围手术期处理英语

Perioperative Management,Perioperative period,Definition not well establishedImportance directly related to the outcome of surgery itselfComposition preoperative preparation & postoperative management,1. Elective surgery2. Restrictive surgery3. Emergent surgery,Preoperative Preparation,The principle Different preparation for different operationThe classification of operations according to the characteristics of operations,To confirm the diagnosis To assess the risk of operation To assess the general condition and function of important organs To evaluate the patients endurance to the operation and risk of operation,Preoperative Assessment,Essential steps in preoperative assessment and preparation,History taking Physical examinationCollating pre-admission information about diagnosisArranging any further diagnostic investigationMaking special preparations for the particular operationInvestigating any intercurrent or occult illness suggested by medical clerking,Essential steps in preoperative assessment and preparation,Discussing the operation with the patient and his family and obtaining signed consentMarking the operation siteMaking arrangements for the operation with the operating theatre staffArranging and informing the anaesthetistPrescribing medication prophylactic antibiotics etc.Planning rehabilitation and convalescence,Psychological preparation talk frankly and appropriately to patientsPhysiological preparation,Adaptive exercise Transfusion Prevention of infection Gastro-intestinal tract preparation Maintenance of fluid, electrolyte and nutrition,General Preparation,Malnutrition and dysfunction of immune system,Malnutrition dramatically increases the morbidity and mortality Preoperative nutritional support is more valuable,Specific Preparation,Hypertension,Mild-to-moderate essential hypertension systolic pressure 180mmHg diastolic pressure 110mmHg,At minimal riskof cardiac complication,Antihypertensive drugs should be used all time Sudden withdrawal of drugs is dangerous,Severe or poorly controlled hypertension,At high risk of perioperative cardiac failure or stroke. This type of patients should not undergo general anaesthesia and surgery until adequately treated. The blood pressure should be reasonably controlled under 160/100 mmHg.,Cardiovascular disease,Ischaemic heart disease Cardiac failure Arrhythmias Valvular heart disease Cerebrovascular disease,Angina,Previous infarction,Stable angina poses little increased riskduring operation but unstable angina is asdangerous as recent myocardial infarction,The risk of reinfarction is about 30% if anoperation is performed during the first 3 months At 6 months the risk is about 10 15% which may be acceptable for important elective surgery,Adequate preparation for heart disease,To correct the fluid and electrolyte imbalance. To correct anaemia through several blood transfusion with small amount. To control the cardiac arrhythmias. (Atrial fibrillation, Tachycardia, Bradycardia),Respiratory dysfunction,Respiratory complications occur in up to 15% of surgical patients and are the leading cause of postoperative mortality in the elderly.,Risk factors for respiratory complication,Chronic obstructive pulmonary or airways disease (Chronic bronchitis, emphysema, bronchiectasis, pneumoconiosis, pulmonary tuberculoses)Cigarette smokingCurrent respiratory infectionsAsthma,Preoperative investigation of respiratory disease,A chest X-ray, CT scan if necessary EKG Spirometer Blood gas measurement,Perioperative management of respiratory disease and high risk patients,1. Preoperative physiotherapy teaching the patient breathing exercises and correct posture2. Drug therapy Theophyllines Prophylactic antibiotics Preoperative bronchodilator Adequate hydration,3. Encourage to stop smoking from the time of book for elective surgery4. Alternation methods of anaesthesia Local, regional or spiral anaesthesia should be considered5. Early postoperative physiotherapy to enhance deep breathing, coughing and general mobility,Liver disorder,The tolerance to operation depends upon the severity of liver function impairment. The liver function could be estimated by Child staging. Malnutrition, ascites and jaundice are contraindications except for emergency surgery.,Preoperative assessment and management,Serological test for HBV and HCV, full blood count, clotting screen and platelet count, plasma urea and electrolytes, bilirubin, transaminases, calcium, phosphate, gamma glutaryl transferase and albumin. When prothrombin time is prolonged, vitamin K should