0901-术前准备及术后处理-姚宏伟课件.ppt

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1、术前准备及术后处理术前准备及术后处理Perioperative Management北京大学第三医院北京大学第三医院普通外科普通外科姚宏伟姚宏伟Dept.ofGeneralSurgery,PekingUniversityThirdHospital1Purpose1.掌握掌握手术前准备手术前准备2.熟悉熟悉手术后处理手术后处理熟悉熟悉术后并发症的预防和治疗术后并发症的预防和治疗 2 Definition:Management before,during&after a surgical operationSuccessful surgery2.Intra-Op management 1.Pre-

2、Op preparation3.Post-Op management3Key pointsPre-Operative PreparationPost-Operative Management41.Pre-Operative Preparation5 Aims To achieve the best status for surgeons and patients6 Principle Individualized preparation&management for different patients&operations ExamplesNodular goiterGastric Carc

3、inomaAcute duodenal perforation with diffuse peritonitis7术前准备内容：一般性准备术前准备内容：一般性准备1.心理准备：心理准备：（1）病人方面）病人方面（2）医生方面）医生方面2.病史采集病史采集体格检查体格检查伴随疾病伴随疾病3.常规（常规（/特殊）化验、检查特殊）化验、检查4.水、电解质及酸碱平衡监测以及调整水、电解质及酸碱平衡监测以及调整5.准备血液制品（选择性）准备血液制品（选择性）6.胃肠道准备：（胃肠道准备：（1）有胃潴留、幽门梗阻者：胃肠减压管并洗胃）有胃潴留、幽门梗阻者：胃肠减压管并洗胃（2）结直肠手术：肠道准备）结直肠

4、手术：肠道准备7.抗生素的预防性应用抗生素的预防性应用（适应证（适应证手术清洁程度分级）手术清洁程度分级）81.营养不良，低白蛋白血症营养不良，低白蛋白血症2.高血压高血压3.非心外科手术合并心脏病者（心衰、心梗）非心外科手术合并心脏病者（心衰、心梗）4.呼吸道疾病呼吸道疾病5.肝功能异常（代偿期肝功能异常（代偿期VS失代偿期）失代偿期）6.肾功能衰竭肾功能衰竭7.糖尿病糖尿病术前准备内容：特殊性准备术前准备内容：特殊性准备9Classification of operations1.Selective operation2.Restrictive operation3.Emergency o

5、peration(1.【医】择期手术)10Assessment of physical statusTo assess the general condition and function of important organsTo evaluate the tolerance capacityASA&APACHE Scoring SystemASA ：American Society of AnesthesiologistsAPACHE：Acute Physiology and Chronic Health Evaluation11ASA classification第I 级：正常，健康第I

6、I级：有轻度系统性疾病第III级：有严重系统性疾病，日常活动受限，尚未丧失工作能力第IV级：有严重系统性疾病，已丧失工作能力，且经常面临生命威胁第V级：无论手术与否，生命难以维持24小时的频死病人I ：normal healthy patientII：patient with mild systemic diseaseIII：patient with severe systemic disease that limits activity,but is not incapacitatingIV：patient that has incapacitating disease that is a

7、constant threat to lifeV：moribund patient not expected to survive 24 hours with or without an operationAnesthetic-related mortalities were 0%,0.17%,0.6%,4.3%,and 10.0%,respectively12APACHE Scoring System13男，72岁，因乙状结肠癌伴急性肠梗阻4天入院.既往：1年前“急性心梗”病史Case 114急诊手术？限期手术？心脏功能评估？术前肠道准备如何开展？Case 115Case 2 患者，男，55

8、岁，因“甲状腺多发结节”入院。既往：糖尿病4年，口服降糖药物，血糖控制不满意 问：此患者需做何术前准备？16Case 2AssessmentSugar controlAdaptive exerciseAntibiotics17 Case 3 患者，男，62岁，无痛性进行性黄疸2周，大便灰白，小便浓茶色，通过B超和CT检查，初步诊断为胰头癌，拟行手术治疗。试问：该病人特殊的术前准备有那些？18Case 3 1.Vitamin K4，胆汁酸盐 2.抗生素 3.保肝药物 4.其他19Case 3该患者合并高血压，冠心病，且4年前曾有心肌梗塞病史，血肌酐156umol/L问：需如何处理，能否手术？20

