围手术期处理 英语

1、Perioperative ManagementPerioperative periodDefinition not well establishedImportance directly related to the outcome of surgery itselfComposition preoperative preparation & postoperative management 1. Elective surgery2. Restrictive surgery3. Emergent surgeryPreoperative PreparationThe principle Dif

2、ferent 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

3、risk of operationPreoperative AssessmentEssential 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

4、 any intercurrent or occult illness suggested by medical clerkingEssential steps in preoperative assessment and preparationDiscussing the operation with the patient and his family and obtaining signed consentMarking the operation siteMaking arrangements for the operation with the operating theatre s

5、taffArranging and informing the anaesthetistPrescribing medication prophylactic antibiotics etc.Planning rehabilitation and convalescencePsychological preparation talk frankly and appropriately to patientsPhysiological preparation Adaptive exercise Transfusion Prevention of infection Gastro-intestin

6、al tract preparation Maintenance of fluid, electrolyte and nutritionGeneral PreparationMalnutrition and dysfunction of immune system Malnutrition dramatically increases the morbidity and mortality Preoperative nutritional support is more valuableSpecific PreparationHypertension Mild-to-moderate esse

7、ntial hypertension systolic pressure 180mmHg diastolic pressure 110mmHg At minimal riskof cardiac complication Antihypertensive drugs should be used all time Sudden withdrawal of drugs is dangerousSevere or poorly controlled hypertension At high risk of perioperative cardiac failure or stroke. This

8、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 diseaseAnginaPrevious

9、infarctionStable 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 importan

10、t elective surgeryAdequate 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 comp

11、lications occur in up to 15% of surgical patients and are the leading cause of postoperative mortality in the elderly.Risk factors for respiratory complicationChronic obstructive pulmonary or airways disease (Chronic bronchitis, emphysema, bronchiectasis, pneumoconiosis, pulmonary tuberculoses)Cigar

12、ette smokingCurrent respiratory infectionsAsthmaPreoperative investigation of respiratory disease A chest X-ray, CT scan if necessary EKG Spirometer Blood gas measurementPerioperative management of respiratory disease and high risk patients1. Preoperative physiotherapy teaching the patient breathing

13、 exercises and correct posture2. Drug therapy Theophyllines Prophylactic antibiotics Preoperative bronchodilator Adequate hydration3. Encourage to stop smoking from the time of book for elective surgery4. Alternation methods of anaesthesia Local, regional or spiral anaesthesia should be considered5.

14、 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 contraindicatio

15、ns 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

16、 prolonged, vitamin K should be given for several days before operation.Renal disordersPreoperative 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-sever

17、e chronic renal failure Operations should be performed under haemodialysis Disorders of Adrenal FunctionAdrenal Insufficiency The most common cause of adrenal insufficiencyis hypothalamo-pituitary-adrenal suppression bylong-term corticosteroid therapy. The lack of adrenal response in these patients

18、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 diabet

19、es 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-ketot

20、ic state.Perioperative managementThe general principle of perioperative managementEstablish 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 a

21、nd to make up for lack of dietary intakeThe general principle of perioperative managementAdd 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 Clo

22、sely monitor the life signs as a routine CVP monitoring is necessary if hemodynamic unstable during operation Other items monitored accordingly Fluid balance Post-operative ManagementPosition and getting up Supine position for spiral anaesthesia Semireclining position for neck and chest operation. L

23、ateral position for obesity patients. Get up as early as possible and make movements as much as possibleDiet 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

24、.Management of Drainage Different drainage for different purpose (infection focus, leakage prevention and massive exudation) Nasal-gastric tube Urinary catheterWound healing and suture removingClassification of incision clean incision contaminated incision infected incisionType of healing Type A per

25、fect healing B some inflammation C infected1. 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 pyrexiaManagement of postoperative complaintNausea

26、and VomitingDrugs (opiates, erythromycin, metronidazole)Bowel obstruction mechanical obstruction Adynamic bowel Hypokalaemia faecal impactionSystemic disorders electrolyte disturbances Uraemia raised intracranial pressureAbdominal distensionMore common after abdominal surgeryHiccup Diaphragm irritat

27、ion or central nervous system stimulated Subphrenic infection should be suspected for continuous hiccupRetention 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 Aspira

28、tion pneumonitis PneumoniaPostoperative HaemorrhageCauses inadequate operative haemostasis a technical mishap as slipped ligatureManagement re-operation to stop bleeding some preparation is necessaryManagement of postoperative complicationsWound Dehiscence (Burst Abdomen)Causes blood supply is poor

29、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 wallMinor wound infections localized pain, redness and a slight dischargeWound Cellulitis

30、and Abscess cellulitis treated by antibiotics abscess treated by surgical drainage Wound InfectionAtelectasis 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 breath