be given for several days before operation.,Renal disorders,Preoperative assessment plasma urea, electrolytes, creatinine and Bicarbonate should be checked Mild chronic renal failure Drugs should be given in smaller doses Fluid and electrolyte homeostasis Moderate-to-severe chronic renal failure Operations should be performed under haemodialysis,Disorders of Adrenal Function,Adrenal Insufficiency The most common cause of adrenal insufficiencyis hypothalamo-pituitary-adrenal suppression bylong-term corticosteroid therapy. The lack of adrenal response in these patients maycause acute post-operative cardiovascular collapse withhypotension and shock. For any steroid-dependent patient, a doctor shouldwrite clearly in the note “Treat any unexplained collapsewith hydrocortisone”.,Diabetes Mellitus,At special risk from general anaesthesia and surgery Patients with diabetes fall into three groups 1. Insulin dependent 2. Taking oral hypoglycaemic medication 3. Diet-controlled,Attempt to maintain blood glucose level between 4 and 10 mmol/L, avoid hypoglycemia in particular. Blood glucose level 13 mmol/L, an unreceptible risk of ketoacidosis or a hyperosmolar non-ketotic state.,Perioperative management,The general principle of perioperative management,Establish good diabetic control before operationGiven insulin as a continuous intravenous infusion during the operative periodGiven an infusion of dextrose throughout the operative period to balance the insulin given and to make up for lack of dietary intake,The general principle of perioperative management,Add potassium to the dextrose infusionMonitor blood glucose and electrolytes frequently throughout the operative and early postoperative period,Recovery room is necessary ICU is optimal if possibleMonitoring,Closely monitor the life signs as a routine CVP monitoring is necessary if hemodynamic unstable during operation Other items monitored accordingly Fluid balance,Post-operative Management,Position and getting up,Supine position for spiral anaesthesia Semireclining position for neck and chest operation. Lateral position for obesity patients. Get up as early as possible and make movements as much as possible,Diet and transfusion,Period of fast depends upon the type of operation. Enteral and parenteral nutrition should be taken into consideration. Fluid and electrolytes homeostasis should be maintained.,Management of Drainage,Different drainage for different purpose (infection focus, leakage prevention and massive exudation) Nasal-gastric tube Urinary catheter,Wound healing and suture removing,Classification of incision clean incision contaminated incision infected incisionType of healing Type A perfect healing B some inflammation C infected,1. Postoperative pain any motions increasing tensions will increase pain Analgesia is obligatory2. Pyrexia common postoperative observation a search be made for a focus of infection non-infective causes of pyrexia,Management of postoperative complaint,Nausea and Vomiting,Drugs (opiates, erythromycin, metronidazole)Bowel obstruction mechanical obstruction Adynamic bowel Hypokalaemia faecal impactionSystemic disorders electrolyte disturbances Uraemia raised intracranial pressure,Abdominal distension,More common after abdominal surgery,Hiccup,Diaphragm irritation or central nervous system stimulated Subphrenic infection should be suspected for continuous hiccup,Retention of urine,There is a palpable suprapubic mass with dull to percussion. Urinary catheter is indicated when diagnosed.,The main postoperative complications:,Atelectasis Chest infection Aspiration pneumonitis Pneumonia,Postoperative Haemorrhage,Causes inadequate operative haemostasis a technical mishap as slipped ligatureManagement re-operation to stop bleeding some preparation is necessary,Management of postoperative complications,Wound Dehiscence (Burst Abdomen),Causes blood supply is poor excess suture tension long-term steroid therapy immunosuppressive therapy malnutrition infection coughing or abdominal distensionManagement re-suturing with tension sutures the whole thickness of the abdominal wall,Minor wound infections localized pain, redness and a slight dischargeWound Cellulitis and Abscess cellulitis treated by antibiotics abscess treated by surgical drainage,Wound Infection,Atelectasis,Airway become obstructed and air is absorbed from the air spaces distal to the obstruction Bronchial secretions are the main cause of this obstructionPrevention and treatment perioperative physiotherapy is the best way for prevention deep breathing e