外科学总论：Preoperative and Postoperative Care

1、2021-6-10 2021-6-10 Judging precisely which patient will survive, or succumb to, any specific operation for a disease, or diseases, is impossible. The many obvious variables such as age, seriousness of the primary disease, and coexisting diseases, account for the intangible nature of risk in any ope

2、ration. 2021-6-10 When asked to guarantee an operation, the experienced surgeon refuses to guarantee anything but his professional concern and competence. Estimation of surgical risk is at best an educated guess based on experience. 2021-6-10 Surgical risk involves three main elements: vThe Patient

3、vThe Disease vThe Treatment 2021-6-10 2021-6-10 Infant prematurity and extreme old age are associated with increased operative risk. With operations of greater magnitude, involving increased physiological stress, the mortality is substantially greater in older patients. 2021-6-10 “A man is as old as

4、 his arteries,” “especially his coronary and cerebral arteries.” When life-threatening disease arises in a patient with serious cardiac disease, even a few hours of intensive cardiac careto control hypertension, arrhythmias, or heart failurecan increase survival. 2021-6-10 Pulmonary disfunctionsinab

5、ility to move air in and out of the lungs, to clear the bronchial tree by coughing, and to perfuse the lungsoften underlie postoperative pulmonary complications. Heavy cigarette smokingmajor cause 2021-6-10 How many flights of stairs can the patient climb? How many blocks can he walk without dyspnea

6、? Can he comfortably carry out routine tasks? If Normal exertion prompts shortness of breath: vPulmonary Ventilation Tests vArterial Blood Gases 2021-6-10 Chronic renal failure increases operative risk. Urine creatinine concentrations should exceed by 10-fold the normal serum levels. 2021-6-10 Jaund

7、ice and ascites usually indicate severe liver disease. A negative history for jaundice and normal serum bilirubin, proteins, alkaline phosphatase, transaminases, and prothrombin time usually indicate an adequate liver. 2021-6-10 Anemia, with fewer red cells to carry oxygen, lowers oxygen delivery to

8、 tissues and impairs the wound healing. Platelet counts below 50,000/ml require pre- or intraoperative platelet transfusions, or both. White blood cells and macrophages defend against infections. 2021-6-10 Leukemia, Hodgkins disease, diabetes, Aacquired immune deficiency syndrome(AIDS), and Immunosu

9、ppressive drugs will impair these first-line defenses. General anesthesia agents and major operations interfere with the bodys immune responses. Broad-spectrum antibiotics must be used for this kind of patients. 2021-6-10 Uncontrolled diabetes, a distinct hazard, must be treated vigorously before in

10、duction of anesthesia. Glucose (=200 g) and insulin must be given together in order for the body to utilize the carbohydrate. In general, hypoglycemia (coma, convulsions) is more hazardous than hyperglycemia. 2021-6-10 Varying states of simple desiccation, extracellular fluid loss, hemorrhage, or lo

11、ss of specific electrolytes can appreciably effect operative risk. 2021-6-10 Chronic disease and subsequent malnutrition impede wound healing. Parenteral hyperalimentation can provide proteins, amino acids, calories (glucose), vitamins, minerals, and fats in short, total nutritional needs. Infusing

12、these hypertonic solutions into high-flow veins has made this life- saving procedure possible. 2021-6-10 Obesity is associated with renal disease, pulmonary problems, diabetes, hypertension, cerebrovascular diseases, and orthopedic problems. Obesity increases operative time, this adds to the risk of

13、 septic, pulmonary, and vascular complication. 2021-6-10 Obese patients require brief operative procedures, intensive respiratory support, rapid mobilization, and sometimes antibiotics and heparin. 2021-6-10 The nature of the disease (Malignant or benign, infected or sterile), the physiological dist

14、urbances it causes, the site, and the length of time the disease has been present are all important factors that affect surgical risk. 2021-6-10 Operations on specific organs are, by and large, more hazardous for malignant diseases than for diseases. 2021-6-10 Septic diseases are more complicated, w

