0901-术前准备及术后处理-姚宏伟课件

术前预备及术后处理

PerioperativeManagement北京大学第三医院一般外科姚宏伟Dept.ofGeneralSurgery,PekingUniversityThirdHospital1Purpose把握手术前预备生疏手术后处理生疏术后并发症的预防和治疗2

Definition:

Managementbefore,during&after

asurgicaloperationSuccessfulsurgery2.Intra-Opmanagement

1.Pre-Oppreparation3.Post-Opmanagement3KeypointsPre-OperativePreparationPost-OperativeManagement41.Pre-OperativePreparation5

Aims

Toachievethebeststatusforsurgeonsandpatients6

Principle

Individualizedpreparation&managementfordifferentpatients&operations

ExamplesNodulargoiterGastricCarcinomaAcuteduodenalperforationwithdiffuseperitonitis7术前预备内容：一般性预备心理预备：〔1〕病人方面

〔2〕医生方面病史采集＋体格检查＋伴随疾病常规〔/特殊〕化验、检查水、电解质及酸碱平衡监测以及调整预备血液制品〔选择性〕胃肠道预备：〔1〕有胃潴留、幽门梗阻者：胃肠减压管并洗胃

〔2〕结直肠手术：肠道预备抗生素的预防性应用

〔适应证手术清洁程度分级〕81.养分不良，低白蛋白血症2.高血压3.非心外科手术合并心脏病者〔心衰、心梗〕4.呼吸道疾病5.肝功能特殊〔代偿期VS失代偿期〕6.肾功能衰竭7.糖尿病术前预备内容：特殊性预备9Classificationofoperations1.Selectiveoperation2.Restrictiveoperation3.Emergencyoperation(1.【医】择期手术)10AssessmentofphysicalstatusToassessthegeneralconditionandfunctionofimportantorgansToevaluatethetolerancecapacityASA&APACHEⅡScoringSystemASA：AmericanSocietyofAnesthesiologistsAPACHE：AcutePhysiologyandChronicHealthEvaluation11ASAclassification第I级：正常，安康

第II级：有轻度系统性疾病

第III级：有严峻系统性疾病，日常活动受限，尚未丧失工作力气

第IV级：有严峻系统性疾病，已丧失工作力气，且常常面临生命威逼

第V级：无论手术与否，生命难以维持24小时的频死病人I：normalhealthypatientII：patientwithmildsystemicdiseaseIII：patientwithseveresystemicdiseasethatlimitsactivity,butisnotincapacitatingIV：patientthathasincapacitatingdiseasethatisaconstantthreattolifeV：moribundpatientnotexpectedtosurvive24hourswithorwithoutanoperationAnesthetic-relatedmortalitieswere0%,0.17%,0.6%,4.3%,and10.0%,respectively12APACHEⅡScoringSystem13男，72岁，因乙状结肠癌伴急性肠梗阻4天入院.既往：1年前“急性心梗”病史Case114急诊手术？限期手术？心脏功能评估？术前肠道预备如何开展？Case115Case2患者，男，55岁，因“甲状腺多发结节”入院。既往：糖尿病4年，口服降糖药物，血糖把握不满足问：此患者需做何术前预备？16Case2AssessmentSugarcontrolAdaptiveexerciseAntibiotics17Case3

患者，男，62岁，无痛性进展性黄疸2周，大便灰白，小便浓茶色，通过B超和CT检查，初步诊断为胰头癌，拟行手术治疗。试问：该病人特殊的术前预备有那些？18Case31.VitaminK4

，胆汁酸盐

2.抗生素

3.保肝药物

4.其他19Case3该患者合并高血压，冠心病，且4年前曾有心肌堵塞病史，血肌酐156umol/L问：需如何处理，能否手术？20Case3血压把握心脏评估肾脏评估21Goldman’scriteria〔CardiacRiskIndexCriteria,CRIS〕RiskofseriouscardiaceventordeathClassI(0to5points)0.9%ClassII(6to12points)7.1%ClassIII(13to25points)16.0%ClassIV(>26points)63.6%22RespiratorydysfunctionRiskfactorsforrespiratorycomplication

COPDAsthmaCurrentrespiratoryinfections23PreoperativemanagementofrespiratorydiseaseAssessmentManagement:Smokingabatement2.Respiratoryphysiotherapy3.Controllinginfection4.Drugtherapy5.Alternationmethodsofanaesthesia24LiverdisorderTheliverfunctioncouldbeestimatedbyChildstaging.25Liverdisorder26ApproachtothepatientwithliverdiseaseSurgeryinthepatientwithliverdisease.MayoClinProc74:593–599,199927Surgeryinthepatientwithliverdisease.MayoClinProc74:593–599,1999.

