術(shù)前準(zhǔn)備及術(shù)后處理姚宏偉PPT學(xué)習(xí)教案

1、會(huì)計(jì)學(xué)1術(shù)前準(zhǔn)備及術(shù)后處理姚宏偉術(shù)前準(zhǔn)備及術(shù)后處理姚宏偉2第1頁/共60頁3 Definition: Management before, during & after a surgical operationSuccessful surgery2. Intra-Op management 1. Pre-Op preparation3. Post-Op management第2頁/共60頁4第3頁/共60頁5第4頁/共60頁6第5頁/共60頁7 Principle Individualized preparation & management for different pat

2、ients & operations ExamplesNodular goiterGastric CarcinomaAcute duodenal perforation with diffuse peritonitis第6頁/共60頁8第7頁/共60頁9第8頁/共60頁101. Selective operation2. Restrictive operation3. Emergency operation(1.【醫(yī)】擇期手術(shù))第9頁/共60頁11ASA ： American Society of AnesthesiologistsAPACHE： Acute Physiology an

3、d Chronic Health Evaluation第10頁/共60頁12第I 級(jí)：正常，健康第II級(jí)：有輕度系統(tǒng)性疾病第III級(jí)：有嚴(yán)重系統(tǒng)性疾病，日?；顒?dòng)受限，尚未喪失工作能力第IV級(jí)：有嚴(yán)重系統(tǒng)性疾病，已喪失工作能力，且經(jīng)常面臨生命威脅第V級(jí)：無論手術(shù)與否，生命難以維持24小時(shí)的頻死病人I ：normal healthy patientII ：patient with mild systemic diseaseIII：patient with severe systemic disease that limits activity, but is not incapacitatingI

4、V：patient that has incapacitating disease that is a 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%, respectively第11頁/共60頁13第12頁/共60頁14第13頁/共60頁15第14頁/共60頁16第15頁/共60頁17第16頁/共6

5、0頁18 Case 3 患者，男，62歲，無痛性進(jìn)行性黃疸2周，大便灰白，小便濃茶色，通過B超和CT檢查，初步診斷為胰頭癌，擬行手術(shù)治療。試問：該病人特殊的術(shù)前準(zhǔn)備有那些？第17頁/共60頁19Case 3 1. Vitamin K4 ， 膽汁酸鹽 2. 抗生素 3. 保肝藥物 4.其他第18頁/共60頁20第19頁/共60頁21第20頁/共60頁22Risk 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 point

6、s) 16.0% Class IV (26 points) 63.6%第21頁/共60頁23Respiratory dysfunctionRisk factors for respiratory complication COPD Asthma Current respiratory infections第22頁/共60頁24Preoperative management of respiratory diseaseAssessmentManagement:1.Smoking abatement2. Respiratory physiotherapy3. Controlling infecti

7、on4. Drug therapy5. Alternation methods of anaesthesia第23頁/共60頁25Liver disorder The liver function could be estimated by Child staging.第24頁/共60頁26第25頁/共60頁27Surgery in the patient with liver disease. Mayo Clin Proc 74:593599, 1999第26頁/共60頁28Liver diseases第27頁/共60頁29Malnutrition Malnutrition increase

8、s the morbidity and mortality of operations dramaticallyApproaches of nutrition support: EN PNEN PN第28頁/共60頁30第29頁/共60頁31第30頁/共60頁32第31頁/共60頁33Post-operative Management Recovery room is necessary ICU is optimal if possibleMonitoring Closely monitor the life signs as a routine Other items monitored a

9、ccordingly第32頁/共60頁34第33頁/共60頁35Wound healing and suture removingClassification of incision clean clean-contaminated contaminated infectedType of healing Type A perfect healing B some inflammation C infected第34頁/共60頁36Wound ClassDefinitionClean（Class I） Uninfected operative wound in which no inflamm

10、ation is encountered and the respiratory, alimentary, genital, or infected urinary tract are not entered. Wounds are primarily closed and, if necessary, drained with closeddrainage. Surgical wounds following blunt trauma should be included in this category if they meet the criteria.Clean-contaminate

11、d（ Class II ） Operative wound in which the respiratory, alimentary, genital or urinary tracts are entered under controlled conditions and without unusual contamination.Contaminated（ Class III ） Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique or gross sp

12、illage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered are included in this category.Dirty（ Class IV ） Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definitio

13、n suggests that the organisms causing postoperative infection were present in the operative field before the operation.第35頁/共60頁37Management of Drainage Nasal-gastric tube Urinary catheter Different drainage for different purpose (infection focus, leakage prevention and massive exudation)Special man

14、agement第36頁/共60頁38 患者，女，70歲，因急性膽管炎行膽囊切除膽總管切開取石，T管引流術(shù)，術(shù)后第3天拔除膽囊床引流管，2周拔除T管，拔管后2小時(shí)出現(xiàn)右上腹痛，發(fā)熱、黃疸，B超提示右上腹有積液。保守?zé)o效于拔管后第2天再行剖腹探查，T管撕裂竇道置管引流術(shù)，術(shù)后2周恢復(fù)出院。問：1.膽囊床引流管和T管應(yīng)如何處理？Case 4第37頁/共60頁39Complaint complicationsNormalAbnormal第38頁/共60頁40 Management of postoperative complaint1. Postoperative pain2. Pyrexia com