15、ith a higher mortality, than sterile or relatively sterile disease are. vPerforated appendicitisearly acute appendicitis. vSeptic cholecystitisuncomplicated cholecystitis 2021-6-10 In descending order of operative risk, the sites are Heart, Thoracic Esophagus, Brain, Rectum, Colon, Stomach, and Lung

16、. The nature and extent of the disease is, of course, an important factor in each site. 2021-6-10 The longer the patient has had the disease, the poorer the operative risk. 2021-6-10 Treatment strongly influences both the Patient and the Disease. This is the only one of the three factors of surgical

17、 risk over which the surgeon has much control. Knowledge of the patients overall status and the disease is the key to successful management. 2021-6-10 One thought should be clearly in mind: Surgical risk increases with the magnitude of the procedure. In choosing among the possible therapeutic option

18、s, the surgeon must weigh this critical factor of surgical magnitude carefully. An additional important factor is the skill of the surgeon and the team. 2021-6-10 Experienced nurses in intensive care units have reduced postoperative mortality more than any other factor. Their efficiency, skill, and

19、dedication are more important than electronic monitors, suction and inhalation equipment, or any of the other mechanical devices that aid in the postoperative care of the patient. 2021-6-10 Urgent Operation vBleeding, Perforation, Obstruction Time-limited Operation vMalignant tumors such as Gastric

20、cancer Elective Operation vGastric ulcer, Benign Tumors, Hernia 2021-6-10 Good Tolerated Condition for Operation Bad Tolerated Condition for Operation 2021-6-10 Psychologic rapport established during the preanesthetic visit will help to gain the patients confidence and reduce the need for excessive

21、sedation. Instruction, suggestion, and psychologic support are important elements of preoperative preparation. The psychologic preparation of a child and his or her parents is of utmost importance. 2021-6-10 Special Training and Education Fluid and Blood Transfusion Prevention of Infection Calories,

22、 Protein and Vitamins Gastrointestinal Preparation Others 2021-6-10 Malnutrition Cardiovascular System vHypertension vHeart Diseases Respiratory System Liver Disease Renal Disease Diabetes 2021-6-10 Diet. v Any patient should have nothing by mouth (NPO), including water and oral drugs. Medications.

23、vNo medication should be given for relief of pain until a diagnosis has been established and a decision has been made whether or not to operate. Fluid therapy. vTo correct dehydration and electrolyte imbalance. Antibiotics. 2021-6-10 Proposed procedure and anesthetic. Consent. Blood components to be

24、 cross-marched. Shower and preparation of the operative site. Nasogastric tube, Foley catheter, and IV fluids. NPO after midnight. All oral medications changed to parenteral administration (IM or IV). Premedication. Enema. 2021-6-10 2021-6-10 Operation performed and type of Anesthesia. Activity. Vit

25、al signs (T, P, R and BP) vTaken frequently, then gradually less often. A daily record of intake and output and of body weight. Care of tubes and drains. Medications. Vomiting and abdominal distension vNasogastric intubation and suction vAntiemetics and others 2021-6-10 Turn, cough, and hyperventila

26、te. Laboratory tests. Wound healing and care (dressing change) vThe type of incision, the grade of healing, vThe time of suture taken out. Discharge orders. vDate and time of discharge vDischarge diagnosis vDate and time of return visit vDischarge medications, dosages, and amounts to be dispensed. 2

27、021-6-10 Complications may occur after almost any operation, regardless of its magnitude. Even simple, routine diagnostic procedures may cause complication and even death. The majority of all postoperative complications are signaled by one of two signs: fever or shock (cardiovascular collapse). 2021

28、-6-10 Fever is the most common evidence of postoperative complications. Mild transient fevers appear after most operations from tissue necrosis, necrosis, hematoma, or cauterization. Higher sustained fever arise with the following four most common postoperative complications (Four Ws): vAtelectasis (collapse of portions of the lung, Wind) vWound infection (Wound) vUrinary infection (Water) vThrombophlebitis (Walk) 2021-6-10 Atelectasis (90%) vTwo major factors: bronchial obstruction with distal