外科学 围手术期处理学习课件

PreoperativeandPostoperativeCareLisongTengMD,PhDTheDepartmentofOncologicalSurgery1stAffiliatedHospitalofZJUMC2025/1/19PreoperativeCare

Judgingpreciselywhichpatientwillsurvive,orsuccumbto,anyspecificoperationforadisease,ordiseases,isimpossible.Themanyobviousvariablessuchasage,seriousnessoftheprimarydisease,andcoexistingdiseases,accountfortheintangiblenatureofriskinanyoperation.2025/1/19Whenaskedtoguaranteeanoperation,theexperiencedsurgeonrefusestoguaranteeanythingbuthisprofessionalconcernandcompetence.Estimationofsurgicalriskisatbestaneducatedguessbasedonexperience.2025/1/19AssessmentofSurgicalRiskSurgicalriskinvolvesthreemainelements:ThePatientTheDiseaseTheTreatment2025/1/19ThePatientAgeHeartLungsKidneyLiverBloodEndocrinesystemPreoperativeTreatmentofDiabetesDehydrationStatesNutritionalStatus2025/1/19AgeInfantprematurityandextremeoldageareassociatedwithincreasedoperativerisk.Withoperationsofgreatermagnitude,involvingincreasedphysiologicalstress,themortalityissubstantiallygreaterinolderpatients.2025/1/19Heart“Amanisasoldashisarteries,”“especiallyhiscoronaryandcerebralarteries.”Whenlife-threateningdiseasearisesinapatientwithseriouscardiacdisease,evenafewhoursofintensivecardiaccare—tocontrolhypertension,arrhythmias,orheartfailure—canincreasesurvival.2025/1/19LungsPulmonarydisfunctions—inabilitytomoveairinandoutofthelungs,toclearthebronchialtreebycoughing,andtoperfusethelungs—oftenunderliepostoperativepulmonarycomplications.Heavycigarettesmoking—majorcause2025/1/19Howmanyflightsofstairscanthepatientclimb?Howmanyblockscanhewalkwithoutdyspnea?Canhecomfortablycarryoutroutinetasks?IfNormalexertionpromptsshortnessofbreath:PulmonaryVentilationTestsArterialBloodGases2025/1/19KidneysChronicrenalfailureincreasesoperativerisk.Urinecreatinineconcentrationsshouldexceedby10-foldthenormalserumlevels.2025/1/19LiverJaundiceandascitesusuallyindicatesevereliverdisease.Anegativehistoryforjaundiceandnormalserumbilirubin,proteins,alkalinephosphatase,transaminases,andprothrombintimeusuallyindicateanadequateliver.2025/1/19Child-Pugh

Score

012Encephalopathynone mild severeAlbumin(g/dl)>3.5 3.0-3.5<3.0bilirubin(mg/dl)<2.0 2.0-3.0 >3.0AscitenoneexistrefractoryPT(S)1-4 4-6 >6

A:5-6;B:7-9;C:10-152025/1/19BloodAnemia,withfewerredcellstocarryoxygen,lowersoxygendeliverytotissuesandimpairsthewoundhealing.Plateletcountsbelow50,000/mlrequirepre-orintraoperativeplatelettransfusions,orboth.Whitebloodcellsandmacrophagesdefendagainstinfections.2025/1/19Leukemia,Hodgkin’sdisease,diabetes,Aacquiredimmunedeficiencysyndrome(AIDS),andImmunosuppressivedrugswillimpairthesefirst-linedefenses.Generalanesthesiaagentsandmajoroperationsinterferewiththebody’simmuneresponses.Broad-spectrumantibioticsmustbeusedforthiskindofpatients.2025/1/19PreoperativeTreatmentofDiabetesUncontrolleddiabetes,adistincthazard,mustbetreatedvigorouslybeforeinductionofanesthesia.Glucose(>=200g)andinsulinmustbegiventogetherinorderforthebodytoutilizethecarbohydrate.Ingeneral,hypoglycemia(coma,convulsions)ismorehazardousthanhyperglycemia.2025/1/19DehydrationStatesVaryingstatesofsimpledesiccation,extracellularfluidloss,hemorrhage,orlossofspecificelectrolytescanappreciablyaffectoperativerisk.2025/1/19NutritionalStatusChronicdiseaseandsubsequentmalnutritionimpedewoundhealing.Parenteral

