围手术期处理英语课件

PerioperativeManagementPerioperativeManagementPerioperativeperiodDefinitionnotwellestablishedImportancedirectlyrelatedtotheoutcomeofsurgeryitselfCompositionpreoperativepreparation&postoperativemanagementPerioperativeperiodDefinition2

1.Electivesurgery2.Restrictivesurgery3.EmergentsurgeryPreoperative

PreparationTheprincipleDifferentpreparationfordifferentoperationTheclassificationofoperationsaccordingtothecharacteristicsofoperations1.ElectivesurgeryPreoperativ3ToconfirmthediagnosisToassesstheriskofoperationToassessthegeneralconditionandfunctionofimportantorgansToevaluatethepatientsendurancetotheoperationandriskofoperationPreoperativeAssessmentToconfirmthediagnosisPreo4Essentialstepsinpreoperative

assessmentandpreparationHistorytakingPhysicalexaminationCollatingpre-admissioninformationaboutdiagnosisArranginganyfurtherdiagnosticinvestigationMakingspecialpreparationsfortheparticularoperationInvestigatinganyintercurrentoroccultillnesssuggestedbymedicalclerkingEssentialstepsinpreoperativ5Essentialstepsinpreoperative

assessmentandpreparationDiscussingtheoperationwiththepatientandhisfamilyandobtainingsignedconsentMarkingtheoperationsiteMakingarrangementsfortheoperationwiththeoperatingtheatrestaffArrangingandinformingtheanaesthetistPrescribingmedicationprophylacticantibioticsetc.PlanningrehabilitationandconvalescenceEssentialstepsinpreoperativ6PsychologicalpreparationtalkfranklyandappropriatelytopatientsPhysiologicalpreparationAdaptiveexerciseTransfusionPreventionofinfectionGastro-intestinaltractpreparationMaintenanceoffluid,electrolyteandnutritionGeneralPreparationPsychologicalpreparationAda7Malnutritionanddysfunctionofimmunesystem

MalnutritiondramaticallyincreasesthemorbidityandmortalityPreoperativenutritionalsupportismorevaluableSpecificPreparationMalnutritionanddysfunctiono8Hypertension

Mild-to-moderateessentialhypertension

systolicpressure＜180mmHg

diastolicpressure＜

110mmHg

AtminimalriskofcardiaccomplicationAntihypertensivedrugsshouldbeusedalltimeSuddenwithdrawalofdrugsisdangerousHypertensionMild-to-modera9SevereorpoorlycontrolledhypertensionAthighriskofperioperativecardiacfailureorstroke.Thistypeofpatientsshouldnotundergogeneralanaesthesiaandsurgeryuntiladequatelytreated.Thebloodpressureshouldbereasonablycontrolledunder160/100mmHg.Severeorpoorlycontrolled10CardiovasculardiseaseIschaemicheartdiseaseCardiacfailureArrhythmiasValvularheartdiseaseCerebrovasculardiseaseCardiovasculardiseaseIschae11AnginaPreviousinfarctionStableanginaposeslittleincreasedriskduringoperationbutunstableanginaisasdangerousasrecentmyocardialinfarctionTheriskofreinfarctionisabout30%ifanoperationisperformedduringthefirst3monthsAt6monthstheriskisabout10~15%whichmaybeacceptableforimportantelectivesurgeryAnginaPreviousinfarctionStabl12AdequatepreparationforheartdiseaseTocorrectthefluidandelectrolyteimbalance.Tocorrectanaemiathroughseveralbloodtransfusionwithsmallamount.Tocontrolthecardiacarrhythmias.

(Atrialfibrillation,Tachycardia,Bradycardia)AdequatepreparationforTo13Respiratorydysfunction

Respiratorycomplicationsoccurinupto15%ofsurgicalpatientsandaretheleadingcauseofpostoperativemortalityintheelderly.Respiratorydysfunction14RiskfactorsforrespiratorycomplicationChronicobstructivepulmonaryorairwaysdisease(Chronicbronchitis,emphysema,bronchiectasis,pneumoconiosis,pulmonarytuberculoses)CigarettesmokingCurrentrespiratoryinfectionsAsthmaRiskfactorsforChronicobstr15Preoperativeinvestigationofrespiratorydisease

AchestX-ray,CTscanifnecessaryEKGSpirometerBloodgasmeasurementPreoperativeinvestigationof16Perioperativemanagementofrespiratorydiseaseandhighriskpatients1.Preoperativephysiotherapyteachingthepatientbreathingexercisesandcorrectposture2.DrugtherapyTheophyllinesProphylacticantibioticsPreoperativebronchodilatorAdequatehydrationPerioperativemanagementof1.173.Encouragetostopsmokingfromthetimeofbookforelectivesurgery4.Alternationmethodsofanaesthesia

Local,regionalorspiralanaesthesiashouldbeconsidered5.

