(1841-1917)WithTheodorBillrothestablishedlargeclinicsinEuropeand,throughdevelopmentofskilledsurgicaltechniquescombinedwithneweranestheticandantisepticprinciples,providedsurgicalresultsthatprovedthesafetyandefficacyofthyroidsurgeryforbenignandmalignantproblemsWilliamStewartHalsted(1852-1922)ASCENTOFSCIENTIFICSURGERYResearchbasedonanatomic,pathologic,andphysiologicprinciplesandemployinganimalexperimentationHalstedianprinciples
ToconfirmthediagnosisToassesstheriskofoperationToassessthegeneralconditionandfunctionofimportantorgansToevaluatethepatientsendurancetotheoperationandriskofoperationPreoperativeAssessmentEssentialStepsHistorytakingPhysicalexaminationArranginganyfurtherdiagnosticinvestigationMakingspecialpreparationsfortheparticularoperationInvestigatinganyintercurrentoroccultillnesssuggestedbymedicalclerkingEssentialStepsDiscussingtheoperationwiththepatientandhisfamilyandobtainingsignedconsentMarkingtheoperationsiteMakingarrangementsfortheoperationwiththeoperatingtheatrestaffArrangingandinformingtheanesthetistsPrescribingmedication:prophylacticantibioticsetc.PlanningrehabilitationandconvalescencePsychologicalpreparation
talkfranklyandappropriatelytopatientsandfamiliesPhysiologicalpreparationAdaptiveexerciseTransfusionPreventionofinfectionGastro-intestinaltractpreparationMaintenanceoffluid,electrolytesandnutritionGeneralPreparationMalnutritionanddysfunctionofimmunesystem
MalnutritiondramaticallyincreasesthemorbidityandmortalityPreoperativenutritionalsupportismorevaluableSpecificPreparationHypertension
Mild-to-moderateessentialhypertension
systolicpressure＜180mmHg
diastolicpressure＜110mmHg
Atminimalriskofcardiaccomplication
AntihypertensivedrugsshouldbeusedalltimeSuddenwithdrawalofdrugsisdangerousSevereorPoorlyControlledHypertensionAthighriskofperioperativecardiacfailureorstroke.Thistypeofpatientsshouldnotundergogeneralanaesthesiaandsurgeryuntiladequatelytreated.Thebloodpressureshouldbereasonablycontrolledunder160/100mmHg.CardiovascularDiseasesIschemicheartdiseaseCardiacfailureArrhythmiasValvularheartdiseaseCerebrovasculardiseaseAnginaandPreviousInfarctionPreviousinfarctionStableanginaposeslittleincreasedriskduringoperationbutunstableanginaisasdangerousasrecentmyocardialinfarctionTheriskofreinfarctionisabout30%ifanoperationisperformedduringthefirst3monthsAt6monthstheriskisabout10~15%whichmaybeacceptableforimportantelectivesurgeryAnginaAdequatePreparationforHeartDiseaseTocorrectthefluidandelectrolytesimbalance.Tocorrectanaemiathroughseveralbloodtransfusionwithsmallamount.Tocontrolthecardiacarrhythmias.(Atrialfibrillation,Tachycardia,Bradycardia)RespiratorydysfunctionRespiratorycomplicationsoccurinupto15%ofsurgicalpatientsandaretheleadingcauseofpostoperativemortalityintheelderly.RiskFactorsforRespiratoryComplicationChronicobstructivepulmonaryorairwaysdiseaseChronicbronchitis,emphysema,bronchiectasis,pneumoconiosis,pulmonarytuberculosesCigarettesmokingCurrentrespiratoryinfectionsAsthmaPreoperativeInvestigationAchestX-rayCTscanifnecessaryEKGSpirometerBloodgasmeasurementPerioperativemanagement`PreoperativephysiotherapyteachingthepatientbreathingexercisesandcorrectpostureDrugtherapyTheophyllinesProphylacticantibioticsPreoperativebronchodilatorAdequatehydrationPerioperativeManagementEncouragetostopsmokingfromthetimeofbookforelectivesurgeryAlternationmethodsofanesthesia
Local,regionalorspiralanesthesiashouldbeconsideredEarlypostoperativephysiotherapy
toenhancedeepbreathing,coughingandgeneralmobility
PerioperativeManagementLiverDisorderThetolerancetooperationdependsupontheseverityofliverfunctionimpairment.TheliverfunctioncouldbeestimatedbyChildstagingorMELDscoreMalnutrition,ascitesandjaundicearecontraindicationsexceptforemergencysurgery.
