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PerioperativeManagementPerioperativeManagementPerioperativeperiodDefinitionnotwellestablishedImportancedirectlyrelatedtotheoutcomeofsurgeryitselfCompositionpreoperativepreparation&postoperativemanagementPerioperativeperiodDefinition2
1.Electivesurgery2.Restrictivesurgery3.EmergentsurgeryPreoperative
PreparationTheprincipleDifferentpreparationfordifferentoperationTheclassificationofoperationsaccordingtothecharacteristicsofoperations1.ElectivesurgeryPreoperativ3ToconfirmthediagnosisToassesstheriskofoperationToassessthegeneralconditionandfunctionofimportantorgansToevaluatethepatientsendurancetotheoperationandriskofoperationPreoperativeAssessmentToconfirmthediagnosisPreo4Essentialstepsinpreoperative
assessmentandpreparationHistorytakingPhysicalexaminationCollatingpre-admissioninformationaboutdiagnosisArranginganyfurtherdiagnosticinvestigationMakingspecialpreparationsfortheparticularoperationInvestigatinganyintercurrentoroccultillnesssuggestedbymedicalclerkingEssentialstepsinpreoperativ5Essentialstepsinpreoperative
assessmentandpreparationDiscussingtheoperationwiththepatientandhisfamilyandobtainingsignedconsentMarkingtheoperationsiteMakingarrangementsfortheoperationwiththeoperatingtheatrestaffArrangingandinformingtheanaesthetistPrescribingmedicationprophylacticantibioticsetc.PlanningrehabilitationandconvalescenceEssentialstepsinpreoperativ6PsychologicalpreparationtalkfranklyandappropriatelytopatientsPhysiologicalpreparationAdaptiveexerciseTransfusionPreventionofinfectionGastro-intestinaltractpreparationMaintenanceoffluid,electrolyteandnutritionGeneralPreparationPsychologicalpreparationAda7Malnutritionanddysfunctionofimmunesystem
MalnutritiondramaticallyincreasesthemorbidityandmortalityPreoperativenutritionalsupportismorevaluableSpecificPreparationMalnutritionanddysfunctiono8Hypertension
Mild-to-moderateessentialhypertension
systolicpressure<180mmHg
diastolicpressure<
110mmHg
AtminimalriskofcardiaccomplicationAntihypertensivedrugsshouldbeusedalltimeSuddenwithdrawalofdrugsisdangerousHypertensionMild-to-modera9SevereorpoorlycontrolledhypertensionAthighriskofperioperativecardiacfailureorstroke.Thistypeofpatientsshouldnotundergogeneralanaesthesiaandsurgeryuntiladequatelytreated.Thebloodpressureshouldbereasonablycontrolledunder160/100mmHg.Severeorpoorlycontrolled10CardiovasculardiseaseIschaemicheartdiseaseCardiacfailureArrhythmiasValvularheartdiseaseCerebrovasculardiseaseCardiovasculardiseaseIschae11AnginaPreviousinfarctionStableanginaposeslittleincreasedriskduringoperationbutunstableanginaisasdangerousasrecentmyocardialinfarctionTheriskofreinfarctionisabout30%ifanoperationisperformedduringthefirst3monthsAt6monthstheriskisabout10~15%whichmaybeacceptableforimportantelectivesurgeryAnginaPreviousinfarctionStabl12AdequatepreparationforheartdiseaseTocorrectthefluidandelectrolyteimbalance.Tocorrectanaemiathroughseveralbloodtransfusionwithsmallamount.Tocontrolthecardiacarrhythmias.
(Atrialfibrillation,Tachycardia,Bradycardia)AdequatepreparationforTo13Respiratorydysfunction
Respiratorycomplicationsoccurinupto15%ofsurgicalpatientsandaretheleadingcauseofpostoperativemortalityintheelderly.Respiratorydysfunction14RiskfactorsforrespiratorycomplicationChronicobstructivepulmonaryorairwaysdisease(Chronicbronchitis,emphysema,bronchiectasis,pneumoconiosis,pulmonarytuberculoses)CigarettesmokingCurrentrespiratoryinfectionsAsthmaRiskfactorsforChronicobstr15Preoperativeinvestigationofrespiratorydisease
AchestX-ray,CTscanifnecessaryEKGSpirometerBloodgasmeasurementPreoperativeinvestigationof16Perioperativemanagementofrespiratorydiseaseandhighriskpatients1.Preoperativephysiotherapyteachingthepatientbreathingexercisesandcorrectposture2.DrugtherapyTheophyllinesProphylacticantibioticsPreoperativebronchodilatorAdequatehydrationPerioperativemanagementof1.173.Encouragetostopsmokingfromthetimeofbookforelectivesurgery4.Alternationmethodsofanaesthesia
Local,regionalorspiralanaesthesiashouldbeconsidered5.