hyperalimentationcanprovideproteins,aminoacids,calories(glucose),vitamins,minerals,andfats—inshort,totalnutritionalneeds.Infusingthesehypertonicsolutionsintohigh-flowveinshasmadethislife-savingprocedurepossible.2025/1/19Obesityisassociatedwithrenaldisease,pulmonaryproblems,diabetes,hypertension,cerebrovasculardiseases,andorthopedicproblems.Obesityincreasesoperativetime,thisaddstotheriskofseptic,pulmonary,andvascularcomplication.2025/1/19Obesepatientsrequirebriefoperativeprocedures,intensiverespiratorysupport,rapidmobilization,andsometimesantibioticsandheparin.2025/1/19TheDiseaseThenatureofthedisease(Malignantorbenign,infectedorsterile),thephysiologicaldisturbancesitcauses,thesite,andthelengthoftimethediseasehasbeenpresentareallimportantfactorsthataffectsurgicalrisk.2025/1/19TheDisease

—MalignantVersusBenignDiseaseOperationsonspecificorgansare,byandlarge,morehazardousformalignantdiseasesthanforbenigndiseases.GastricCancer—gastriculcerThyroidCancer—thyroidnodule2025/1/19TheDisease

—SepticVersusSterileDiseaseSepticdiseasesaremorecomplicated,withahighermortality,thansterileorrelativelysterilediseaseare.Perforatedappendicitis—earlyacuteappendicitis.Septiccholecystitis—uncomplicatedcholecystitis2025/1/19TheDisease

—SiteoftheDiseaseIndescendingorderofoperativerisk,thesitesareHeart,ThoracicEsophagus,Brain,Rectum,Colon,Stomach,andLung.Thenatureandextentofthediseaseis,ofcourse,animportantfactorineachsite.2025/1/19TheDisease

—TimeElementThelongerthepatienthashadthedisease,thepoorertheoperativerisk.2025/1/19TheTreatmentTreatmentstronglyinfluencesboththePatientandtheDisease.Thisistheonlyoneofthethreefactorsofsurgicalriskoverwhichthesurgeonhasmuchcontrol.Knowledgeofthepatient’soverallstatusandthediseaseisthekeytosuccessfulmanagement.2025/1/19TheTreatment

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MagnitudeoftheOperationOnethoughtshouldbeclearlyinmind:Surgicalriskincreaseswiththemagnitudeoftheprocedure.Inchoosingamongthepossibletherapeuticoptions,thesurgeonmustweighthiscriticalfactorofsurgicalmagnitudecarefully.Anadditionalimportantfactoristheskillofthesurgeonandtheteam.2025/1/19Accordingtothetimeofoperation:UrgentOperation(emergency)Bleeding,Perforation,ObstructionTime-limitedOperation(confine)MalignanttumorssuchasGastriccancerElectiveOperation(selective)Gastriculcer,BenignTumors,Hernia2025/1/19AccordingtoPatient’sToleratedConditionforOperation:GoodToleratedConditionforOperationBadToleratedConditionforOperation2025/1/19PreoperativePreparation

—PsychologicPreparationPsychologicrapportestablishedduringthepreanestheticvisitwillhelptogainthepatient’sconfidenceandreducetheneedforexcessivesedation.Instruction,suggestion,andpsychologicsupportareimportantelementsofpreoperativepreparation.Thepsychologicpreparationofachildandhisorherparentsisofutmostimportance.2025/1/19PreoperativePreparation