9、Case 3血压控制心脏评估肾脏评估21Goldmans criteria（Cardiac Risk Index Criteria,CRIS）Risk of serious cardiac event or deathClass I(0 to 5 points)0.9%Class II(6 to 12 points)7.1%Class III(13 to 25 points)16.0%Class IV(26 points)63.6%22Respiratory dysfunctionRisk factors for respiratory complication COPD Asthma Cur

10、rent respiratory infections23Preoperative management of respiratory diseaseAssessmentManagement:1.Smoking abatement2.2.Respiratory physiotherapy3.3.Controlling infection4.4.Drug therapy5.Alternation methods of anaesthesia24Liver disorder The liver function could be estimated by Child staging.25Liver

11、 disorder26Approach to the patient with liver diseaseSurgery in the patient with liver disease.Mayo Clin Proc 74:593599,199927Surgery in the patient with liver disease.Mayo Clin Proc 74:593599,1999.Liver diseases28Malnutrition Malnutrition increases the morbidity and mortality of operations dramatic

12、allyApproaches of nutrition support:EN PNEN PN29术前讨论以及病情总结302.Post-Operative Management31General managementManagement of postoperative complaintManagement of postoperative complications32Post-operative Management Recovery room is necessary ICU is optimal if possibleMonitoring Closely monitor the lif

13、e signs as a routine Other items monitored accordingly33General managementPosition and getting up（Analgesia）DietFluid infusionWound healing and suture removing34Wound healing and suture removingClassification of incision clean clean-contaminated contaminated infectedType of healing Type A perfect he

14、aling B some inflammation C infected35Surgical wound classificationWound ClassDefinitionClean（Class I）Uninfected operative wound in which no inflammation is encountered and the respiratory,alimentary,genital,or infected urinary tract are not entered.Wounds are primarily closed and,if necessary,drain

15、ed with closeddrainage.Surgical wounds following blunt trauma should be included in this category if they meet the criteria.Clean-contaminated（Class II）Operative wound in which the respiratory,alimentary,genital or urinary tracts are entered under controlled conditions and without unusual contaminat

16、ion.Contaminated（Class III）Open,fresh,accidental wounds.In addition,operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract,and incisions in which acute,nonpurulent inflammation is encountered are included in this category.Dirty（Class IV）Old traumatic woun

17、ds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera.This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.36Management of Drainage Nasal-gastric tube Urinary cathet

18、er Different drainage for different purpose (infection focus,leakage prevention and massive exudation)Special management37 患者，女，70岁，因急性胆管炎行胆囊切除胆总管切开取石，T管引流术，术后第3天拔除胆囊床引流管，2周拔除T管，拔管后2小时出现右上腹痛，发热、黄疸，B超提示右上腹有积液。保守无效于拔管后第2天再行剖腹探查，T管撕裂窦道置管引流术，术后2周恢复出院。问：1.胆囊床引流管和T管应如何处理？Case 438 Managementofpostoperative

19、complaintandcomplicationsComplaint complicationsNormalAbnormal39 Management of postoperative complaint1.Postoperative pain2.Pyrexia common postoperative observation 40 Case 5 患者，男，76岁，因急性阑尾炎并穿孔急诊全麻下行阑尾切除，腹腔引流术。术后第1天T 38.5；第2天 38.2;第3天38 ；第45天 37.7 38.5。Q1:患者体温为正常恢复过程吗？Q2：分析可能原因及处理41postoperative fev

20、erCauses 1.surgical factor wound abdominal cavity leakage 2.non-surgical factor Atelectasis/pneumonia urinary system infection DVT pylephlebitis Management 42Nausea and VomitingAnesthesiaBowel obstruction mechanical obstruction Adynamic bowelSystemic disorders electrolyte disturbances Uraemia raised