Earlypostoperativephysiotherapy
toenhancedeepbreathing,coughingandgeneralmobility
3.Encouragetostopsmokingf18LiverdisorderThetolerancetooperationdependsupontheseverityofliverfunctionimpairment.TheliverfunctioncouldbeestimatedbyChildstaging.Malnutrition,ascitesandjaundicearecontraindicationsexceptforemergencysurgery.
LiverdisorderThetolerance19PreoperativeassessmentandmanagementSerologicaltestforHBVandHCV,fullbloodcount,clottingscreenandplateletcount,plasmaureaandelectrolytes,bilirubin,transaminases,calcium,phosphate,gammaglutaryltransferaseandalbumin.Whenprothrombintimeisprolonged,vitaminKshouldbegivenforseveraldaysbeforeoperation.PreoperativeassessmentSero20RenaldisordersPreoperativeassessmentplasmaurea,electrolytes,creatinineandBicarbonateshouldbecheckedMildchronicrenalfailureDrugsshouldbegiveninsmallerdosesFluidandelectrolytehomeostasisModerate-to-severechronicrenalfailureOperationsshouldbeperformedunderhaemodialysis
RenaldisordersPreoperativeas21DisordersofAdrenalFunctionAdrenalInsufficiencyThemostcommoncauseofadrenalinsufficiencyishypothalamo-pituitary-adrenalsuppressionbylong-termcorticosteroidtherapy.Thelackofadrenalresponseinthesepatientsmaycauseacutepost-operativecardiovascularcollapsewithhypotensionandshock.Foranysteroid-dependentpatient,adoctorshouldwriteclearlyinthenote“Treatanyunexplainedcollapsewithhydrocortisone”.DisordersofAdrenalFunctionA22DiabetesMellitusAtspecialriskfromgeneralanaesthesiaandsurgery
Patientswithdiabetesfallintothreegroups1.Insulindependent2.Takingoralhypoglycaemicmedication3.Diet-controlledDiabetesMellitusAtspecia23Attempttomaintainbloodglucoselevelbetween4and10mmol/L,avoidhypoglycemiainparticular.Bloodglucoselevel>13mmol/L,anunreceptibleriskofketoacidosisorahyperosmolarnon-ketoticstate.PerioperativemanagementAttempttomaintainbloodgl24ThegeneralprincipleofperioperativemanagementEstablishgooddiabeticcontrolbeforeoperationGiveninsulinasacontinuousintravenousinfusionduringtheoperativeperiodGivenaninfusionofdextrosethroughouttheoperativeperiodtobalancetheinsulingivenandtomakeupforlackofdietaryintakeThegeneralprincipleofperio25ThegeneralprincipleofperioperativemanagementAddpotassiumtothedextroseinfusionMonitorbloodglucoseandelectrolytesfrequentlythroughouttheoperativeandearlypostoperativeperiodThegeneralprincipleofperio26
Recoveryroomisnecessary
ICUisoptimalifpossibleMonitoring
CloselymonitorthelifesignsasaroutineCVPmonitoringisnecessaryifhemodynamicunstableduringoperationOtheritemsmonitoredaccordinglyFluidbalancePost-operativeManagementRecoveryroomisneces27PositionandgettingupSupinepositionforspiralanaesthesiaSemirecliningpositionforneckandchestoperation.Lateralpositionforobesitypatients.GetupasearlyaspossibleandmakemovementsasmuchaspossiblePositionandgettingupSupin28DietandtransfusionPeriodoffastdependsuponthetypeofoperation.Enteralandparenteralnutritionshouldbetakenintoconsideration.Fluidandelectrolyteshomeostasisshouldbemaintained.DietandtransfusionPeriodo29ManagementofDrainageDifferentdrainagefordifferentpurpose(infectionfocus,leakagepreventionandmassiveexudation)Nasal-gastrictubeUrinarycatheterManagementofDrainageDiffere30WoundhealingandsutureremovingClassificationofincisioncleanincisioncontaminatedincisioninfectedincisionTypeofhealing