Earlypostoperativephysiotherapy

toenhancedeepbreathing,coughingandgeneralmobility

3.Encouragetostopsmokingf18LiverdisorderThetolerancetooperationdependsupontheseverityofliverfunctionimpairment.TheliverfunctioncouldbeestimatedbyChildstaging.Malnutrition,ascitesandjaundicearecontraindicationsexceptforemergencysurgery.

LiverdisorderThetolerance19PreoperativeassessmentandmanagementSerologicaltestforHBVandHCV,fullbloodcount,clottingscreenandplateletcount,plasmaureaandelectrolytes,bilirubin,transaminases,calcium,phosphate,gammaglutaryltransferaseandalbumin.Whenprothrombintimeisprolonged,vitaminKshouldbegivenforseveraldaysbeforeoperation.PreoperativeassessmentSero20RenaldisordersPreoperativeassessmentplasmaurea,electrolytes,creatinineandBicarbonateshouldbecheckedMildchronicrenalfailureDrugsshouldbegiveninsmallerdosesFluidandelectrolytehomeostasisModerate-to-severechronicrenalfailureOperationsshouldbeperformedunderhaemodialysis

RenaldisordersPreoperativeas21DisordersofAdrenalFunctionAdrenalInsufficiencyThemostcommoncauseofadrenalinsufficiencyishypothalamo-pituitary-adrenalsuppressionbylong-termcorticosteroidtherapy.Thelackofadrenalresponseinthesepatientsmaycauseacutepost-operativecardiovascularcollapsewithhypotensionandshock.Foranysteroid-dependentpatient,adoctorshouldwriteclearlyinthenote“Treatanyunexplainedcollapsewithhydrocortisone”.DisordersofAdrenalFunctionA22DiabetesMellitusAtspecialriskfromgeneralanaesthesiaandsurgery

Patientswithdiabetesfallintothreegroups1.Insulindependent2.Takingoralhypoglycaemicmedication3.Diet-controlledDiabetesMellitusAtspecia23Attempttomaintainbloodglucoselevelbetween4and10mmol/L,avoidhypoglycemiainparticular.Bloodglucoselevel＞13mmol/L,anunreceptibleriskofketoacidosisorahyperosmolarnon-ketoticstate.PerioperativemanagementAttempttomaintainbloodgl24ThegeneralprincipleofperioperativemanagementEstablishgooddiabeticcontrolbeforeoperationGiveninsulinasacontinuousintravenousinfusionduringtheoperativeperiodGivenaninfusionofdextrosethroughouttheoperativeperiodtobalancetheinsulingivenandtomakeupforlackofdietaryintakeThegeneralprincipleofperio25ThegeneralprincipleofperioperativemanagementAddpotassiumtothedextroseinfusionMonitorbloodglucoseandelectrolytesfrequentlythroughouttheoperativeandearlypostoperativeperiodThegeneralprincipleofperio26

Recoveryroomisnecessary

ICUisoptimalifpossibleMonitoring

CloselymonitorthelifesignsasaroutineCVPmonitoringisnecessaryifhemodynamicunstableduringoperationOtheritemsmonitoredaccordinglyFluidbalancePost-operativeManagementRecoveryroomisneces27PositionandgettingupSupinepositionforspiralanaesthesiaSemirecliningpositionforneckandchestoperation.Lateralpositionforobesitypatients.GetupasearlyaspossibleandmakemovementsasmuchaspossiblePositionandgettingupSupin28DietandtransfusionPeriodoffastdependsuponthetypeofoperation.Enteralandparenteralnutritionshouldbetakenintoconsideration.Fluidandelectrolyteshomeostasisshouldbemaintained.DietandtransfusionPeriodo29ManagementofDrainageDifferentdrainagefordifferentpurpose(infectionfocus,leakagepreventionandmassiveexudation)Nasal-gastrictubeUrinarycatheterManagementofDrainageDiffere30WoundhealingandsutureremovingClassificationofincisioncleanincisioncontaminatedincisioninfectedincisionTypeofhealing

