上交大外科學(xué)課件10圍手術(shù)期處理（英文版）

PerioperativeManagementPerioperative---periodDefinitionnotwellestablishedImportancedirectlyrelatedtotheoutcomeofsurgeryitselfCompositionpreoperativepreparation&postoperativemanagement

1.Electivesurgery2.Restrictivesurgery3.EmergentsurgeryPreoperative

PreparationTheprincipleDifferentpreparationfordifferentoperationTheclassificationofoperationsaccordingtothecharacteristicsofoperationsElectivesurgeryRestrictivesurgeryEmergentsurgeryDr.EvilSays….$$$$????TheodorKocher(1841-1917)WithTheodorBillrothestablishedlargeclinicsinEuropeand,throughdevelopmentofskilledsurgicaltechniquescombinedwithneweranestheticandantisepticprinciples,providedsurgicalresultsthatprovedthesafetyandefficacyofthyroidsurgeryforbenignandmalignantproblemsWilliamStewartHalsted(1852-1922)ASCENTOFSCIENTIFICSURGERYRresearchbasedonanatomic,pathologic,andphysiologicprinciplesandemployinganimalexperimentationHalstedianprinciples

ToconfirmthediagnosisToassesstheriskofoperationToassessthegeneralconditionandfunctionofimportantorgansToevaluatethepatientsendurancetotheoperationandriskofoperationPreoperativeAssessmentEssentialstepsinpreoperative

assessmentandpreparationHistorytakingPhysicalexaminationCollatingpre-admissioninformationaboutdiagnosisArranginganyfurtherdiagnosticinvestigationMakingspecialpreparationsfortheparticularoperationInvestigatinganyintercurrentoroccultillnesssuggestedbymedicalclerkingEssentialstepsinpreoperative

assessmentandpreparationDiscussingtheoperationwiththepatientandhisfamilyandobtainingsignedconsentMarkingtheoperationsiteMakingarrangementsfortheoperationwiththeoperatingtheatrestaffArrangingandinformingtheanaesthetistPrescribingmedicationprophylacticantibioticsetc.PlanningrehabilitationandconvalescencePsychologicalpreparationtalkfranklyandappropriatelytopatientsPhysiologicalpreparationAdaptiveexerciseTransfusionPreventionofinfectionGastro-intestinaltractpreparationMaintenanceoffluid,electrolyteandnutritionGeneralPreparationMalnutritionanddysfunctionofimmunesystem

MalnutritiondramaticallyincreasesthemorbidityandmortalityPreoperativenutritionalsupportismorevaluableSpecificPreparationHypertension

Mild-to-moderateessentialhypertension

systolicpressure＜180mmHg

diastolicpressure＜

110mmHg

AtminimalriskofcardiaccomplicationAntihypertensivedrugsshouldbeusedalltimeSuddenwithdrawalofdrugsisdangerousSevereorpoorlycontrolledhypertensionAthighriskofperioperativecardiacfailureorstroke.Thistypeofpatientsshouldnotundergogeneralanaesthesiaandsurgeryuntiladequatelytreated.Thebloodpressureshouldbereasonablycontrolledunder160/100mmHg.CardiovasculardiseaseIschaemicheartdiseaseCardiacfailureArrhythmiasValvularheartdiseaseCerebrovasculardiseaseAnginaPreviousinfarctionStableanginaposeslittleincreasedriskduringoperationbutunstableanginaisasdangerousasrecentmyocardialinfarctionTheriskofreinfarctionisabout30%ifanoperationisperformedduringthefirst3monthsAt6monthstheriskisabout10~15%whichmaybeacceptableforimportantelectivesurgeryWeightingofCardiacRiskFactorsCriterion(RiskFactor)CardiacComplications(%)CardiacDeaths(%)PointsHistoryAge>70yrMI<6moearlier1137523510PhysicalExaminationS3galloporJVDImportantVAS34172013113FromGoldmanL:Cardiacrisksandcomplicationsofnoncardiacsurgery.AnnInternMed98:504-513,1983.

WeightingofCardiacRiskFactorscontinueCriterion(RiskFactor)CardiacComplications(%)CardiacDeaths(%)PointsElectrocardiogramRhythmotherthansinusorPACs>5PVCs/min193091477Generalstatus

Po2<60orPco2>50mmHg;K<3.0orHCO3<20mEq/L;BUN>50orCr>3mg/dl;abnormalAST;chronicliverdisease;bedridden1143SurgeryIntraperitoneal;intrathoracic;oraorticEmergency9.5132.5544AdequatepreparationforheartdiseaseTocorrectthefluidandelectrolyteimbalance.Tocorrectanaemiathroughseveralbloodtransfusionwithsmallamount.Tocontrolthecardiacarrhythmias.