TypeAperfecthealingBsomeinflammationCinfectedWoundhealingandsutureremov311.PostoperativepainanymotionsincreasingtensionswillincreasepainAnalgesiaisobligatory2.Pyrexiacommonpostoperativeobservationasearchbemadeforafocusofinfectionnon-infectivecausesofpyrexiaManagementofpostoperativecomplaint1.PostoperativepainManagemen32NauseaandVomitingDrugs(opiates,erythromycin,metronidazole)BowelobstructionmechanicalobstructionAdynamicbowelHypokalaemiafaecalimpactionSystemicdisorderselectrolytedisturbancesUraemiaraisedintracranialpressureNauseaandVomitingDrugs(opi33AbdominaldistensionMorecommonafterabdominalsurgeryHiccupDiaphragmirritationorcentralnervoussystemstimulatedSubphrenicinfectionshouldbesuspectedforcontinuoushiccupAbdominaldistensionMorecommo34RetentionofurineThereisapalpablesuprapubicmasswithdulltopercussion.Urinarycatheterisindicatedwhendiagnosed.RetentionofurineThereisa35Themainpostoperativecomplications:AtelectasisChestinfectionAspirationpneumonitisPneumoniaThemainpostoperativecomplic36PostoperativeHaemorrhageCausesinadequateoperativehaemostasisatechnicalmishapasslippedligatureManagementre-operationtostopbleedingsomepreparationisnecessaryManagementof
postoperativecomplicationsPostoperativeHaemorrhageCause37WoundDehiscence(BurstAbdomen)Causesbloodsupplyispoorexcesssuturetensionlong-termsteroidtherapyimmunosuppressivetherapymalnutritioninfectioncoughingorabdominaldistensionManagementre-suturingwithtensionsuturesthewholethicknessoftheabdominalwallWoundDehiscence(BurstAbdome38Minorwoundinfectionslocalizedpain,rednessandaslightdischargeWoundCellulitisandAbscesscellulitistreatedbyantibioticsabscesstreatedbysurgicaldrainage
WoundInfectionMinorwoundinfectionsWoundIn39AtelectasisAirwaybecomeobstructedandairisabsorbedfromtheairspacesdistaltotheobstructionBronchialsecretionsarethemaincauseofthisobstructionPreventionandtreatmentperioperativephysiotherapyisthebestwayforpreventiondeepbreathingexercisesregularadjustmentsofposturevigorouscoughingflexiblebronchoscopytoaspirateoccludingmucusplugsAtelectasisAirwaybecomeobs40UrinaryTractInfectionsCausesreducedurinaryoutputreducing“flushing”ofbladderincompletebladderemptyinginadequateperinealhygieneTreatment
ensuringadequatefluidinputappropriateantibioticsUrinaryTractInfectionsCauses41DeepveinthrombosisCauses
bedboundafteroperationvenousstasisplasmaconcentratedduedehydrationviscosityincreasedManifestationsswellingofthelegtendernessofthecalfmuscleincreasedwarmthofthelegcalfpainonpassivedorsiflexionofthefootDeepveinthrombosisCauses42TreatmentAnticoagulation:Systemicthrombolytictherapy:
streptokinaseLocalthrombolyticdrugsismorepromisingintravenousheparinsubcutaneousheparinoralwarfarintherapyTreatmentintravenousheparin43postoperativemobilizationadequatehydrationavoidingcalfpressurePreventionforhighriskcaseslowdosesubcutaneousheparincalfcompressiondevicesgraded-compression‘a(chǎn)nti-embolism’stockingsIntravenousdextranWarfarinanticoagulationpostoperativemobilizationP44ThankyouThankyou45PerioperativeManagementPerioperativeManagementPerioperativeperiodDefinitionnotwellestablishedImportancedirectlyrelatedtotheoutcomeofsurgeryitselfCompositionpreoperativepreparation&postoperativemanagementPerioperativeperiodDefinition47
1.Electivesurgery2.Restrictivesurgery3.EmergentsurgeryPreoperative
PreparationTheprincipleDifferentpreparationfordifferentoperationTheclassificationofoperationsaccordingtothecharacteristicsofoperations1.ElectivesurgeryPreoperativ48ToconfirmthediagnosisToassesstheriskofoperationToassessthegeneralconditionandfunctionofimportantorgansToevaluatethepatientsendurancetotheoperationandriskofoperationPreoperativeAssessmentToconfirmthediagnosisPreo49Essentialstepsinpreoperative
