1、Perioperative period Definition not well established Importance directly related to the outcome of surgery itself Composition preoperative preparation&postoperative management 1.Elective surgery2.Restrictive surgery3.Emergent surgeryPreoperative PreparationThe principle Different preparation for dif
2、ferent operationThe classification of operations according to the characteristics of operationsl To confirm the diagnosisl To assess the risk of operationl To assess the general condition and function of important organsl To evaluate the patients endurance to the operation and risk of operationPreop
3、erative AssessmentEssential steps in preoperative assessment and preparation History taking Physical examination Collating pre-admission information about diagnosis Arranging any further diagnostic investigation Making special preparations for the particular operation Investigating any intercurrent
4、or occult illness suggested by medical clerkingEssential steps in preoperative assessment and preparation Discussing the operation with the patient and his family and obtaining signed consent Marking the operation site Making arrangements for the operation with the operating theatre staff Arranging
5、and informing the anaesthetist Prescribing medication prophylactic antibiotics etc.Planning rehabilitation and convalescencePsychological preparation talk frankly and appropriately to patientsPhysiological preparation Adaptive exercise Transfusion Prevention of infection Gastro-intestinal tract prep
6、aration Maintenance of fluid,electrolyte and nutritionGeneral PreparationMalnutrition and dysfunction of immune system Malnutrition dramatically increases the morbidity and mortality Preoperative nutritional support is more valuableSpecific PreparationHypertension Mild-to-moderate essential hyperten
7、sion systolic pressure 180mmHg diastolic pressure 110mmHg At minimal riskof cardiac complication Antihypertensive drugs should be used all time Sudden withdrawal of drugs is dangerousSevere or poorly controlled hypertension At high risk of perioperative cardiac failure or stroke.This type of patient
8、s should not undergo general anaesthesia and surgery until adequately treated.The blood pressure should be reasonably controlled under 160/100 mmHg.Cardiovascular diseasel Ischaemic heart diseasel Cardiac failurel Arrhythmiasl Valvular heart diseasel Cerebrovascular diseaseAnginaPrevious infarctionS
9、table angina poses little increased riskduring operation but unstable angina is asdangerous as recent myocardial infarction The risk of reinfarction is about 30%if anoperation is performed during the first 3 months At 6 months the risk is about 10 15%which may be acceptable for important elective su
10、rgeryAdequate preparation for heart disease To correct the fluid and electrolyte imbalance.To correct anaemia through several blood transfusion with small amount.To control the cardiac arrhythmias.(Atrial fibrillation,Tachycardia,Bradycardia)Respiratory dysfunction Respiratory complications occur in
11、 up to 15%of surgical patients and are the leading cause of postoperative mortality in the elderly.Risk factors for respiratory complicationlChronic obstructive pulmonary or airways disease(Chronic bronchitis,emphysema,bronchiectasis,pneumoconiosis,pulmonary tuberculoses)lCigarette smokinglCurrent r
12、espiratory infectionslAsthmaPreoperative investigation of respiratory disease A chest X-ray,CT scan if necessary EKG Spirometer Blood gas measurementPerioperative management of respiratory disease and high risk patients1.Preoperative physiotherapy teaching the patient breathing exercises and correct
13、 posture2.Drug therapyl Theophyllinesl Prophylactic antibioticsl Preoperative bronchodilatorl Adequate hydration3.Encourage to stop smoking from the time of book for elective surgery4.Alternation methods of anaesthesia Local,regional or spiral anaesthesia should be considered5.Early postoperative ph
14、ysiotherapy to enhance deep breathing,coughing and general mobility Liver disorder The tolerance to operation depends upon the severity of liver function impairment.The liver function could be estimated by Child staging.Malnutrition,ascites and jaundice are contraindications except for emergency sur
15、gery.Preoperative assessment and management Serological test for HBV and HCV,full blood count,clotting screen and platelet count,plasma urea and electrolytes,bilirubin,transaminases,calcium,phosphate,gamma glutaryl transferase and albumin.When prothrombin time is prolonged,vitamin K should be given
16、for several days before operation.Renal disordersPreoperative assessment plasma urea,electrolytes,creatinine and Bicarbonate should be checked Mild chronic renal failure Drugs should be given in smaller doses Fluid and electrolyte homeostasis Moderate-to-severe chronic renal failure Operations shoul
17、d be performed under haemodialysis Disorders of Adrenal FunctionAdrenal Insufficiencyl The most common cause of adrenal insufficiencyis hypothalamo-pituitary-adrenal suppression bylong-term corticosteroid therapy.l The lack of adrenal response in these patients maycause acute post-operative cardiova