TypeAperfecthealingBsomeinflammationCinfectedWoundhealingandsutureremov311.PostoperativepainanymotionsincreasingtensionswillincreasepainAnalgesiaisobligatory2.Pyrexiacommonpostoperativeobservationasearchbemadeforafocusofinfectionnon-infectivecausesofpyrexiaManagementofpostoperativecomplaint1.PostoperativepainManagemen32NauseaandVomitingDrugs(opiates,erythromycin,metronidazole)BowelobstructionmechanicalobstructionAdynamicbowelHypokalaemiafaecalimpactionSystemicdisorderselectrolytedisturbancesUraemiaraisedintracranialpressureNauseaandVomitingDrugs(opi33AbdominaldistensionMorecommonafterabdominalsurgeryHiccupDiaphragmirritationorcentralnervoussystemstimulatedSubphrenicinfectionshouldbesuspectedforcontinuoushiccupAbdominaldistensionMorecommo34RetentionofurineThereisapalpablesuprapubicmasswithdulltopercussion.Urinarycatheterisindicatedwhendiagnosed.RetentionofurineThereisa35Themainpostoperativecomplications:AtelectasisChestinfectionAspirationpneumonitisPneumoniaThemainpostoperativecomplic36PostoperativeHaemorrhageCausesinadequateoperativehaemostasisatechnicalmishapasslippedligatureManagementre-operationtostopbleedingsomepreparationisnecessaryManagementof

postoperativecomplicationsPostoperativeHaemorrhageCause37WoundDehiscence(BurstAbdomen)Causesbloodsupplyispoorexcesssuturetensionlong-termsteroidtherapyimmunosuppressivetherapymalnutritioninfectioncoughingorabdominaldistensionManagementre-suturingwithtensionsuturesthewholethicknessoftheabdominalwallWoundDehiscence(BurstAbdome38Minorwoundinfectionslocalizedpain,rednessandaslightdischargeWoundCellulitisandAbscesscellulitistreatedbyantibioticsabscesstreatedbysurgicaldrainage

WoundInfectionMinorwoundinfectionsWoundIn39AtelectasisAirwaybecomeobstructedandairisabsorbedfromtheairspacesdistaltotheobstructionBronchialsecretionsarethemaincauseofthisobstructionPreventionandtreatmentperioperativephysiotherapyisthebestwayforpreventiondeepbreathingexercisesregularadjustmentsofposturevigorouscoughingflexiblebronchoscopytoaspirateoccludingmucusplugsAtelectasisAirwaybecomeobs40UrinaryTractInfectionsCausesreducedurinaryoutputreducing“flushing”ofbladderincompletebladderemptyinginadequateperinealhygieneTreatment

ensuringadequatefluidinputappropriateantibioticsUrinaryTractInfectionsCauses41DeepveinthrombosisCauses

bedboundafteroperationvenousstasisplasmaconcentratedduedehydrationviscosityincreasedManifestationsswellingofthelegtendernessofthecalfmuscleincreasedwarmthofthelegcalfpainonpassivedorsiflexionofthefootDeepveinthrombosisCauses42TreatmentAnticoagulation:Systemicthrombolytictherapy:

streptokinaseLocalthrombolyticdrugsismorepromisingintravenousheparinsubcutaneousheparinoralwarfarintherapyTreatmentintravenousheparin43postoperativemobilizationadequatehydrationavoidingcalfpressurePreventionforhighriskcaseslowdosesubcutaneousheparincalfcompressiondevicesgraded-compression‘anti-embolism’stockingsIntravenousdextranWarfarinanticoagulationpostoperativemobilizationP44ThankyouThankyou45PerioperativeManagementPerioperativeManagementPerioperativeperiodDefinitionnotwellestablishedImportancedirectlyrelatedtotheoutcomeofsurgeryitselfCompositionpreoperativepreparation&postoperativemanagementPerioperativeperiodDefinition47

1.Electivesurgery2.Restrictivesurgery3.EmergentsurgeryPreoperative

PreparationTheprincipleDifferentpreparationfordifferentoperationTheclassificationofoperationsaccordingtothecharacteristicsofoperations1.ElectivesurgeryPreoperativ48ToconfirmthediagnosisToassesstheriskofoperationToassessthegeneralconditionandfunctionofimportantorgansToevaluatethepatientsendurancetotheoperationandriskofoperationPreoperativeAssessmentToconfirmthediagnosisPreo49Essentialstepsinpreoperative

assessmentandpreparationHistorytakingPhysicalexaminationCollatingpre-admissioninformationaboutdiagnosisArranginganyfurtherdiagnosticinvestigationMakingspecialpreparationsfortheparticularoperationInvestigatinganyintercurrentoroccultillnesssuggestedbymedicalclerkingEssentialstepsinpreoperativ50Essentialstepsinpreoperative

