Transcript 没有幻灯片标题 - Shantou University

Perioperative Management
Perioperative period :
Definition
not well established
Importance
directly related to the outcome of surgery
itself
Composition
preoperative preparation & postoperative
management
Preoperative Preparation
The principle
Different preparation for different operation
The classification of operations according to
the characteristics of operations
1. Elective surgery
2. Restrictive surgery
3. Emergency surgery
Perioperative Assessment
• To confirm the diagnosis
• To assess the risk of operation
• To assess the general condition and function
of important organs
• The endurance of the patient to
operation be evaluated
General Preparation
Psychological preparation
talk frankly and appropriately to patients
Physiological preparation
• Adaptive exercise
• Transfusion
• Prevention of infection
• Gastro-intestinal tract preparation
• Maintenance of fluid, electrolyte and nutrition
Specific Preparation
Malnutrition and dysfunction of immune system
• Malnutrition increases the morbidity and
mortality of operations dramatically
• Preoperative nutritional support is more
valuable
Hypertension
Mild-to-moderate essential hypertension
systolic pressure ＜ 180mmHg
diastolic pressure ＜ 110mmHg
At minimal risk
of 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 reasonablly
be controlled under 160/100 mmHg.
Cardiovascular disease
1. Ischaemic heart disease
2. Cardiac failure
3. Arrhythmias
4. Valvular heart disease
5. Cerebrovascular disease
Cardiac risk index system
see table 16-1
Angina
Stable angina poses little increased risk
during operation but unstable angina is as
dangerous as recent myocardial infarction.
Previous infarction
• The risk of reinfarction is about 30% if an
operation 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 in 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.
The main postoperative complications:
•
•
•
•
Atelectasis
Chest infection
Aspiration pneumonitis
Pneumonia
Risk factors for
respiratory complication
Chronic obstructive pulmonary or airways disease
(Chronic bronchitis, emphysema, bronchiectasis,
pneumoconiosis, pulmonary tuberculoses)
Cigarette smoking
Current respiratory infections
Asthma
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 posture
2. Drug therapy
Theophyllines
Prophylactic antibiotics
Preoperative bronchodilator
Adequate hydration
3. Encourage to stop smoking from the time
of book for elective surgery
4. Alternation methods of anaesthesia
Local, regional or spiral anaesthesia should be
considered
5. Early postoperative physiotherapy
to enhance deep breathing, coughing and general
mobility
Liver disorder
• The tolerance 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 insufficiency
is hypothalamo-pituitary-adrenal suppression by
long-term corticosteroid therapy.
The lack of adrenal response in these patients may
cause acute post-operative cardiovascular collapse with
hypotension and shock.
For any steroid-dependent patient, a doctor should
write clearly in the note “Treat any unexplained collapse
with 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
Perioperative management
• 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.
Post-operative Management
Recovery room is necessary
ICU is optimal if possible
Monitoring
• Closely monitor the life signs as a routine
• CVP monitoring is necessary if hemodynamic
unstable during operation
• Other items monitored accordingly
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.
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 incision
Type of healing
Type A perfect healing
B some inflammation
C infected
Management of postoperative complaint
1. Postoperative pain
any motions increasing tensions will increase pain
Analgesia is obligatory
2. Pyrexia
common postoperative observation
a search be made for a focus of infection
non-infective causes of pyrexia
Nausea and Vomiting
Drugs (opiates, erythromycin, metronidazole)
Bowel obstruction
mechanical obstruction
Adynamic bowel
Hypokalaemia
faecal impaction
Systemic 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.
Management of
postoperative complications
Postoperative Haemorrhage
Causes
inadequate operative haemostasis
a technical mishap as slipped ligature
Management
re-operation to stop bleeding
some preparation is necessary
Wound Dehiscence (Burst Abdomen)
Causes
blood supply is poor
excess suture tension
long-term steroid therapy
immunosuppressive therapy
malnutrition
infection
coughing or abdominal distension
Management
re-suturing with tension sutures the
whole thickness of the abdominal wall
Wound Infection
Minor wound infections
localized pain, redness and a slight
discharge
Wound Cellulitis and Abscess
cellulitis treated by antibiotics
abscess treated by surgical drainage
Atelectasis
• Airway become obstructed and air is absorbed from
the air spaces distal to the obstruction
• Bronchial secretions are the main cause of this
obstruction
Prevention and treatment
• perioperative physiotherapy is the best way for
prevention
• deep breathing exercises
• regular adjustments of posture
• vigorous coughing
• flexible bronchoscopy to aspirate occluding
mucus plugs
Urinary Tract Infections
Causes
• reduced urinary output
• reducing “flushing” of bladder
• incomplete bladder emptying
• inadequate perineal hygiene
Treatment
• ensuring adequate fluid input
• appropriate antibiotics
Deep vein thrombosis
Causes
• bed bound after operation
• venous stasis
• plasma concentrated due dehydration
• viscosity increased
Manifestations
• swelling of the leg
• tenderness of the calf muscle
• increased warmth of the leg
• calf pain on passive dorsiflexion of the
foot
Treatment
Anticoagulation:
intravenous heparin
subcutaneous heparin
oral warfarin therapy
Systemic thrombolytic therapy:
streptokinase
Local thrombolytic drugs is more promising
Prevention
• postoperative mobilization
• adequate hydration
• avoiding calf pressure
for high risk cases
• low dose subcutaneous heparin
• calf compression devices
• graded-compression ‘anti-embolism’
stockings
• Intravenous dextran
• Warfarin anticoagulation