21、 intracranial pressure43Retention of urine There is a palpable suprapubic mass with dull to percussion.Urinary catheter is indicated when diagnosed.44Abdominal distensionSingultusOther complaint45Case 6 患者，男，患者，男，42岁，因胰头癌行岁，因胰头癌行Whipple 手术，术手术，术后第一天心率快，第二天出现出现血压下降、烦躁不后第一天心率快，第二天出现出现血压下降、烦躁不安、面色苍白等。安

22、、面色苍白等。试分析此病人出现了什么问题？还需作那些检查以试分析此病人出现了什么问题？还需作那些检查以证实诊断？证实诊断？如何处理？如何处理？46Management of postoperative complicationsPostoperative HaemorrhageCauses inadequate operative haemostasis a technical mishap as slipped ligature Management re-operation to stop bleeding some preparation is necessary47Case 7 患者，

23、女，患者，女，72岁。因急性胆囊炎急诊行胆囊切岁。因急性胆囊炎急诊行胆囊切除术，采用经右上腹直肌切口。术后有咳嗽和腹胀，除术，采用经右上腹直肌切口。术后有咳嗽和腹胀，第第2天晚天晚8点剧烈咳嗽后突然出现切口处有崩裂感，随点剧烈咳嗽后突然出现切口处有崩裂感，随后有淡血性液体及肠管从切口处涌出。试问此病人出后有淡血性液体及肠管从切口处涌出。试问此病人出现了什么问题？如何解决？现了什么问题？如何解决？48Wound Dehiscence(Burst Abdomen)Causes blood supply is poor excess suture tension long-term steroid

24、therapy immunosuppressive therapy malnutrition infection coughing or abdominal distensionManagement re-suturing with tension sutures the whole thickness of the abdominal wall49 1.患者，女，患者，女，60岁，患类风湿性关节炎岁，患类风湿性关节炎20年，常年年，常年服用强的松服用强的松 10 mg qd.突发上腹痛突发上腹痛8小时入院，急诊以急小时入院，急诊以急性弥漫性腹膜炎，上消化道溃疡穿孔行手术治疗，行胃性弥漫性腹膜

25、炎，上消化道溃疡穿孔行手术治疗，行胃大部切除术。手术顺利，关腹前突然出现不明原因的血大部切除术。手术顺利，关腹前突然出现不明原因的血压降低，经用各种抗休克治疗不见效而死亡。试问：此压降低，经用各种抗休克治疗不见效而死亡。试问：此病人的病人的死亡原因死亡原因是什么？是什么？思考题（1）50思考题结肠手术的术前准备术前预防性抗生素的使用指征术后发热的常见原因分析51Thanks for your attention52Diabetes Mellitus At special risk from general anaesthesia and surgery Three groups53Periop

26、erative managementInsulinAttempt to maintain blood glucose level between 5.6 and 11.2 mmol/L,avoid hypoglycemia in particular.Urine Glu+54Hypertension 收缩压 160mmHg 舒张压 100mmHg Antihypertensive drugs should be used all time，Sudden withdrawal of drugs is dangerous55Cardiovascular disease1.Ischaemic hea

27、rt disease2.Cardiac failure3.Arrhythmias4.Valvular heart disease56Renal disordersPreoperative assessment BUN,Scr,Ccr，Mild chronic renal failure Drugs should be given in smaller doses Fluid and electrolyte homeostasis Severe chronic renal failure Operations should be performed under haemodialysis 57m

28、anifestation localized pain,redness and a slight dischargeTreatment antibiotics physical therapy surgical drainage prophylaxisWound Infection58Atelectasis Airway become obstructed and air is absorbed from the air spaces distal to the obstruction Bronchial secretions are the main cause of this obstru

29、ctionPrevention 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 plugs59Urinary Tract InfectionsCausesUroschesisUse of catheterTreatment ensuring adequate fluid input appropriate antibiotics60