外科学课件：9围术期处理.ppt

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围术期处理,第一节,术前准备,概念,围术期是指从决定手术治疗起，到与本次手术有关的治疗基本结束为止的一段时间。,包括手术前、手术中和手术后三个阶段。,目的是为了病人手术顺利做准备并促进手术后尽快康复。,手术分类,急症手术,限期手术,择期手术,（一）一般准备,-,病人心理准备,病情担心，想了解,医护人员的帮助：病情介绍，治疗过程，诊治过程程序，可能的副作用，疾病的预后,知情同意事项,（一）一般准备,病人,-,生理准备,1,、为手术后变化的适应性锻炼,2,、输血补液（,Hb,70g,/l,）,3,、预防感染,4,、胃肠道准备,5,、其它,病人特殊准备,-,营养不良,:,低蛋白血症。因病所致体重下降超过,20%,，死亡率上升，手术后感染率增加,3,倍。血浆白蛋白低于,30g/L,或转铁蛋白低于,0.15g/L,，应营养支持。,病人特殊准备,-,脑血管病：手术期发生不常见。危险因素，老年、高血压、冠心病、糖尿病和吸烟。,有脑卒中史者，择期手术应推迟,2,周，最好,6,周。,病人特殊准备,-,心血管疾病：,高血压：,160/100mmHg,以下可不必处理；血压过高者（,180/110mmHg,）应处理，使其平稳在一定水平，再手术。,心脏病：,病人特殊准备,-,肺功能障碍,危险因素：慢阻肺、吸烟、老年、肥胖、急性呼吸道感染。,血气分析，肺功能检查，胸部,X,线检查或,CT,。,每天吸烟超过,10,支应停止，急性呼吸道感染治愈后,12,周择期手术。哮喘发作期。,病人特殊准备,-,肾疾病,急性肾衰危险因素：手术前有肾功能不全、心衰、老年、手术中低血压、脓毒血症、使用肾毒性药物等。,病人特殊准备,-,糖尿病：并发症发生率和死亡率较无糖尿病者上升,50%,。,术前评估：糖尿病慢性并发症和血糖控制情况。,5.611.2mmol/L,病人特殊准备,-,凝血障碍,常规凝血试验阳性发现率低，,PT,、,APTT,，血小板计数，识别严重凝血异常只有,0.2%,。,病史、查体最重要！,手术前,7,天停用阿司匹林，,10,天停用氯吡咯雷，血小板小于,50 x10,9,/L,时建议补充血小板。,抗凝治疗病人，血友病病人处理。,病人特殊准备,-,下肢静脉血栓形成的预防：,肺血栓栓塞症（,PTE,）的血栓主要来源与深静脉血栓形成（,DVT,）。,西方国家发病率在,0.1%,，美国因血栓死亡的每年超过,29,万。,外科手术,VTE,发生率。,预防：低分子肝素钙、踝泵锻炼、口服华法林等。,