围手术期处理-英语.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Perioperative Management,Perioperative period,Definition,not well established,Importance,directly related to the outcome of surgery,itself,Composition,preoperative preparation&postoperative,management,1.Elective surgery,2.Restrictive surgery,3.Emergent surgery,Preoperative,Preparation,The principle,Different preparation for different operation,The classification of operations according to,the characteristics of operations,To confirm the diagnosis,To assess the risk of operation,To assess the general condition and function,of important organs,To evaluate the patients endurance to,the operation and risk of operation,Preoperative Assessment,Essential steps in preoperative assessment and preparation,History taking,Physical examination,Collating pre-admission information about diagnosis,Arranging any further diagnostic investigation,Making special preparations for the particular operation,Investigating any intercurrent or occult illness suggested by medical clerking,Malnutrition and dysfunction of immune system,Malnutrition dramatically increases,the morbidity and mortality,Preoperative nutritional support is more,valuable,Specific Preparation,Hypertension,Mild-to-moderate essential hypertension,systolic pressure ,180,mmHg,diastolic pressure,110,mmHg,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 be reasonably,controlled under,160/100,mmHg,.,Cardiovascular disease,Ischaemic,heart disease,Cardiac failure,Arrhythmias,Valvular,heart disease,Cerebrovascular,disease,Angina,Previous infarction,Stable angina poses little increased risk,during operation but unstable angina is as,dangerous as recent myocardial 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 with 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,.,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 to operation 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,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.,Perioperative management,The general principle of perioperative management,Establish good diabetic control before operation,Given insulin as a continuous intravenous infusion during the operative period,Given an infusion of dextrose throughout the operative period to balance the insulin given and to make up for lack of dietary intake,The general principle of perioperative management,Add potassium to the dextrose infusion,Monitor blood glucose and electrolytes frequently throughout the operative and early postoperative period,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,Fluid balance,Post-operative Management,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 and make,movements as much 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,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,Management of postoperative complaint,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.,The main postoperative complications:,Atelectasis,Chest infection,Aspiration pneumonitis,Pneumonia,Postoperative Haemorrhage,Causes,inadequate operative haemostasis,a technical mishap as slipped ligature,Management,re-operation to stop bleeding,some preparation is necessary,Management of postoperative complications,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,Minor wound infections,localized pain,redness and a slight,discharge,Wound Cellulitis and Abscess,cellulitis,treated by antibiotics,abscess treated by surgical drainage,Wound Infection,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:,Systemic thrombolytic therapy:,streptokinase,Local thrombolytic drugs is more promising,intravenous heparin,subcutaneous heparin,oral warfarin therapy,postoperative mobilization,adequate hydration,avoiding calf pressure,Prevention,for high risk cases,low dose subcutaneous heparin,calf compression devices,graded-compression anti-embolism,stockings,Intravenous,dextran,Warfarin,anticoagulation,Thank you,