PreoperativeAssessmentandManagementHBVandHCV,CBCClottingscreenandplateletcountElectrolytesLiverandrenalfunctionWhenprothrombintimeisprolonged,vitaminKshouldbegivenforseveraldaysbeforeoperation.RenalDisordersPreoperativeassessmentplasmaurea,electrolytes,creatinineandBicarbonateshouldbecheckedMildchronicrenalfailure
DrugsshouldbegiveninsmallerdosesFluidandelectrolytehomeostasisModerate-to-severechronicrenalfailure
Operationsshouldbeperformedunderhaemodialysis
DiabetesMellitusAtspecialriskfromgeneralanesthesiaandsurgery
Patientswithdiabetesfallintothreegroups1.Insulindependent2.Takingoralhypoglycaemicmedication3.Diet-controlledAttempttomaintainbloodglucoselevelbetween4and10mmol/Lavoidhypoglycemiainparticular.Bloodglucoselevel＞13mmol/LAnunreceptibleriskofketoacidosisorahyperosmolarnon-ketoticstate.PerioperativeManagementEstablishgooddiabeticcontrolbeforeoperationGiveninsulinasacontinuousintravenousinfusionduringtheoperativeperiodGivenaninfusionofdextrosethroughouttheoperativeperiodtobalancetheinsulingivenandtomakeupforlackofdietaryintakePerioperativeManagementPatientswithdiabetes:
whatpre-operativeassessmentisimportant?DocumentthefollowingTypeofdiabetesLengthoftimesincediagnosisCurrentmanagementCurrentglycemiccontrolHgBA1cGlucometerdtaPresenceofcomplicationsNeuropathyNephropathyRetinopathyAutonomicneuropathyincreaseriskofpostopgastroparesisandurinarytractinfectionPerioperativeanagementAddpotassiumtothedextroseinfusionMonitorbloodglucoseandelectrolytesfrequentlythroughouttheoperativeandearlypostoperativeperiod
Recoveryroomisnecessary
ICUisoptimalifpossibleMonitoring
CloselymonitorthelifesignsasaroutineCVPmonitoringisnecessaryifhemodynamicunstableduringoperationOtheritemsmonitoredaccordinglyFluidbalancePost-operativeManagementPositionandGetting-upSupinepositionforspiralanaesthesiaSemirecliningpositionforneckandchestoperation.Lateralpositionforobesitypatients.GetupasearlyaspossibleandmakemovementsasmuchaspossibleDietandTransfusionPeriodoffastdependsuponthetypeofoperation.Enteralandparenteralnutritionshouldbetakenintoconsideration.Fluidandelectrolyteshomeostasisshouldbemaintained.ManagementofDrainageDifferentdrainagefordifferentpurpose(infectionfocus,leakagepreventionandmassiveexudation)Nasal-gastrictubeUrinarycatheterWoundHealingandSutureRemovingClassificationofincision
cleanincisioncontaminatedincisioninfectedincisionTypeofhealing
TypeAperfecthealingBsomeinflammationCinfectedPostoperativepain
anymotionsincreasingtensionswillincreasepainAnalgesiaisobligatoryPyrexia
commonpostoperativeobservationasearchbemadeforafocusofinfectionnon-infectivecausesofpyrexiaManagementofPostoperativeComplaintsNauseaandVomitingDrugsopiates,antibiotics,metronidazoleBowelobstructionmechanicalobstructionAdynamicbowelHypokalaemiafaecalimpactionSystemicdisorderselectrolytedisturbancesUraemiaraisedintracranialpressureAbdominalDistensionMorecommonafterabdominalsurgeryHiccupDiaphragmirritationorcentralnervoussystemstimulatedSubphrenicinfectionshouldbesuspectedforcontinuoushiccupRetentionofUrineThereisapalpablesuprapubicmasswithdulltopercussion.Urinarycatheterisindicatedwhendiagnosed.ThemainpostoperativecomplicationsAtelectasisChestinfectionAspirationpneumonitisPneumoniaPostoperativeHaemorrhageCausesinadequateoperativehaemostasisatechnicalmishapasslippedligatureManagementre-operationtostopbleedingsomepreparationisnecessaryPostoperativecomplicationsWoundDehiscence(BurstAbdomen)Causesbloodsupplyispoorexcesssuturetensionlong-termsteroidtherapyimmunosuppressivetherapymalnutritioninfectioncoughingorabdominaldistensionManagementre-suturingwithtensionsuturesthewholethicknessoftheabdominalwallMinorwoundinfectionslocalizedpain,rednessandaslightdischargeWoundCellulitisandAbscesscellulitistreatedbyantibioticsabscesstreatedbysurgical drainage
WoundInfectionAtelectasis
AirwayobstructedairisabsorbedfromtheairspacesdistaltotheobstructionBronchialsecretionsarethemainPreventionandtreatment
perioperativephysiotherapyisthebestwayforpreventiondeepbreathingexercisesregularadjustmentsofposturevigorouscoughingflexiblebronchoscopytoaspirateoccludingmucusplugsUrinaryTractInfectionsCausesreducedurinaryoutputreducing“flushing”ofbladderincompletebladderemptyinginadequateperinealhygieneTreatment
ensuringadequatefluidinputappropriateantibioticsCauses
bedboundafteroperationvenousstasisplasmaconcentratedduedehydrationviscosityincreasedManifestationsswellingofthelegtendernessofthecalfmuscleincreasedwarmthofthelegcalfpainonpassivedorsiflexionofthefootDeepVeinThrombosisTreatment
Anticoagulation:
Systemicthrombolytictherapy:
streptokinaseLocalthrombolyticdrugsismorepromisingintravenousheparinsubcutaneousheparinoralwarfarintherapyDeepVeinThrombosispostoperativemobilizationadequatehydrationavoidingcalfpressurePreventionHighRiskCaseslowdosesubcutaneousheparincalfcompressiondevicesgraded-compression‘anti-embolism’stockingsIntravenousdextranWarfarinanticoagulationDeepVeinThrombosisSamplePreoperativeChecklistOperativepermit,appropriatelysignedandwitnessedDietaryconsiderationsForabdominaloperation,liquiddietandlaxativestoensureclean,collapsedbowelNothingbymouthatleast6hrbeforeoperationReviewoflife-supportsystemsVitalsignsrecordedoftenenoughtoestablishnormalvaluesPulmonarysystem:chestfilms;OtherstudiesasindicatedCardiacfunction:electrocardiogram;OtherstudiesasindicatedSamplePreoperativeChecklistRenalfunction:urinalysis;Bloodureanitrogenandposs
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