15、mon postoperative observation 第39頁/共60頁41 Case 5 患者，男，76歲，因急性闌尾炎并穿孔急診全麻下行闌尾切除，腹腔引流術(shù)。術(shù)后第1天T 38.5 ；第2天 38.2 ; 第3天38 ；第45天 37.7 38.5。Q1: 患者體溫為正?；謴?fù)過程嗎？Q2：分析可能原因及處理第40頁/共60頁42postoperative feverCauses 1. surgical factor wound abdominal cavity leakage 2. non-surgical factor Atelectasis/ pneumonia urinary

16、system infection DVT pylephlebitis Management 第41頁/共60頁43Nausea and VomitingAnesthesiaBowel obstruction mechanical obstruction Adynamic bowelSystemic disorders electrolyte disturbances Uraemia raised intracranial pressure第42頁/共60頁44Retention of urine There is a palpable suprapubic mass with dull to

17、percussion. Urinary catheter is indicated when diagnosed.第43頁/共60頁45Abdominal distensionSingultusOther complaint第44頁/共60頁46Case 6 患者，男，患者，男，42歲，因胰頭癌行歲，因胰頭癌行Whipple 手術(shù)，術(shù)手術(shù)，術(shù)后第一天心率快，第二天出現(xiàn)出現(xiàn)血壓下降、煩躁不后第一天心率快，第二天出現(xiàn)出現(xiàn)血壓下降、煩躁不安、面色蒼白等。安、面色蒼白等。 試分析此病人出現(xiàn)了什么問題？還需作那些檢查以試分析此病人出現(xiàn)了什么問題？還需作那些檢查以證實(shí)診斷？證實(shí)診斷？ 如何處理？如何處理？

18、 第45頁/共60頁47Management of postoperative complicationsPostoperative HaemorrhageCauses inadequate operative haemostasis a technical mishap as slipped ligature Management re-operation to stop bleeding some preparation is necessary第46頁/共60頁48Case 7 患者，女，患者，女，72歲。因急性膽囊炎急診行膽囊切歲。因急性膽囊炎急診行膽囊切除術(shù)，采用經(jīng)右上腹直肌切口。術(shù)

19、后有咳嗽和腹脹除術(shù)，采用經(jīng)右上腹直肌切口。術(shù)后有咳嗽和腹脹，第，第2天晚天晚8點(diǎn)劇烈咳嗽后突然出現(xiàn)切口處有崩裂感點(diǎn)劇烈咳嗽后突然出現(xiàn)切口處有崩裂感，隨后有淡血性液體及腸管從切口處涌出。試問此，隨后有淡血性液體及腸管從切口處涌出。試問此病人出現(xiàn)了什么問題？如何解決？病人出現(xiàn)了什么問題？如何解決？第47頁/共60頁49Wound Dehiscence (Burst Abdomen)Causes blood supply is poor excess suture tension long-term steroid therapy immunosuppressive therapy malnutri

20、tion infection coughing or abdominal distensionManagement re-suturing with tension sutures the whole thickness of the abdominal wall第48頁/共60頁50 1. 患者，女，患者，女，60歲，患類風(fēng)濕性關(guān)節(jié)炎歲，患類風(fēng)濕性關(guān)節(jié)炎20年，常年年，常年服用強(qiáng)的松服用強(qiáng)的松 10 mg qd. 突發(fā)上腹痛突發(fā)上腹痛8小時(shí)入院，急診以急小時(shí)入院，急診以急性彌漫性腹膜炎，上消化道潰瘍穿孔行手術(shù)治療，行胃性彌漫性腹膜炎，上消化道潰瘍穿孔行手術(shù)治療，行胃大部切除術(shù)。手術(shù)順利，關(guān)腹

21、前突然出現(xiàn)不明原因的血大部切除術(shù)。手術(shù)順利，關(guān)腹前突然出現(xiàn)不明原因的血壓降低，經(jīng)用各種抗休克治療不見效而死亡。試問：此壓降低，經(jīng)用各種抗休克治療不見效而死亡。試問：此病人的病人的死亡原因死亡原因是什么？是什么？思考題（1）第49頁/共60頁51第50頁/共60頁52第51頁/共60頁53Diabetes Mellitus At special risk from general anaesthesia and surgery Three groups第52頁/共60頁54Perioperative managementInsulinAttempt to maintain blood gluco

22、se level between 5.6 and 11.2 mmol/L, avoid hypoglycemia in particular.Urine Glu +第53頁/共60頁55Hypertension 收縮壓 160mmHg 舒張壓 100mmHg Antihypertensive drugs should be used all time， Sudden withdrawal of drugs is dangerous第54頁/共60頁56Cardiovascular disease1. Ischaemic heart disease2. Cardiac failure3. Arrhythmias4. Valvular heart disease第55頁/共60頁57Renal disordersPreoperative assessment BUN, Scr , Ccr， Mild chronic renal failure Drugs should be given in smaller doses Fluid and electrolyte homeostasis Sev