assessmentandpreparationDiscussingtheoperationwiththepatientandhisfamilyandobtainingsignedconsentMarkingtheoperationsiteMakingarrangementsfortheoperationwiththeoperatingtheatrestaffArrangingandinformingtheanaesthetistPrescribingmedicationprophylacticantibioticsetc.PlanningrehabilitationandconvalescenceEssentialstepsinpreoperativ51PsychologicalpreparationtalkfranklyandappropriatelytopatientsPhysiologicalpreparationAdaptiveexerciseTransfusionPreventionofinfectionGastro-intestinaltractpreparationMaintenanceoffluid,electrolyteandnutritionGeneralPreparationPsychologicalpreparationAda52Malnutritionanddysfunctionofimmunesystem

MalnutritiondramaticallyincreasesthemorbidityandmortalityPreoperativenutritionalsupportismorevaluableSpecificPreparationMalnutritionanddysfunctiono53Hypertension

Mild-to-moderateessentialhypertension

systolicpressure＜180mmHg

diastolicpressure＜

110mmHg

AtminimalriskofcardiaccomplicationAntihypertensivedrugsshouldbeusedalltimeSuddenwithdrawalofdrugsisdangerousHypertensionMild-to-modera54SevereorpoorlycontrolledhypertensionAthighriskofperioperativecardiacfailureorstroke.Thistypeofpatientsshouldnotundergogeneralanaesthesiaandsurgeryuntiladequatelytreated.Thebloodpressureshouldbereasonablycontrolledunder160/100mmHg.Severeorpoorlycontrolled55CardiovasculardiseaseIschaemicheartdiseaseCardiacfailureArrhythmiasValvularheartdiseaseCerebrovasculardiseaseCardiovasculardiseaseIschae56AnginaPreviousinfarctionStableanginaposeslittleincreasedriskduringoperationbutunstableanginaisasdangerousasrecentmyocardialinfarctionTheriskofreinfarctionisabout30%ifanoperationisperformedduringthefirst3monthsAt6monthstheriskisabout10~15%whichmaybeacceptableforimportantelectivesurgeryAnginaPreviousinfarctionStabl57AdequatepreparationforheartdiseaseTocorrectthefluidandelectrolyteimbalance.Tocorrectanaemiathroughseveralbloodtransfusionwithsmallamount.Tocontrolthecardiacarrhythmias.

(Atrialfibrillation,Tachycardia,Bradycardia)AdequatepreparationforTo58Respiratorydysfunction

Respiratorycomplicationsoccurinupto15%ofsurgicalpatientsandaretheleadingcauseofpostoperativemortalityintheelderly.Respiratorydysfunction59RiskfactorsforrespiratorycomplicationChronicobstructivepulmonaryorairwaysdisease(Chronicbronchitis,emphysema,bronchiectasis,pneumoconiosis,pulmonarytuberculoses)CigarettesmokingCurrentrespiratoryinfectionsAsthmaRiskfactorsforChronicobstr60Preoperativeinvestigationofrespiratorydisease

AchestX-ray,CTscanifnecessaryEKGSpirometerBloodgasmeasurementPreoperativeinvestigationof61Perioperativemanagementofrespiratorydiseaseandhighriskpatients1.Preoperativephysiotherapyteachingthepatientbreathingexercisesandcorrectposture2.DrugtherapyTheophyllinesProphylacticantibioticsPreoperativebronchodilatorAdequatehydrationPerioperativemanagementof1.623.Encouragetostopsmokingfromthetimeofbookforelectivesurgery4.Alternationmethodsofanaesthesia

Local,regionalorspiralanaesthesiashouldbeconsidered5.

Earlypostoperativephysiotherapy

toenhancedeepbreathing,coughingandgeneralmobility

3.Encouragetostopsmokingf63LiverdisorderThetolerancetooperationdependsupontheseverityofliverfunctionimpairment.TheliverfunctioncouldbeestimatedbyChildstaging.Malnutrition,ascitesandjaundicearecontraindicationsexceptforemergencysurgery.

