1、1,术前准备及术后处理Perioperative Management,北京大学第三医院 普通外科 姚宏伟Dept. of General Surgery, Peking University Third Hospital,2,Purpose,掌握手术前准备熟悉手术后处理 熟悉术后并发症的预防和治疗,3,Definition: Management before, during & after a surgical operation,4,Key points,Pre-Operative PreparationPost-Operative Management,5,1. Pre-Operati
2、ve Preparation,6,Aims To achieve the best status for surgeons and patients,7,Principle Individualized preparation & management for different patients & operations ExamplesNodular goiterGastric CarcinomaAcute duodenal perforation with diffuse peritonitis,8,术前准备内容：一般性准备,心理准备： （1）病人方面 （2）医生方面 病史采集 体格检查
3、 伴随疾病常规（/特殊）化验、检查 水、电解质及酸碱平衡监测以及调整准备血液制品（选择性）胃肠道准备：（1）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 抗生素的预防性应用 （适应证 手术清洁程度分级）,9,1. 营养不良，低白蛋白血症2. 高血压3. 非心外科手术合并心脏病者（心衰、心梗）4. 呼吸道疾病5. 肝功能异常（代偿期 VS 失代偿期）6. 肾功能衰竭7. 糖尿病,术前准备内容：特殊性准备,10,Classification of operations,1. Selective operation2. Restrictive operation3. Emerg
4、ency operation(1.【医】择期手术),11,Assessment of physical statusTo assess the general condition and function of important organsTo evaluate the tolerance capacityASA & APACHE Scoring System,ASA ： American Society of AnesthesiologistsAPACHE： Acute Physiology and Chronic Health Evaluation,12,ASA classificat
5、ion,第I 级：正常，健康第II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
6、 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,13,APACHE Scoring System,14,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 1,15,急诊手术？限期手术？心脏功能评估？术
7、前肠道准备如何开展？,Case 1,16,Case 2,患者，男，55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？,17,Case 2,AssessmentSugar controlAdaptive exerciseAntibiotics,18,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？,19,Case 3 1. Vitamin K4 ， 胆汁酸盐 2. 抗生素 3. 保肝药物 4.其他,20,Case 3,该患者合
8、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？,21,Case 3,血压控制心脏评估肾脏评估,22,Goldmans 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%,23,Respiratory
9、 dysfunction,Risk factors for respiratory complication COPD Asthma Current respiratory infections,24,Preoperative management of respiratory disease,AssessmentManagement:Smoking abatement2. Respiratory physiotherapy3. Controlling infection4. Drug therapy5. Alternation methods of anaesthesia,25,Liver
10、disorder,The liver function could be estimated by Child staging.,26,Liver disorder,27,Approach to the patient with liver disease,Surgery in the patient with liver disease. Mayo Clin Proc 74:593599, 1999,28,Surgery in the patient with liver disease. Mayo Clin Proc 74:593599, 1999.,Liver diseases,29,M
11、alnutrition,Malnutrition increases the morbidity and mortality of operations dramaticallyApproaches of nutrition support: EN PN,EN PN,30,术前讨论以及病情总结,31,2. Post-Operative Management,32,General managementManagement of postoperative complaintManagement of postoperative complications,33,Post-operative Ma
12、nagement,Recovery room is necessary ICU is optimal if possibleMonitoring,Closely monitor the life signs as a routine Other items monitored accordingly,34,General management,Position and getting up（ Analgesia）DietFluid infusionWound healing and suture removing,35,Wound healing and suture removing,Cla
13、ssification of incision clean clean-contaminated contaminated infectedType of healing Type A perfect healing B some inflammation C infected,36,Surgical wound classification,37,Management of Drainage,Nasal-gastric tube Urinary catheter Different drainage for different purpose (infection focus, leakag
14、e prevention and massive exudation),Special management,38,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 4,39,Management of postoperative complaint and complications,Complaint complications,NormalAb
15、normal,40,Management of postoperative complaint,Postoperative pain2. Pyrexia common postoperative observation,41,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,42,postoperative feverCauses 1. surgical factor wound abdominal cavit
16、y leakage 2. non-surgical factor Atelectasis/ pneumonia urinary system infection DVT pylephlebitis Management,43,Nausea and Vomiting,AnesthesiaBowel obstruction mechanical obstruction Adynamic bowelSystemic disorders electrolyte disturbances Uraemia raised intracranial pressure,44,Retention of urine
17、,There is a palpable suprapubic mass with dull to percussion. Urinary catheter is indicated when diagnosed.,45,Abdominal distensionSingultus,Other complaint,46,Case 6 患者，男，42岁，因胰头癌行Whipple 手术，术后第一天心率快，第二天出现出现血压下降、烦躁不安、面色苍白等。 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？ 如何处理？,47,Management of postoperative complicati
18、ons,Postoperative Haemorrhage,Causes inadequate operative haemostasis a technical mishap as slipped ligature Management re-operation to stop bleeding some preparation is necessary,48,Case 7 患者，女，72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，第2天晚8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。试问此病人出现了什么问题？如何解决？,49,Wou
19、nd Dehiscence (Burst Abdomen),Causes blood supply is poor excess suture tension long-term steroid therapy immunosuppressive therapy malnutrition infection coughing or abdominal distensionManagement re-suturing with tension sutures the whole thickness of the abdominal wall,50,1. 患者，女，60岁，患类风湿性关节炎20年，
20、常年服用强的松 10 mg qd. 突发上腹痛8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：此病人的死亡原因是什么？,思考题（1）,51,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,52,Thanks for your attention,53,Diabetes Mellitus,At special risk from general anaesthesia and surgery Three groups,54,Perioperative ma
21、nagement,InsulinAttempt to maintain blood glucose level between 5.6 and 11.2 mmol/L, avoid hypoglycemia in particular.Urine Glu +,55,Hypertension,收缩压 160mmHg 舒张压 100mmHg,Antihypertensive drugs should be used all time， Sudden withdrawal of drugs is dangerous,56,Cardiovascular disease,1. Ischaemic hea
22、rt disease2. Cardiac failure3. Arrhythmias4. Valvular heart disease,57,Renal disorders,Preoperative 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 haemodi
23、alysis,58,manifestation localized pain, redness and a slight dischargeTreatment antibiotics physical therapy surgical drainage prophylaxis,Wound Infection,59,Atelectasis,Airway become obstructed and air is absorbed from the air spaces distal to the obstruction Bronchial secretions are the main cause
24、 of this obstructionPrevention 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 plugs,60,Urinary Tract Infections,CausesUroschesisUse of catheter,Treatment,ensuring adequate fluid input appropriate antibiotics,
