Transcript 外科學概論 合併症 合併症 副作用 ;

外科學概論 合併症
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錯綜複雜; 糾紛, 混亂 節外生枝
棘手的問題, 混亂的原因
『醫學』併發症
Complications 合併症
Side Effects
副作用 結果; 後果
Sequela
後遺症 續發症; 後發病; 後遺症
Results
結果; 後果
Outcome
後果; 結論
Prognosis
預後
參考資料：Chapter – Complication
『Schwartz』 ：『 Principles of Surgery』
General Complications
重點 1.
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Wound Complications
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Postoperative Parotiditis ( 省略 )
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Postoperative Respiratory Complications
重點 3.
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Cardiac / Circulatory Complications
簡介 4.
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Diabetes Mellitus
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Fat Embolism syndrome
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Psychiatric Complications (省略 )
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Complications of Gastrointestinal Surgery
腮腺炎
油脂栓塞症候群
重點 2.
Wound Complications
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Wound Infection
Wound Hemorrhage,
Hematoma,
Seroma
Wound Dehiscence
傷口合併症
傷口感染 ∮∮
出血
血塊
血清凝塊
綻裂
 Intra-abdominal Hematoma and Abscess
傷口感染
 手術傷口
ΦClean
... Part’l contaminated ... Conta’d wound
 病的因素
ΦAge, Nutrition, Immunity, BW,..
ΦDisease, Defense, Deficiency.
 醫療的因素
Hospital environment. ΦPersonnel: Med.,
Guest or Trader, .. Φ Med. Instrument & article…..
Φ
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感染的因素
Φ FB, Infection, Contamination..
Retro-gastric →
Hematoma
and
Abscess
Subhepatic ↓
Subphrenic↓
 and
Rectal pouch,
Caecal fossa ...
Wound Incision -- Wound Complications -- Wound Dehiscence
Upper median incision
Para-median incision
Para-rectal incision
McBurney incision
Gastrointestinal Surgery
腸胃道外科
Gastrointestinal Anastomosis
After total Gastrectomy
After subtotal Gastrectomy
After proximal cardiectomy
After antrectomy
Entero-enterostomy
Jejuno-colostomy
Ileo-colostomy, Ceco-ileostomy
Coco-colostomy
Appendectomy
Complications of Gastrointestinal
Surgery
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Gastrointestinal Anastomosis
• Total Gastrectomy
• Subtotal Gastrectomy
 Billroth I Gastro-duodenostomy
 Billroth II
Gastro-jejunostomy
 Billroth III Inadvert Gastroileostomy
Total Gastrectomy
Cardiectomy
x-1
Resection x-1
Subtotal Gastrectomy x-2
Resection x-2
Antrectomy x-3
Resection x-3
Complications of Gastrointestinal Surgery
腸胃道外科合併症
Postoperative Complications
手術後合併症
* Suture disrupt –duodenal stump / gastrojejunostomy.
* Peritonitis; ileus.
腹膜炎;腸阻塞
* Retrogastric hematoma / abscess.
胃後血腫/膿瘍
* Subphrenic / subhepatic abscess.
膈下/肝下膿瘍
* Intra- or extraluminal bleeding.
腸道外/內出血
* Pancreatitis, pancreatic necrosis.
胰臟炎/胰臟壞死
Retro-gastric →
Hematoma
and
Abscess
Subhepatic ↓
Subphrenic↓
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Rectal pouch,
Caecal fossa ...