Liverdiseases28Malnutrition

MalnutritionincreasesthemorbidityandmortalityofoperationsdramaticallyApproachesofnutritionsupport:ENPNENPN29术前争论以及病情总结302.Post-OperativeManagement31GeneralmanagementManagementofpostoperativecomplaintManagementofpostoperativecomplications32Post-operativeManagement

Recoveryroomisnecessary

ICUisoptimalifpossibleMonitoring

CloselymonitorthelifesignsasaroutineOtheritemsmonitoredaccordingly33GeneralmanagementPositionandgettingup〔Analgesia〕DietFluidinfusionWoundhealingandsutureremoving34WoundhealingandsutureremovingClassificationofincisioncleanclean-contaminatedcontaminatedinfectedTypeofhealing

TypeAperfecthealingBsomeinflammationCinfected35Surgicalwoundclassification36ManagementofDrainageNasal-gastrictubeUrinarycatheter

Differentdrainagefordifferentpurpose(infectionfocus,leakagepreventionandmassiveexudation)Specialmanagement37患者，女，70岁，因急性胆管炎行胆囊切除胆总管切开取石，T管引流术，术后第3天拔除胆囊床引流管，2周拔除T管，拔管后2小时消逝右上腹痛，发热、黄疸，B超提示右上腹有积液。保守无效于拔管后第2天再行剖腹探查，T管撕裂窦道置管引流术，术后2周恢复出院。问：1.胆囊床引流管和T管应如何处理？Case438

ManagementofpostoperativecomplaintandcomplicationsComplaintcomplicationsNormalAbnormal39ManagementofpostoperativecomplaintPostoperativepain2.Pyrexiacommonpostoperativeobservation

40Case5患者，男，76岁，因急性阑尾炎并穿孔急诊全麻下行阑尾切除，腹腔引流术。术后第1天T38.5℃；第2天38.2℃;第3天38℃；第4~5天37.7~38.5℃。Q1:患者体温为正常恢复过程吗？Q2：分析可能缘由及处理41postoperativefeverCauses

1.surgicalfactor

wound

abdominalcavity

leakage

2.non-surgicalfactor

Atelectasis/

pneumonia

urinarysysteminfectionDVT

pylephlebitis……Management

42NauseaandVomitingAnesthesiaBowelobstructionmechanicalobstructionAdynamicbowelSystemicdisorderselectrolytedisturbancesUraemiaraisedintracranialpressure43Retentionofurine

Thereisapalpablesuprapubicmasswithdulltopercussion.Urinarycatheterisindicatedwhendiagnosed.44AbdominaldistensionSingultusOthercomplaint45Case6患者，男，42岁，因胰头癌行Whipple手术，术后第一天心率快，其次天消逝消逝血压下降、烦躁担忧、面色苍白等。

试分析此病人消逝了什么问题？还需作那些检查以证明诊断？如何处理？46ManagementofpostoperativecomplicationsPostoperativeHaemorrhageCausesinadequateoperativehaemostasisatechnicalmishapasslippedligature

……Managementre-operationtostopbleedingsomepreparationisnecessary47Case7患者，女，72岁。因急性胆囊炎急诊行胆囊切除术，承受经右上腹直肌切口。术后有咳嗽和腹胀，第2天晚8点猛烈咳嗽后突然消逝切口处有崩裂感，随后有淡血性液体及肠管从切口处涌出。试问此病人消逝了什么问题？如何解决？48WoundDehiscence(BurstAbdomen)Causesbloodsupplyispoorexcesssuturetensionlong-termsteroidtherapyimmunosuppressivetherapymalnutritioninfectioncoughingorabdominaldistensionManagementre-suturingwithtensionsuturesthewholethicknessoftheabdominalwall491.患者，女，60岁，患类风湿性关节炎20年，常年服用强的松10mgqd.突发上腹痛8小时入院，急诊以急性布满性腹膜炎，上消化道溃疡穿孔行手术治疗，行胃大部切除术。手术顺当，关腹前突然消逝不明缘由的血压降低，经用各种抗休克治疗不见效而死亡。试问：此病人的死亡缘由是什么？思考题〔1〕50思考题结肠手术的术前预备术前预防性抗生素的使用指征术后发热的常见缘由分析51Thanksforyourattention52DiabetesMellitus

AtspecialriskfromgeneralanaesthesiaandsurgeryThreegroups53PerioperativemanagementInsulinAttempttomaintainbloodglucoselevelbetween5.6

and11.2mmol/L,avoidhypoglycemiainparticular.UrineGlu+~++54Hypertension

收缩压＜160mmHg

舒张压＜100mmHg

Antihypertensivedrugsshouldbeusedalltime，Suddenwithdrawalofdrugsisdangerous55Cardiovasculardisease1.Ischaemicheartdisease2.Cardiacfailure3.Arrhythmias4.Valvularheartdisease56RenaldisordersPreoperativeassessmentBUN,Scr,Ccr，Mildchronicrenalfailure

DrugsshouldbegiveninsmallerdosesFluidand