(Atrialfibrillation,Tachycardia,Bradycardia)Respiratorydysfunction

Respiratorycomplicationsoccurinupto15%ofsurgicalpatientsandaretheleadingcauseofpostoperativemortalityintheelderly.RiskfactorsforrespiratorycomplicationChronicobstructivepulmonaryorairwaysdisease(Chronicbronchitis,emphysema,bronchiectasis,pneumoconiosis,pulmonarytuberculoses)CigarettesmokingCurrentrespiratoryinfectionsAsthmaPreoperativeinvestigationofrespiratorydisease

AchestX-ray,CTscanifnecessaryEKGSpirometerBloodgasmeasurementPerioperativemanagementofrespiratorydiseaseandhighriskpatients1.Preoperativephysiotherapyteachingthepatientbreathingexercisesandcorrectposture2.DrugtherapyTheophyllinesProphylacticantibioticsPreoperativebronchodilatorAdequatehydration3.Encouragetostopsmokingfromthetimeofbookforelectivesurgery4.Alternationmethodsofanaesthesia

Local,regionalorspiralanaesthesiashouldbeconsidered5.

Earlypostoperativephysiotherapy

toenhancedeepbreathing,coughingandgeneralmobility

LiverdisorderThetolerancetooperationdependsupontheseverityofliverfunctionimpairment.TheliverfunctioncouldbeestimatedbyChildstaging.Malnutrition,ascitesandjaundicearecontraindicationsexceptforemergencysurgery.

PreoperativeassessmentandmanagementSerologicaltestforHBVandHCV,fullbloodcount,clottingscreenandplateletcount,plasmaureaandelectrolytes,bilirubin,transaminases,calcium,phosphate,gammaglutaryltransferaseandalbumin.Whenprothrombintimeisprolonged,vitaminKshouldbegivenforseveraldaysbeforeoperation.RenaldisordersPreoperativeassessmentplasmaurea,electrolytes,creatinineandBicarbonateshouldbecheckedMildchronicrenalfailureDrugsshouldbegiveninsmallerdosesFluidandelectrolytehomeostasisModerate-to-severechronicrenalfailureOperationsshouldbeperformedunderhaemodialysis

DisordersofAdrenalFunctionAdrenalInsufficiencyThemostcommoncauseofadrenalinsufficiencyishypothalamo-pituitary-adrenalsuppressionbylong-termcorticosteroidtherapy.Thelackofadrenalresponseinthesepatientsmaycauseacutepost-operativecardiovascularcollapsewithhypotensionandshock.Foranysteroid-dependentpatient,adoctorshouldwriteclearlyinthenote“Treatanyunexplainedcollapsewithhydrocortisone”.DiabetesMellitusAtspecialriskfromgeneralanaesthesiaandsurgery

Patientswithdiabetesfallintothreegroups1.Insulindependent2.Takingoralhypoglycaemicmedication3.Diet-controlledAttempttomaintainbloodglucoselevelbetween4and10mmol/L,avoidhypoglycemiainparticular.Bloodglucoselevel＞13mmol/L,anunreceptibleriskofketoacidosisorahyperosmolarnon-ketoticstate.PerioperativemanagementThegeneralprincipleofperioperativemanagementEstablishgooddiabeticcontrolbeforeoperationGiveninsulinasacontinuousintravenousinfusionduringtheoperativeperiodGivenaninfusionofdextrosethroughouttheoperativeperiodtobalancetheinsulingivenandtomakeupforlackofdietaryintakePatientswithdiabetes:

whatpre-operativeassessmentisimportant?DocumentthefollowingTypeofdiabetesLengthoftimesincediagnosisCurrentmanagementCurrentglycemiccontrolHgBA1cGlucometerdtaPresenceofcomplicationsNeuropathyNephropathyRetinopathyAutonomicneuropathyincreaseriskofpostopgastroparesisandurinarytractinfectionThegeneralprincipleofperioperativemanagementAddpotassiumtothedextroseinfusionMonitorbloodglucoseandelectrolytesfrequentlythroughouttheoperativeandearlypostoperativeperiod