Complications of Gastrointestinal Surgery
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Vascular Complications
Hemorrhage
Gangrene
血管合併症
出血
壞疽
Complications of Gastrointestinal Surgery
Mechanical Problem
胃腸造口開口阻塞
b. Afferent ( Blind ) Loop Syndrome
傳入盲圈症候群
c. Intestinal Obstruction
腸阻塞
d. Inadvert Gastroileostomy 胃迴腸造口吻合術
a. Stoma Obstruction
Anastomotic Leakage
吻合部的滲漏
Complications of Gastrointestinal Surgery
External Fistula and Stoma Complications
腸道瘻管和開口端合併症
 Fistula
瘻管
 External Stoma Complications
胃腸造口開口端合併症
General Complications
術後呼吸系統合併症
Postoperative Respiratory Complications
 Atelectasis
無氣肺/肺塌陷
 Respiratory Failure
呼吸衰竭
 Pulmonary edema
肺水腫
( Pulmonary congestion )
General Complications
Atelectasis
Lobar Atelectasis
Segmental Atelectasis
Plate like Atelectasis
Reduced Alveolar Surface Tension
Bronchial
Secretion Obstruction
Fever, Rapid RR / HR, Collapse / Purification
General Complications
Treatment of Atelectasis
Patent Air Way
Enforced Respiration
Ventilator Support
Return to Normal Surfactant
Clear the Bronchial Passage
Warm & Moist Inhalation
Complete Respiratory Care
Fluid supply & Antibiotics
General Complications
Respiratory Failure
呼吸衰竭
Definition
PaO2 < Predicted normal
PaCO2 > 50 mmHg
metabolic alkalosis
Pathophysiology
Hypoventilation
Diffusion defect
Abnormal V/Q ratio
Shunting
Reduction in Cardiac Output
Hb/Dissociation Curve Alteration
General Complications
Pulmonary Edema ( Pulmonary Congestion )
Ventilation FiO2 ↓，Airway
，Alveolar Tension ↓
O2 carrier ↓ ( Massive Bleeding / Mete-Hb )
Diffusion
Interstitial Membrane Resistance↑
Vascular Osmotic Pressure ↓/ Electrolyte
Perfusion
Pumping Failure，AV Shunt etc.,
Shock ， Vascular Stagnation
Peripheral Resistance ↑ / Requirement ↑
以『供需失調』的概念，去瞭解Pulmonary Congestion
General Complications
Treatment of Pulmonary Edema
Ventilation FiO2
，Patent Airway，Keep Alveolar Tension
Fresh Blood Transfusion
Diffusion
Steroid ： Reduce Interstitial Fibrosis
Diuretics ，Albumin/Plasma/Colloid
Perfusion
Cardiotonics ， Diuretics ，Colloid
Prevent & Treat Shock
Requirement ↓ ， Peripheral Resistance ↓
調整『供需失序』，去治療Pulmonary Edema
General Complications
Respiratory Failure
呼吸衰竭
Indication for Respiratory Support
•FiO2
•Qs/Qt
•A-aDO2
•VD/VT
•PEEP
Close
monitoring
Intubation
Tracheostomy
RR
12-25
25-35
>35
VC, ml/kg
70-30
30-45
<15
F. inspiratory
100-50
50-25
<25
A – aDO2
50-200
200-350
>350
PaO2
100-75
200-70
<70
Air
Mask O2
O2 Inhalation
•CPAP
•IPPB
VD/VT
0.3-0.4
0.4-0.6
>0.6
•IMV
PaCO2
35-45
45-60
>60+
General Complications
Complications Following Respiratory Support
Endotracheal Intubation /Tracheostomy
Airway Aphonia
Wound
Bleeding/Infection
Cuff Pressure - Erosion/Bleeding
/Stricture/ Granuloma
Mechanical Ventilator
PEEP – Pneumothorax
Prolonged Ventilator Use / Oxygen Intoxication
Lung Edema / Weaning Failure
General Complications
Cardiac Complications
心臟的合併症
a. Arrhythmias
心律不整
b. Myocardial Infarction
心肌梗塞
General Complications
Cardiac Complications -- Arrhythmias
Old age > 60y , Arteriorsclerosis, Heart Diseas, Hypertension
Anesthesia ( Halothane ) → AV Dissociation,
Electrolyte
Paroxysmal Supraventricular Tachycardia
Chest Surgery
Paroxysmal ventricular Tachycardia
Myocardial Infarction
Atrial Flutter, Sinus Tachycardia
Positive Breathing
AV Nodal Rhythm , AV Block
Perioperative Cardiac Arrhythmias
Sinus Bradycardia,
Premature Contraction
General Complications
Cardiac Complications -- Myocardial Infarction
Coronary Artery Thrombosis
Myocardial Infarction
Anoxia, Hypotension, Hemorrhage,
Dehydration, Fluid & Electrolyte Disturbance,
Arrhythmias
ECG, SGOT, CPK-MB, BGA, Isotope Scan
Digitalization, Diuretics, Vasopressor & Shock
Treatment, Adequate Ventilation, Treat Anemia,
Relief Pain, Sedation, ICU Swan Ganz Catheter
Monitor
Circulatory Complications
Arterial system
Coronary Artery Embolism
Carotid Artery Embolism
Mesenteric Artery Embolism
Embolectomy / Anti-coagulant
Venous system
Mesenteric Venous Thrombo-phlebitis
Thrombo-phlebitis of the Limbs
Thrombectomy / Facioyomy
Gangrene
Lymphatic system
Preoperative Evaluation
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Lung
Heart
Liver
Kidney
GI
Others
O.R.
Anesthesia
Pre
medication
NPO
Fluid
e+
Others
I&O
另類話題
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醫學生的憧憬
醫師角色的扮演
醫學倫理
成長與調適
外科醫師的個性快、狠、準
外科醫療團隊
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醫病關係
理想與現實
另類醫療資源
醫療法
醫療糾紛
全民健保, IT, etc.