assessmentandpreparationHistorytakingPhysicalexaminationCollatingpre-admissioninformationaboutdiagnosisArranginganyfurtherdiagnosticinvestigationMakingspecialpreparationsfortheparticularoperationInvestigatinganyintercurrentoroccultillnesssuggestedbymedicalclerkingEssentialstepsinpreoperativ50Essentialstepsinpreoperative
assessmentandpreparationDiscussingtheoperationwiththepatientandhisfamilyandobtainingsignedconsentMarkingtheoperationsiteMakingarrangementsfortheoperationwiththeoperatingtheatrestaffArrangingandinformingtheanaesthetistPrescribingmedicationprophylacticantibioticsetc.PlanningrehabilitationandconvalescenceEssentialstepsinpreoperativ51PsychologicalpreparationtalkfranklyandappropriatelytopatientsPhysiologicalpreparationAdaptiveexerciseTransfusionPreventionofinfectionGastro-intestinaltractpreparationMaintenanceoffluid,electrolyteandnutritionGeneralPreparationPsychologicalpreparationAda52Malnutritionanddysfunctionofimmunesystem
MalnutritiondramaticallyincreasesthemorbidityandmortalityPreoperativenutritionalsupportismorevaluableSpecificPreparationMalnutritionanddysfunctiono53Hypertension
Mild-to-moderateessentialhypertension
systolicpressure<180mmHg
diastolicpressure<
110mmHg
AtminimalriskofcardiaccomplicationAntihypertensivedrugsshouldbeusedalltimeSuddenwithdrawalofdrugsisdangerousHypertensionMild-to-modera54SevereorpoorlycontrolledhypertensionAthighriskofperioperativecardiacfailureorstroke.Thistypeofpatientsshouldnotundergogeneralanaesthesiaandsurgeryuntiladequatelytreated.Thebloodpressureshouldbereasonablycontrolledunder160/100mmHg.Severeorpoorlycontrolled55CardiovasculardiseaseIschaemicheartdiseaseCardiacfailureArrhythmiasValvularheartdiseaseCerebrovasculardiseaseCardiovasculardiseaseIschae56AnginaPreviousinfarctionStableanginaposeslittleincreasedriskduringoperationbutunstableanginaisasdangerousasrecentmyocardialinfarctionTheriskofreinfarctionisabout30%ifanoperationisperformedduringthefirst3monthsAt6monthstheriskisabout10~15%whichmaybeacceptableforimportantelectivesurgeryAnginaPreviousinfarctionStabl57AdequatepreparationforheartdiseaseTocorrectthefluidandelectrolyteimbalance.Tocorrectanaemiathroughseveralbloodtransfusionwithsmallamount.Tocontrolthecardiacarrhythmias.
(Atrialfibrillation,Tachycardia,Bradycardia)AdequatepreparationforTo58Respiratorydysfunction
Respiratorycomplicationsoccurinupto15%ofsurgicalpatientsandaretheleadingcauseofpostoperativemortalityintheelderly.Respiratorydysfunction59RiskfactorsforrespiratorycomplicationChronicobstructivepulmonaryorairwaysdisease(Chronicbronchitis,emphysema,bronchiectasis,pneumoconiosis,pulmonarytuberculoses)CigarettesmokingCurrentrespiratoryinfectionsAsthmaRiskfactorsforChronicobstr60Preoperativeinvestigationofrespiratorydisease
AchestX-ray,CTscanifnecessaryEKGSpirometerBloodgasmeasurementPreoperativeinvestigationof61Perioperativemanagementofrespiratorydiseaseandhighriskpatients1.Preoperativephysiotherapyteachingthepatientbreathingexercisesandcorrectposture2.DrugtherapyTheophyllinesProphylacticantibioticsPreoperativebronchodilatorAdequatehydrationPerioperativemanagementof1.623.Encouragetostopsmokingfromthetimeofbookforelectivesurgery4.Alternationmethodsofanaesthesia
Local,regionalorspiralanaesthesiashouldbeconsidered5.
Earlypostoperativephysiotherapy
toenhancedeepbreathing,coughingandgeneralmobility
3.Encouragetostopsmokingf63LiverdisorderThetolerancetooperationdependsupontheseverityofliverfunctionimpairment.TheliverfunctioncouldbeestimatedbyChildstaging.Malnutrition,ascitesandjaundicearecontraindicationsexceptforemergencysurgery.
