围手术期处理宣讲

围手术期解决

Managementof

Perioperativeperiod浙医一院肿瘤中心滕理送第1页Pre-OpandPost-OpCareCancerStatistics,2023.CACANCERJCLIN2023.Preoperativepreparation术前准备Postoperativemanagement术后解决Postoperativecomplications并发症解决第2页EmergencyoperationTraumawithmassivebleedingacuteintracranialhematomawithbrainherniaAcutearterialembolismAbdominalhollowcavityorganruptureorperforationBowelobstructionwithbloodinsufficiency第3页Confine/SelectiveOperationConfineoperationRadicaldissectionofmalignancySelectiveoperationHerniarepair,benigntumorresection第4页PreoperativegeneralpreparationOperationagreementSmokingcessationDigestivetractpreparationAntibioticsNutritionalsupplementBloodpreparationSkinpreparationDietbeforesurgery第5页PreoperativeassessmentCardiacriskPulmonaryriskHepaticriskNutritionalriskMetabolicrisk第6页CardiacvascularriskEjectionfraction,>35%Arrythmia,ventricularrate<100Myocardialinfarction,6monthlaterGoldman’sindexFactorscontributetocardiacriskJugularvenousdistention,RecentMIPrematureventricularcontraction>5/min,rhythmotherthansinus,aorticvalvularstenosis,age>70,chestorabdominalsurgery,EmergencyECG,DCG,Ultrasonic/heart第7页pulmonaryriskSmokingCOPDPulmonaryfunctiontestBloodgasHighPCO2andlowFEV1第8页HepaticriskBilirubin,serumalbumin,Prothrombintime,ascitis,encephalopathy40%mortalitywitheitherBilirubin>2,Albumin<30,PT>16orencephalopathy80%-85%mortalitywiththreeofabovepresent,orBilirubin>4orAlbumin<20,orbloodamnonia>150第9页NutritionalriskLossof20%ofbodyweightinmonthsSerumAlbumin<3AnergytoskinantigenSerumtransferrin<200mg/dlNutritionalsupportpreferablyviagutatleast4-5days第10页MetabolicriskHyperglycemiaCorrectionofacidosischangetoinsulininjectionalittlebithigherthannormalispreferable5.6~11.2mmol/LTest:bloodglucose(Fasting+aftermeal)第11页PostoperativemanagementMonitorVitalsign(HR,R,T,Bp,SpO2)Generalappearance(alertness,distress,pain,)painUrinevolumedrainageWoundDietActivity第12页ExampleGastroectomy50KgTPNInfusion2023~3000mltotalvolume1000~2023KcalForexample：50%glucose200ml,10%GS500ml,5%GNS1000ml,Aminoacid500ml,Fatemulsion250mlOralfluidintake3-4daysafterpasswind,semifluid5-6days3-5daysremovedrainage7-9daysremovesuture第13页Wound:whentoremovesutureHeadandneck:4-5daysLowerabdominalandperineum:6-7daysChest,upperabdominal,back:7-9daysExtremities:10-12daysTensionreducingsuture:14daysAged,diabetes,malnutrition,delayed第14页Woundrecording/gradingWoundtypeⅠcleanⅡprobablecontaminated,GItract,Respiratorytract,Genital/UrinarytractⅢcontaminated,perforation,cellulitisHealing甲级乙级inflammation，fluidretention丙级infectionRecordingAcuteappendicitiswithperforationⅢ/甲第15页PostoperativecomplicationsFeverPulmonarycomplicationChestpainDisorientation/comaUrinarycomplicationsAbdominaldistentionFluidandelectrolytes第16页FeverBacteremia30-45minafterinvasiveprocedureChillsandtemperaturespikeWorkup:bloodculture,antibioticsAtelectasisPneunomiaUninarytractinfectionDeepvenousthrombophlebitisWoundinfectionDeepabscess“Wind,Water,Walk,Wound”第17页PulmonarycomplicationAspirationAwakeintubationwithfullstomachIntraoperativetensionpneumothoraxTB,pulmonarybleb+positivepressurebreathing第18页ChestpainPerioperativemyocardialinfarctionSTdepression,T-waveflatteningTroponin,EKG,CK-MBPulmonaryembolusImmobilizedpatient,suddenonset,shortnessofbreath,tachycardic,ABG,Pulmonaryangiogram,CTwithcontrast第19页Disorientation/comaHypoxiaAdultrespiratorydistresssyndromeOftencomplicatedbysepsisBilateralpulmonaryinfiltrateswithnoCHFDeliriumHyponatremiaLargefluidintake,rapidlyloweringsodiumHypernatremiaPituitaryoperationwithdiabetsinsipidusAmmoniumintoxicationCirrhoticpatientwithbleedingvaricesundergoesportocavalshunt第20页UrinarycomplicationsPostoperativeurinaryretentionCatheterizationifnourine6hourpost-opZerourineoutputPluggedcatheterLowurinaryoutputFluiddeficitAcuterenalfailureFluidchallenge:IV500mlin10min第21页AbdominaldistentionParalyticileusExpectedinafewdayspost-op,hypokalemiaEarlymechnicalbowelobstructionOgilviesyndromeParalyticileusofthecolonElderlysedentarypatientsX-rayshowmassivelydilatedcolon第22页FluidandelectrolytesHypokalemiaPotassiumlostfromGItract,urine(loopduretics),moveintocellsMetabolicacidosisProductionoffixedacid,lossofbuffers(bicarbonaterichfluidlossinGI),renalfailureLowPH,lowbicarbonate,Treatunderlyingcause,bicarbonateadmin第23页Male,43suddenonsetofpainonlowerabdominalfor2hourwithvomitingStrangulatedherniaandbowelobstruction第24页Male，45，transferedstomachache6hoursAcuteappendicitis第25页Female85increasingAbodPain2daysStrangulatedintestinalobstruction第26页Female,60,fatiguefor2months第27页Female,53,breastmassa