4.3术前术后041516课件

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