LiverdisorderThetolerance64PreoperativeassessmentandmanagementSerologicaltestforHBVandHCV,fullbloodcount,clottingscreenandplateletcount,plasmaureaandelectrolytes,bilirubin,transaminases,calcium,phosphate,gammaglutaryltransferaseandalbumin.Whenprothrombintimeisprolonged,vitaminKshouldbegivenforseveraldaysbeforeoperation.PreoperativeassessmentSero65RenaldisordersPreoperativeassessmentplasmaurea,electrolytes,creatinineandBicarbonateshouldbecheckedMildchronicrenalfailureDrugsshouldbegiveninsmallerdosesFluidandelectrolytehomeostasisModerate-to-severechronicrenalfailureOperationsshouldbeperformedunderhaemodialysis

RenaldisordersPreoperativeas66DisordersofAdrenalFunctionAdrenalInsufficiencyThemostcommoncauseofadrenalinsufficiencyishypothalamo-pituitary-adrenalsuppressionbylong-termcorticosteroidtherapy.Thelackofadrenalresponseinthesepatientsmaycauseacutepost-operativecardiovascularcollapsewithhypotensionandshock.Foranysteroid-dependentpatient,adoctorshouldwriteclearlyinthenote“Treatanyunexplainedcollapsewithhydrocortisone”.DisordersofAdrenalFunctionA67DiabetesMellitusAtspecialriskfromgeneralanaesthesiaandsurgery

Patientswithdiabetesfallintothreegroups1.Insulindependent2.Takingoralhypoglycaemicmedication3.Diet-controlledDiabetesMellitusAtspecia68Attempttomaintainbloodglucoselevelbetween4and10mmol/L,avoidhypoglycemiainparticular.Bloodglucoselevel＞13mmol/L,anunreceptibleriskofketoacidosisorahyperosmolarnon-ketoticstate.PerioperativemanagementAttempttomaintainbloodgl69ThegeneralprincipleofperioperativemanagementEstablishgooddiabeticcontrolbeforeoperationGiveninsulinasacontinuousintravenousinfusionduringtheoperativeperiodGivenaninfusionofdextrosethroughouttheoperativeperiodtobalancetheinsulingivenandtomakeupforlackofdietaryintakeThegeneralprincipleofperio70ThegeneralprincipleofperioperativemanagementAddpotassiumtothedextroseinfusionMonitorbloodglucoseandelectrolytesfrequentlythroughouttheoperativeandearlypostoperativeperiodThegeneralprincipleofperio71

Recoveryroomisnecessary

ICUisoptimalifpossibleMonitoring

CloselymonitorthelifesignsasaroutineCVPmonitoringisnecessaryifhemodynamicunstableduringoperationOtheritemsmonitoredaccordinglyFluidbalancePost-operativeManagementRecoveryroomisneces72PositionandgettingupSupinepositionforspiralanaesthesiaSemirecliningpositionforneckandchestoperation.Lateralpositionforobesitypatients.GetupasearlyaspossibleandmakemovementsasmuchaspossiblePositionandgettingupSupin73DietandtransfusionPeriodoffastdependsuponthetypeofoperation.Enteralandparenteralnutritionshouldbetakenintoconsideration.Fluidandelectrolyteshomeostasisshouldbemaintained.DietandtransfusionPeriodo74ManagementofDrainageDifferentdrainagefordifferentpurpose(infectionfocus,leakagepreventionandmassiveexudation)Nasal-gastrictubeUrinarycatheterManagementofDrainageDiffere75WoundhealingandsutureremovingClassificationofincisioncleanincisioncontaminatedincisioninfectedincisionTypeofhealing

TypeAperfecthealingBsomeinflammationCinfectedWoundhealingandsutureremov761.PostoperativepainanymotionsincreasingtensionswillincreasepainAnalgesiaisobligatory2.Pyrexiacommonpostoperativeobservationasearchbemadeforafocusofinfectionnon-infectivecausesofpyrexiaManagementofpostoperativecomplaint1.PostoperativepainManagemen77NauseaandVomitingDrugs(opiates,erythromycin,metronidazole)BowelobstructionmechanicalobstructionAdynamicbowelHypokalaemiafaecalimpactionSystemicdisorderselectrolytedisturbancesUraemiaraisedintracranialpressureNauseaandVomitingDrugs(opi78AbdominaldistensionMorecommonafterabdominalsurgeryHiccupDiaphragmirritationorcentralnervoussystemstimulatedSubphrenicinfectionshouldbesuspectedforcontinuoushiccupAbdominaldistensionMorecommo79RetentionofurineThereisapalpablesuprapubicmasswithdulltopercussion.Urinarycatheterisindicatedwhendiagnosed.RetentionofurineThereisa80Themainpostoperativecomplications:AtelectasisChestinfectionAspirationpneumonitisPn