LiverdisorderThetolerance64PreoperativeassessmentandmanagementSerologicaltestforHBVandHCV,fullbloodcount,clottingscreenandplateletcount,plasmaureaandelectrolytes,bilirubin,transaminases,calcium,phosphate,gammaglutaryltransferaseandalbumin.Whenprothrombintimeisprolonged,vitaminKshouldbegivenforseveraldaysbeforeoperation.PreoperativeassessmentSero65RenaldisordersPreoperativeassessmentplasmaurea,electrolytes,creatinineandBicarbonateshouldbecheckedMildchronicrenalfailureDrugsshouldbegiveninsmallerdosesFluidandelectrolytehomeostasisModerate-to-severechronicrenalfailureOperationsshouldbeperformedunderhaemodialysis
RenaldisordersPreoperativeas66DisordersofAdrenalFunctionAdrenalInsufficiencyThemostcommoncauseofadrenalinsufficiencyishypothalamo-pituitary-adrenalsuppressionbylong-termcorticosteroidtherapy.Thelackofadrenalresponseinthesepatientsmaycauseacutepost-operativecardiovascularcollapsewithhypotensionandshock.Foranysteroid-dependentpatient,adoctorshouldwriteclearlyinthenote“Treatanyunexplainedcollapsewithhydrocortisone”.DisordersofAdrenalFunctionA67DiabetesMellitusAtspecialriskfromgeneralanaesthesiaandsurgery
Patientswithdiabetesfallintothreegroups1.Insulindependent2.Takingoralhypoglycaemicmedication3.Diet-controlledDiabetesMellitusAtspecia68Attempttomaintainbloodglucoselevelbetween4and10mmol/L,avoidhypoglycemiainparticular.Bloodglucoselevel>13mmol/L,anunreceptibleriskofketoacidosisorahyperosmolarnon-ketoticstate.PerioperativemanagementAttempttomaintainbloodgl69ThegeneralprincipleofperioperativemanagementEstablishgooddiabeticcontrolbeforeoperationGiveninsulinasacontinuousintravenousinfusionduringtheoperativeperiodGivenaninfusionofdextrosethroughouttheoperativeperiodtobalancetheinsulingivenandtomakeupforlackofdietaryintakeThegeneralprincipleofperio70ThegeneralprincipleofperioperativemanagementAddpotassiumtothedextroseinfusionMonitorbloodglucoseandelectrolytesfrequentlythroughouttheoperativeandearlypostoperativeperiodThegeneralprincipleofperio71
Recoveryroomisnecessary
ICUisoptimalifpossibleMonitoring
CloselymonitorthelifesignsasaroutineCVPmonitoringisnecessaryifhemodynamicunstableduringoperationOtheritemsmonitoredaccordinglyFluidbalancePost-operativeManagementRecoveryroomisneces72PositionandgettingupSupinepositionforspiralanaesthesiaSemirecliningpositionforneckandchestoperation.Lateralpositionforobesitypatients.GetupasearlyaspossibleandmakemovementsasmuchaspossiblePositionandgettingupSupin73DietandtransfusionPeriodoffastdependsuponthetypeofoperation.Enteralandparenteralnutritionshouldbetakenintoconsideration.Fluidandelectrolyteshomeostasisshouldbemaintained.DietandtransfusionPeriodo74ManagementofDrainageDifferentdrainagefordifferentpurpose(infectionfocus,leakagepreventionandmassiveexudation)Nasal-gastrictubeUrinarycatheterManagementofDrainageDiffere75WoundhealingandsutureremovingClassificationofincisioncleanincisioncontaminatedincisioninfectedincisionTypeofhealing
TypeAperfecthealingBsomeinflammationCinfectedWoundhealingandsutureremov761.PostoperativepainanymotionsincreasingtensionswillincreasepainAnalgesiaisobligatory2.Pyrexiacommonpostoperativeobservationasearchbemadeforafocusofinfectionnon-infectivecausesofpyrexiaManagementofpostoperativecomplaint1.PostoperativepainManagemen77NauseaandVomitingDrugs(opiates,erythromycin,metronidazole)BowelobstructionmechanicalobstructionAdynamicbowelHypokalaemiafaecalimpactionSystemicdisorderselectrolytedisturbancesUraemiaraisedintracranialpressureNauseaandVomitingDrugs(opi78AbdominaldistensionMorecommonafterabdominalsurgeryHiccupDiaphragmirritationorcentralnervoussystemstimulatedSubphrenicinfectionshouldbesuspectedforcontinuoushiccupAbdominaldistensionMorecommo79RetentionofurineThereisapalpablesuprapubicmasswithdulltopercussion.Urinarycatheterisindicatedwhendiagnosed.RetentionofurineThereisa80Themainpostoperativecomplications:AtelectasisChestinfectionAspirationpneumonitisPn
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