—PhysicalPreparationSpecialTrainingandEducationFluidandBloodTransfusionPreventionofInfectionCalories,ProteinandVitaminsGastrointestinalPreparationOthers2025/1/19SpecificOrgansandSystemsMalnutritionCardiovascularSystemHypertensionHeartDiseasesRespiratorySystemLiverDiseaseRenalDiseaseDiabetes2025/1/19PreoperativeOrderforUrgentOperationDiet.Anypatientshouldhavenothingbymouth(NPO),includingwaterandoraldrugs.Medications.Nomedicationshouldbegivenforreliefofpainuntiladiagnosishasbeenestablishedandadecisionhasbeenmadewhetherornottooperate.Fluidtherapy.Tocorrectdehydrationandelectrolyteimbalance.Antibiotics.2025/1/19PreoperativeOrderforElectiveOperationProposedprocedureandanesthetic.Consent.Bloodcomponentstobecross-marched.Showerandpreparationoftheoperativesite.Nasogastrictube,Foleycatheter,andIVfluids.NPOaftermidnight.Alloralmedicationschangedtoparenteraladministration(IMorIV).Premedication.Enema.2025/1/19PostoperativeManagement2025/1/19TheTreatment

—PostoperativeCareExperiencednursesinintensivecareunitshavereducedpostoperativemortalitymorethananyotherfactor.Theirefficiency,skill,anddedicationaremoreimportantthanelectronicmonitors,suctionandinhalationequipment,oranyoftheothermechanicaldevicesthataidinthepostoperativecareofthepatient.2025/1/19PostoperativeOrders—IOperationperformedandtypeofAnesthesia.Activity.Vitalsigns(T,P,RandBP)Takenfrequently,thengraduallylessoften.Adailyrecordofintakeandoutputandofbodyweight.Careoftubesanddrains.Medications(Paincontrol)VomitingandabdominaldistensionNasogastricintubationandsuctionAntiemeticsandothers2025/1/19PostoperativeOrders—IITurn,cough,andhyperventilate.Laboratorytests.Woundhealingandcare(dressingchange)Thetypeofincision,thegradeofhealing,Thetimeofsuturetakenout.Dischargeorders.DateandtimeofdischargeDischargediagnosisDateandtimeofreturnvisitDischargemedications,dosages,andamountstobedispensed.2025/1/19SurgicalcomplicationsComplicationsmayoccurafteralmostanyoperation,regardlessofitsmagnitude.Evensimple,routinediagnosticproceduresmaycausecomplicationandevendeath.Themajorityofallpostoperativecomplicationsaresignaledbyoneoftwosigns:feverorshock(cardiovascularcollapse).2025/1/19SurgicalComplications—FeverFeveristhemostcommonevidenceofpostoperativecomplications.Mildtransientfeversappearaftermostoperationsfromtissuenecrosis,necrosis,hematoma,orcauterization.Highersustainedfeverarisewiththefollowingfourmostcommonpostoperativecomplications(FourW’s):Atelectasis(collapseofportionsofthelung,Wind)Woundinfection(Wound)Urinaryinfection(Water)Thrombophlebitis(Walk)2025/1/19LungProblems(Wind)WithintheFirst48HoursAtelectasis(90%)Twomajorfactors:bronchialobstructionwithdistalgasabsorptionandhypoventilationorineffectualrespiration.Respiratorydistresssyndrome(ARDS)RespiratoryFailurePulmonaryEdema2025/1/19Woundinfections(Wound)Mostsurgicalinfectionswithin5to7days.Heat,redness,andtendernessinawounddemandinvestigationandsurgicaldrainage.Dryingoftissuesbylongexposure,operationoncontaminatedstructures,grossobesity,diabetes,malnutrition,immunosuppression,oroperationsonveryyoungorveryoldpatientsaredirectlyrelatedtoanincreaseinsepsisrate.Abdominalwounddehiscence.WoundHemorrhage,hematoma,andSeroma.2025/1/19UrinaryInfection(Water)5to8DaysThrombophlebitis(Walk)7to14Days“Third-daySurgicalFever”comesfrominflamationsurroundingintravenouscatheters.CardiovascularCollapseAcuteParotiditisAspirationofVomitusOthers2025/1/19OthersAcuteGastricDialationRetentionofUrinePostoperativeHemorrhageIntestinalObstructionParalyticIleusAnastomoticLeak2025/1/19Case1童×,男，58岁，既往高血压病史，突发胸背剧痛6小时。。查体：血压２００／８６mmHg，端坐位，痛苦貌，大汗淋漓，呼吸困难。行胸腹主