Recoveryroomisnecessary

ICUisoptimalifpossibleMonitoring

CloselymonitorthelifesignsasaroutineCVPmonitoringisnecessaryifhemodynamicunstableduringoperationOtheritemsmonitoredaccordinglyFluidbalancePost-operativeManagementPositionandgettingupSupinepositionforspiralanaesthesiaSemirecliningpositionforneckandchestoperation.Lateralpositionforobesitypatients.GetupasearlyaspossibleandmakemovementsasmuchaspossibleDietandtransfusionPeriodoffastdependsuponthetypeofoperation.Enteralandparenteralnutritionshouldbetakenintoconsideration.Fluidandelectrolyteshomeostasisshouldbemaintained.ManagementofDrainageDifferentdrainagefordifferentpurpose(infectionfocus,leakagepreventionandmassiveexudation)Nasal-gastrictubeUrinarycatheterWoundhealingandsutureremovingClassificationofincisioncleanincisioncontaminatedincisioninfectedincisionTypeofhealing

TypeAperfecthealingBsomeinflammationCinfected1.PostoperativepainanymotionsincreasingtensionswillincreasepainAnalgesiaisobligatory2.Pyrexiacommonpostoperativeobservationasearchbemadeforafocusofinfectionnon-infectivecausesofpyrexiaManagementofpostoperativecomplaintNauseaandVomitingDrugs(opiates,erythromycin,metronidazole)BowelobstructionmechanicalobstructionAdynamicbowelHypokalaemiafaecalimpactionSystemicdisorderselectrolytedisturbancesUraemiaraisedintracranialpressureAbdominaldistensionMorecommonafterabdominalsurgeryHiccupDiaphragmirritationorcentralnervoussystemstimulatedSubphrenicinfectionshouldbesuspectedforcontinuoushiccupRetentionofurineThereisapalpablesuprapubicmasswithdulltopercussion.Urinarycatheterisindicatedwhendiagnosed.Themainpostoperativecomplications:AtelectasisChestinfectionAspirationpneumonitisPneumoniaPostoperativeHaemorrhageCausesinadequateoperativehaemostasisatechnicalmishapasslippedligatureManagementre-operationtostopbleedingsomepreparationisnecessaryManagementof

postoperativecomplicationsWoundDehiscence(BurstAbdomen)Causesbloodsupplyispoorexcesssuturetensionlong-termsteroidtherapyimmunosuppressivetherapymalnutritioninfectioncoughingorabdominaldistensionManagementre-suturingwithtensionsuturesthewholethicknessoftheabdominalwallMinorwoundinfectionslocalizedpain,rednessandaslightdischargeWoundCellulitisandAbscesscellulitistreatedbyantibioticsabscesstreatedbysurgical drainage

WoundInfectionAtelectasisAirwaybecomeobstructedandairisabsorbedfromtheairspacesdistaltotheobstructionBronchialsecretionsarethemaincauseofthisobstructionPreventionandtreatmentperioperativephysiotherapyisthebestwayforpreventiondeepbreathingexercisesregularadjustmentsofposturevigorouscoughingflexiblebronchoscopytoaspirateoccludingmucusplugsUrinaryTractInfectionsCausesreducedurinaryoutputreducing“flushing”ofbladderincompletebladderemptyinginadequateperinealhygieneTreatment

ensuringadequatefluidinputappropriateantibioticsDeepveinthrombosisCauses

bedboundafteroperationvenousstasisplasmaconcentratedduedehydrationviscosityincreasedManifestationsswellingofthelegtendernessofthecalfmuscleincreasedwarmthofthelegcalfpainonpassivedorsiflexionofthefootTreatmentAnticoagulation:Systemicthrombolytictherapy:

streptokinaseLocalthrombolyticdrugsismorepromisingintravenousheparinsubcutaneousheparinoralwarfarintherapypostoperativemobilizationadequatehydrationavoidingcalfpressurePreventionforhighriskcaseslowdosesubcutaneousheparincalfcompressiondevicesgraded-compression‘a(chǎn)nti-embolism’stockingsIntravenousdextranWarfarinanticoagulationSamplePreoperativeChecklistOperativepermit,appropriatelysignedandwitnessedDietaryconsiderationsForabdominaloperation,liquiddietandlaxativestoensureclean,collapsedbowelNothingbymouthatleast6hrbeforeoperationSamplePreoperativeChecklistReviewoflife-supportsystemsVitalsignsrecordedoftenenoughtoestablishnormalvaluesPulmonarysystem:chestfilms;Othe