18、scular collapse withhypotension and shock.l For any steroid-dependent patient,a doctor shouldwrite clearly in the note “Treat any unexplained collapsewith hydrocortisone”.Diabetes Mellitus At special risk from general anaesthesia and surgery Patients with diabetes fall into three groups 1.Insulin de
19、pendent 2.Taking oral hypoglycaemic medication 3.Diet-controlled Attempt to maintain blood glucose level between 4 and 10 mmol/L,avoid hypoglycemia in particular.Blood glucose level 13 mmol/L,an unreceptible risk of ketoacidosis or a hyperosmolar non-ketotic state.Perioperative managementThe general
20、 principle of perioperative management Establish good diabetic control before operation Given insulin as a continuous intravenous infusion during the operative period Given an infusion of dextrose throughout the operative period to balance the insulin given and to make up for lack of dietary intakeT
21、he general principle of perioperative management Add potassium to the dextrose infusion Monitor blood glucose and electrolytes frequently throughout the operative and early postoperative period Recovery room is necessary ICU is optimal if possibleMonitoring Closely monitor the life signs as a routin
22、e CVP monitoring is necessary if hemodynamic unstable during operation Other items monitored accordingly Fluid balance Post-operative ManagementPosition and getting up Supine position for spiral anaesthesia Semireclining position for neck and chest operation.Lateral position for obesity patients.Get
23、 up as early as possible and make movements as much as possibleDiet and transfusion Period of fast depends upon the type of operation.Enteral and parenteral nutrition should be taken into consideration.Fluid and electrolytes homeostasis should be maintained.Management of Drainage Different drainage
24、for different purpose (infection focus,leakage prevention and massive exudation)Nasal-gastric tube Urinary catheterWound healing and suture removingClassification of incisionl clean incisionl contaminated incisionl infected incisionType of healing Type A perfect healing B some inflammation C infecte
25、d1.Postoperative pain any motions increasing tensions will increase pain Analgesia is obligatory2.Pyrexial common postoperative observationl a search be made for a focus of infection l non-infective causes of pyrexiaManagement of postoperative complaintNausea and VomitingDrugs (opiates,erythromycin,
26、metronidazole)Bowel obstruction mechanical obstruction Adynamic bowel Hypokalaemia faecal impactionSystemic disorders electrolyte disturbances Uraemia raised intracranial pressureAbdominal distensionMore common after abdominal surgeryHiccup Diaphragm irritation or central nervous system stimulated S
27、ubphrenic infection should be suspected for continuous hiccupRetention of urine There is a palpable suprapubic mass with dull to percussion.Urinary catheter is indicated when diagnosed.The main postoperative complications:Atelectasis Chest infection Aspiration pneumonitis PneumoniaPostoperative Haem
28、orrhageCauses inadequate operative haemostasis a technical mishap as slipped ligatureManagement re-operation to stop bleeding some preparation is necessaryManagement of postoperative complicationsWound Dehiscence(Burst Abdomen)Causesl blood supply is poorl excess suture tensionl long-term steroid th
29、erapyl immunosuppressive therapyl malnutritionl infectionl coughing or abdominal distensionManagement re-suturing with tension sutures the whole thickness of the abdominal wallMinor wound infections localized pain,redness and a slight dischargeWound Cellulitis and Abscessl cellulitis treated by anti
30、bioticsl abscess treated by surgical drainage Wound InfectionAtelectasis Airway become obstructed and air is absorbed from the air spaces distal to the obstruction Bronchial secretions are the main cause of this obstructionPrevention and treatment perioperative physiotherapy is the best way for prev
31、ention deep breathing exercises regular adjustments of posture vigorous coughing flexible bronchoscopy to aspirate occluding mucus plugsUrinary Tract InfectionsCauses reduced urinary output reducing“flushing”of bladder incomplete bladder emptying inadequate perineal hygieneTreatment ensuring adequat
32、e fluid input appropriate antibioticsDeep vein thrombosisCauses bed bound after operation venous stasis plasma concentrated due dehydration viscosity increasedManifestations swelling of the leg tenderness of the calf muscle increased warmth of the leg calf pain on passive dorsiflexion of the footTre
33、atment Anticoagulation:Systemic thrombolytic therapy:streptokinase Local thrombolytic drugs is more promisingintravenous heparinsubcutaneous heparinoral warfarin therapy postoperative mobilization adequate hydration avoiding calf pressure Preventionfor high risk cases low dose subcutaneous heparin calf compression devices graded-compression anti-embolism stockings Intravenous dextran Warfarin anticoagulationThank you
